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Pneumothorax is defined as the presence of air or gas in the pleural cavity (ie, the potential space
between the visceral and parietal pleura of the lung), which can impair oxygenation and/or
ventilation. The clinical results are dependent on the degree of collapse of the lung on the
affected side. If the pneumothorax is significant, it can cause a shift of the mediastinum and
compromise hemodynamic stability. Air can enter the intrapleural space through a
communication from the chest wall (ie, trauma) or through the lung parenchyma across the
visceral pleura. See the image below.
Catamenial pneumothorax: Women aged 30-40 years with onset of symptoms within 48
hours of menstruation, right-sided pneumothorax, and recurrence
Diagnosis
History and physical examination remain the keys to making the diagnosis of pneumothorax.
Examination of patients with this condition may reveal diaphoresis and cyanosis (in the case of
tension pneumothorax). Affected patients may also reveal altered mental status changes,
including decreased alertness and/or consciousness (a rare finding).
Findings on lung auscultation vary depending on the extent of the pneumothorax. Respiratory
findings may include the following:
Asymmetric lung expansion: Mediastinal and tracheal shift to contralateral side (large
tension pneumothorax)
Distant or absent breath sounds: Unilaterally decreased/absent lung sounds common, but
decreased air entry may be absent even in advanced state of pneumothorax
Tachycardia: Most common finding; if heart rate is faster than 135 beats/min, tension
pneumothorax likely
Pulsus paradoxus
Chest computed tomography scanning: Most reliable imaging study for diagnosis of
pneumothorax but not recommended for routine use in pneumothorax
Chest ultrasonography
Management
Although there is general agreement on the management of pneumothorax, a full consensus
about management of initial or recurrent pneumothorax does not exist. Rather, many clinicians
use a risk stratification framework as well as other approaches for choosing among options to
restore lung volume and an air-free pleural space and to prevent recurrences.[1]
The range of medical therapeutic options for pneumothorax includes the following:
Simple aspiration
Surgery
If the patient has had repeated episodes of pneumothorax or if the lung remains unexpanded after
5 days with a chest tube in place, operative therapy such as the following may be necessary:
Laser treatment
Open thoracotomy
Pharmacotherapy
The following medications may be used to aid in the management of patients with
pneumothorax:
Background
Pneumothorax is defined as the presence of air or gas in the pleural cavity (ie, the
potential space between the visceral and parietal pleura of the lung). The clinical results
are dependent on the degree of collapse of the lung on the affected side. Pneumothorax
can impair oxygenation and/or ventilation. If the pneumothorax is significant, it can cause
a shift of the mediastinum and compromise hemodynamic stability. Air can enter the
intrapleural space through a communication from the chest wall (ie, trauma) or through
the lung parenchyma across the visceral pleura.
Among the topics this article will discuss are several areas of new information in the
medical literature: (1) studies comparing aspiration and tube drainage for treatment of
primary spontaneous pneumothorax, (2) long-term follow-up of surgical treatment of
pneumothorax, (3) assessment of the impact of pleurodesis on transplantation outcomes
in patients with lymphangiomyomatosis, (4) demonstrated utility of ultrasonography in
the bedside diagnosis of iatrogenic pneumothorax, and (5) inability of ultrasonography to
distinguish between intrapulmonary bullae and pneumothorax.
See also Restoring an Air-Free Pleural Space in Pneumothorax.
Tension pneumothorax
Pneumomediastinum
Pneumomediastinum from
barotrauma may result in tension pneumothorax and obstructive shock.
The inner surface of the thoracic cage (parietal pleura) is contiguous with the outer surface of the
lung (visceral pleura); this space contains a small amount of lubricating fluid and is normally
under negative pressure compared to the alveoli. Determinants of pleural pressure are the
opposing recoil forces of the lung and chest wall.
Pathophysiology
The underlying pathophysiology of pneumothorax is reviewed in this section.
Spontaneous pneumothorax
Spontaneous pneumothorax in most patients occurs from the rupture of blebs and bullae.
Although primary spontaneous pneumothorax (PSP) is defined as occurring in patients without
underlying pulmonary disease, these patients have asymptomatic blebs and bullae detected on
computed tomography scans or during thoracotomy. PSP is typically observed in tall, young
people without parenchymal lung disease and is thought to be related to increased shear forces in
the apex.
Although PSP is associated with the presence of apical pleural blebs, the exact anatomic site of
air leakage is often uncertain. Fluorescein-enhanced autofluorescence thoracoscopy (FEAT) is a
novel method to examine the site of air leak in PSP. FEAT-positive lesions can be detected that
appear normal when viewed under normal white-light thoracoscopy.[3]
In normal respiration, the pleural space has a negative pressure. As the chest wall expands
outward, the surface tension between the parietal and visceral pleura expands the lung outward.
