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Try free for 5 days Evidence-based content, created and peer-reviewed by physicians. Read the disclaimer. Summary Pneumothorax develops when air enters the pleural space as the result of disease or injury. Definition Pneumothorax : a collection of air within the pleural space between the lung visceral pleura and the chest wall parietal pleura that can lead to partial or complete pulmonary collapse. May be classified as: [1] Spontaneous pneumothorax Primary spontaneous pneumothorax : occurs in patients without clinically apparent underlying lung disease Secondary spontaneous pneumothorax : occurs as a complication of underlying lung disease Recurrent pneumothorax: a second episode of spontaneous pneumothorax , either ipsilateral or contralateral Traumatic pneumothorax : a type of pneumothorax caused by a trauma e.
Etiology Spontaneous pneumothorax Primary idiopathic or simple pneumothorax Caused by ruptured su bpleural apical blebs Risk factors Family history Male sex Young age Asthenic body habitus slim, tall statur e e.
Air shifts between the lungs. Tension pneumothorax Disrupted visceral pleura , parietal pleura , or tracheobronchial tree One-way valve mechanism, in which air enters the pleural space on inspiration but cannot exit Progressive accumulation of air in the pleural spac e and increasing positive pressure within the chest Collapse of ipsilateral lung ; compression of contralateral lung , trachea , heart , and superior vena cava ; angulation of inferior vena cava Impaired respiratory function, reduced venous return to the heart Reduced cardiac output Hypoxia and hemodyna mic instability Clinical features Patients range from being asymptomatic to having features of hemodynamic compromise.
Diagnostics General principles [8] The diagnosis of pneumothorax is usually confirmed by chest x-ray. Ultrasound is becoming an increasingly accepted modality for identifying pneumothorax and is part of the eFAST.
Tension pneumothorax is primarily a clinical diagnosis and prolonged diagnostic studies should be avoided in favor of initiating immediate treatment. Imaging Chest x-ray [6] [8] Indications : all patients suspected of having pneumothorax Procedure : Upright PA chest x-ray in inspiration is the modality of choice. Ultrasound [9] Indications Trauma eFAST Quick bedside assessment Supportive findings [14] Absence of pleural sliding Absence of B-lines Barcode sign instead of seashore sign in M-mode Combination of prominent A-lines and absent B-lines Chest CT [6] Indications Uncertain diagnosis despite chest x-ray and complex cases In suspected underlying lung disease, to determine the likelihood of recurrent disease Detailed assessment of bullae Presurgical workup Findings : similar to CXR Determination of pneumothorax size The size of a pneumothorax is assessed via imaging e.
How a pneumothorax is measured depends on regional guidelines, hospital policies, and personal preferences: Apex-to-cupola distance [8] Interpleural distance at the level of the lung hilus [6] Collins method : Calculated pneumothorax size in percent of hemithorax [15] [16] The interpleural distance on a PA CXR is measured in centimeters at three points. Treatment Approach [6] [8] All patients Assess patient stability see, e.
Provide respiratory support and treat dyspnea. Evaluate the type and size of pneumothorax. Unstable or high-risk patients : e. Stable spontaneous pneumothorax management : depends on the risk of progression and recurrence Low-risk: conservative management Higher risk: chest tube placement Traumatic pneumothorax management Most patients require chest tube placement. Decompression of a pneumothorax can sometimes rapidly improve dyspnea , making mechanical ventilation unnecessary.
Treatment based on stability, type, and size For stable patients, management depends on apex-to-cupola distance. Traumatic pneumothorax management [22] [23] The treatment of unstable or high-risk traumatic pneumothorax e.
Consider observation only in hemodynamically stable patients with small pneumothoraces. Significant chest trauma: Assess for other thoracic injuries, e. Open pneumothorax [22] [23] Immediately apply simple, partially occlusive dressings taped at 3 out of 4 sides of the lesion. Follow dressing with tube thoracostomy. Observe for development of tension pneumothorax. No chest tube is inserted or secured. Aspirate air using a large syringe until resistance is felt or the patient begins to cough excessively.
Surgery Indications [6] Recurrent ipsilateral pneumothorax episodes Bilateral or contralateral pneumothorax Persistent air leak or insufficient lung re-expansion for 5—7 days despite chest tube placement Extensive underlying lung disease High-risk occupation e. Admission criteria [22] Patients requiring a chest tube typically require hospital admission, except for those meeting select criteria for home management.
However, these criteria do not apply to the following conditions, in which admission is always recommended: All patients with : Tension pneumothorax Secondary spontaneous pneumothorax Traumatic pneumothorax Patients with spontaneous primary pneumothorax and any of the following: Signs of hypoxia or hemodynamic instability Evidence of progression on repeat chest x-ray Difficulty adhering to discharge instructions Consider ICU admission for unstable patients or those with large secondary pneumothoraces.
Trauma center [23] Transfer to a trauma center is recommended for patients with traumatic pneumothorax and any of the following once stabilizing procedures have been performed. Criteria for outpatient management [8] [22] Patients must be able to: Understand discharge instructions Attend 24—48 hour follow-up [6] [8] Imaging criteria for stable patients with spontaneous primary pneumothorax Managed with observation only: improved or stable on repeat CXR at 3—6 hours Managed with needle aspiration : improved on repeat CXR 4—6 hours after aspiration Discharge instructions [6] [22] Advise patients to seek immediate medical attention if breathlessness or chest pain worsens.
Failed needle decompression of bilateral spontaneous tension pneumothorax. Acta Anaesthesiologica Scandinavica. Doelken P. Placement and management of thoracostomy tubes. Parsons PE ed. Accessed October 2, The right place in the right space? Awareness of site for needle thoracocentesis. Emergency Medicine Journal. Pleural decompression and drainage during trauma reception and resuscitation.
Epidemiology of pneumothorax—finally something solid out of thin air. Results of surgical treatment for secondary spontaneous pneumothorax according to underlying diseases.
European Journal of Cardiothoracic Surgery. Thoracic Trauma. Test your knowledge. A year-old boy is brought to the emergency department via ambulance after he was involved in a motor vehicle collision. The patient is unconscious on arrival. MRI shows small microhemorrhages in the brain stem. The patient remains unconscious for the next 7 hours. Based on these findings, which of the following is the most likely diagnosis?
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