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https://upload.medbullets.com/topic/120667/images/spontanpneumothorax.jpg
Snapshot
  • A 22-year-old man presents to the emergency department with chest pain.  He was playing basketball when his symptoms suddenly started.  The patient is a tall man, and there is no observable trauma to the chest wall.  He is hemodynamically stable and currently endorses pleuritic chest pain. (Pneumothorax)  
Introduction
  • Clinical definition
    • air entry into the chest cavity that causes collapse of the lung without signs of tension physiology (hypotension, tachycardia, and jugular venous distention (JVD))
    • primary pneumothorax
      • no underlying pulmonary disease
    • secondary pneumothorax
      • underlying pulmonary disease
  • Epidemiology
    • demographics
      • primary pneumothorax
        • tall and thin men
    • risk factors
      • secondary pneumothorax
        • smoking
  • Pathogenesis
    • mechanism
      • rupture of an emphysematous bleb 
  • Associated conditions
    • primary pneumothorax
      • a spontaneous process
    • secondary pneumothorax
      • COPD
      • asthma
      • cystic fibrosis
      • infection (pneumonia, abscess, and tuberculosis)
      • interstitial lung disease
      • connective tissue disease
      • procedures (subclavian lines, thoracentesis, bronchoscopy, and mechanical ventilation) 
      • blunt trauma
Presentation
  • Symptoms
    • sudden-onset, unilateral, pleuritic chest pain
    • dyspnea
  • Physical exam
    • decreased or absent breath sounds
    • hyperresonance on percussion
    • absence of tracheal deviation/JVD (this would imply a tension pneumothorax)
    • decreased or absent tactile fremitus
Studies
  • Diagnostic testing
    • imaging
      • chest radiograph 
        • best initial test 
          • will show collapsed lung (lack of pulmonary markings extending to periphery)
      • computed tomography (CT) of the chest
        • most accurate test 
          • often not indicated but can be ordered if clinical suspicion with a normal appearing chest radiograph
          • can further elucidate other injuries (rib fractures)
      • ultrasound 
        • will demonstrate an absence of lung sliding
Differential
  • Primary spontaneous pneumothorax
  • Secondary spontaneous pneumothorax
  • Tension pneumothorax 
    • distinguishing factor
      • tension physiology present (hypotension, tachycardia, JVD, and poor O2 saturation)
      • can be associated with procedures such as central line placement 
  • Panic attack 
    • distinguishing factor
      • only sinus tachycardia without other organic etiologies of symptoms
Treatment
  • Management approach
    • always start with the ABC's of trauma prior to diagnostic testing
  • Small pneumothorax, stable vitals, and asymptomatic patient
    • 100% oxygen and observation
      • the pneumothorax will resorb
  • Large pneumothorax and symptomatic patient
    • aspiration (needle thoracocentesis)
    • chest tube/pigtail catheter
      • indications
        • lower threshold to place chest tube if a secondary pneumothorax
        • can be primary treatment or if needle aspiration fails
  • Recurrent pneumothorax
    • video-assisted thoracoscopic surgery
    • pleurodesis
      • injection of an irritant into pleural space scars pleural layers together
Complications
  • Recurrence
  • Bilateral pneumothoraces can cause hemodynamic instability
  • May progress to a tension pneumothorax

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