The lung tissue intrinsically has an elastic recoil, tending to collapse inwards. If the pleural space
is invaded by gas from a ruptured bleb, the lung collapses until equilibrium is achieved or the
rupture is sealed. As the pneumothorax enlarges, the lung becomes smaller. The main
physiologic consequence of this process is a decrease in vital capacity and partial pressure of
oxygen.
Lung inflammation and oxidative stress are hypothesized to be important to the pathogenesis of
PSP.[4] Current smokers, at increased risk for PSP, have increased numbers of inflammatory cells
in the small airways. Bronchoalveolar lavage (BAL) studies in patients with PSP reveal that the
degree of inflammation correlates with the extent of emphysematouslike changes (ELCs). One
hypothesis is that ELCs result from degradation of lung tissue due to imbalances of enzymes and
antioxidants released by innate immune cells.[5] In one study, erythrocyte superoxide dismutase
activity was significantly lower and plasma malondialdehyde levels higher in patients with PSP
than in normal control subjects.[4]
A growing body of evidence suggests that genetic factors may be important in the pathogenesis
of many cases of PSP. Familial clustering of this condition has been reported. Genetic disorders
that have been linked to PSP include Marfan syndrome, homocystinuria, and Birt-Hogg-Dube
(BHD) syndrome.
Birt-Hogg-Dube syndrome is an autosomal dominant disorder that is characterized by benign
skin tumors (hair follicle hamartomas), renal and colon cancer, and spontaneous pneumothorax.
Spontaneous pneumothorax occurs in about 22% of patients with this syndrome. The gene
responsible for this syndrome is a tumor suppressor gene located on band 17p11.2. The gene
encoding folliculin (FLCN) is thought to be the etiology of Birt-Hogg-Dube syndrome. Multiple
mutations have been found, and phenotypic variation is recognized. In one study, 8 patients
without skin or renal involvement had lung cysts and spontaneous pneumothorax.[6] A germ-line
mutation to this gene has been found in 5 patients, and genetic testing is now available.
Tension pneumothorax
Tension pneumothorax occurs anytime a disruption involves the visceral pleura, parietal pleura,
or the tracheobronchial tree. This condition develops when injured tissue forms a 1-way valve,
allowing air inflow with inhalation into the pleural space and prohibiting air outflow. The volume
of this nonabsorbable intrapleural air increases with each inspiration because of the 1-way valve
effect. As a result, pressure rises within the affected hemithorax. In addition to this mechanism,
the positive pressure used with mechanical ventilation therapy can cause air trapping.
As the pressure increases, the ipsilateral lung collapses and causes hypoxia. Further pressure
increases cause the mediastinum to shift toward the contralateral side and impinge on and
compress both the contralateral lung and impair the venous return to the right atrium. Hypoxia
results as the collapsed lung on the affected side and the compressed lung on the contralateral
side compromise effective gas exchange. This hypoxia and decreased venous return caused by
compression of the relatively thin walls of the atria impair cardiac function. Kinking of the
inferior vena cava is thought to be the initial event restricting blood to the heart. It is most
evident in trauma patients who are hypovolemic with reduced venous blood return to the heart.
Arising from numerous causes, this condition rapidly progresses to respiratory insufficiency,
cardiovascular collapse, and, ultimately, death if unrecognized and untreated.
Pneumomediastinum
With pneumomediastinum, excessive intra-alveolar pressures lead to rupture of alveoli bordering
the mediastinum. Air escapes into the surrounding connective tissue and dissects further into the
mediastinum. Esophageal trauma or elevated airway pressures may also allow air to dissect into
the mediastinum. Air may then travel superiorly into the visceral, retropharyngeal, and
subcutaneous spaces of the neck. From the neck, the subcutaneous compartment is continuous
throughout the body; thus, air can diffuse widely. Mediastinal air can also pass inferiorly into the
retroperitoneum and other extraperitoneal compartments. If the mediastinal pressure rises
abruptly or if decompression is not sufficient, the mediastinal parietal pleura may rupture and
cause a pneumothorax (in 10-18% of patients).
A wide variety of disease states and circumstances may result in a pneumothorax.
Smoking
Marfan syndrome
Pregnancy
Familial pneumothorax
Blebs and bullae (sometimes called emphysematouslike changes or ELCs) are related to the
occurrence of primary spontaneous pneumothorax. Thoracic computerized tomography (CT)
scans of patients with PSP shows ipsilateral ELC in 89% and contralateral changes in 80%
compared with a rate of 20% among control subjects matched for age and smoking.[2]
Nonsmokers with PSP had CT scan ELC abnormalities of 80% compared with a rate of 0%
among nonsmoker controls without PSP.[2]
Although patients with PSP do not have overt parenchymal disease, this condition is heavily
associated with smoking80-90% of primary spontaneous pneumothorax (PSP) cases occur in
smokers or former smokers, and the relative risk of PSP increases as the number of cigarettes
smoked per day increases; that is, the risk of PSP is related to the intensity of smoking, with 102times higher incidence rates in males who smoke heavily (ie, >22 cigarettes/d), compared with a
7-fold increase in males who smoke lightly (1-12 cigarettes/d). This incremental risk with
increasing number of cigarettes smoked per day is much more pronounced in female smokers.
Typical PSP patients also tend to have a tall and thin body habitus. Whether height affects
development of subpleural blebs or whether more negative apical pleural pressures cause
preexisting blebs to rupture is unclear.
Pregnancy is an unrecognized risk factor, as suggested by a 10-year retrospective series in which
5 of 250 spontaneous pneumothorax cases were in pregnant women.[7] The cases were all
managed successfully with simple aspiration or vacuum-assisted thoracostomy (VATS), and no
harm occurred to mother or fetus.[7]
Other associations with pneumothorax include increased intrathoracic pressure with Valsalva,
although results contrary to popular belief, most spontaneous pneumothoraces occur while the
patient is at rest. Changes in atmospheric pressure, proximity to loud music, and low frequency
noises are other reported factors.
Familial associations have been noted in more than 10% of patients. Some are due to rare
connective tissue diseases, but mutations in the gene encoding folliculin (FLCN) have been
described. These patients may represent an incomplete penetrance of an autosomal dominant
genetic disorder. Birt-Hogg-Dube syndrome is characterized by benign skin growths, pulmonary
cysts, and renal cancers and is caused by mutations in the FLCN gene. In one family study, 9
ascertained cases of spontaneous pneumothorax were reported among 54 members. A review of
the literature summarized 61 reports of familial spontaneous pneumothorax among 22 families.
Up to 10% patients with spontaneous pneumothorax report a positive family history.[8]
Although rare, spontaneous pneumothorax occurring bilaterally and progressing to tension
pneumothorax has been documented.
Diseases and conditions associated with secondary spontaneous pneumothorax include the
following:
Asthma
Necrotizing pneumonia
Tuberculosis
Sarcoidosis
Cystic fibrosis
Lymphangioleiomyomatosis
Severe acute respiratory syndrome (SARS): A reported 1.7% of SARS patients developed
spontaneous pneumothorax. [10]
Secondary spontaneous pneumothoraces (SSP) occur in the presence of lung disease, primarily
in the presence of COPD. Other diseases that may be present when SSPs occur include
tuberculosis, sarcoidosis, cystic fibrosis, malignancy, and idiopathic pulmonary fibrosis.
Thoracentesis
Tracheostomy
Acute respiratory distress syndrome ( ARDS) and positive pressure ventilation in the
ICU: High peak airway pressures can translate into barotrauma in up to 3% of patients on
a ventilator and up to 5% of patients with ARDS. [17]
Rib fracture
Traumatic pneumothoraces can result from both penetrating and nonpenetrating lung injuries.
Complications include hemopneumothorax and bronchopleural fistula. Traumatic
pneumothoraces often can create a 1-way valve in the pleural space (only letting in air without
escape) and can lead to a tension pneumothorax.
Tension pneumothorax
The most common etiologies of tension pneumothorax are either iatrogenic or related to trauma,
such as the following:
Blunt or penetrating trauma: Disruption of either the visceral or parietal pleura occurs and
is often associated with rib fractures, although rib fractures are not necessary for tension
pneumothorax to occur.
Tension pneumothorax occurs commonly in the ICU setting in patients who are ventilated with
positive pressure, and practitioners must always consider this when changes in respiratory or
hemodynamic status occur. Infants requiring ventilatory assistance and those with meconium
aspiration have a particularly high risk for tension pneumothorax. Aspirated meconium may
serve as a 1-way valve and produce a tension pneumothorax.
Any penetrating wound that produces an abnormal passageway for gas exchange into the pleural
spaces and that results in air trapping may produce a tension pneumothorax. Blunt trauma, with
or without associated rib fractures, and incidents such as unrestrained head-on motor vehicle
accidents, falls, and altercations involving laterally directed blows may also cause tension
pneumothoraces.
Significant chest injuries carry an estimated 10-50% risk of associated pneumothorax; in about
50% of these cases, the pneumothorax may not be seen on standard radiographs and are therefore
deemed occult. In one study, 12% of patients with asymptomatic chest stab wounds had a
delayed pneumothorax or hemothorax. McPherson et al analyzed data from the Vietnam Wound
Data and Munitions Effectiveness Team study and determined that tension pneumothorax was
the cause of death in 3-4% of fatally wounded combat casualties.[27]
Acupuncture is a traditional Chinese medicine technique used worldwide by alternative medical
practitioners. Acupuncture's most frequently reported serious complication is pneumothorax; in
one Japanese report of 55,291 acupuncture treatments, an approximate incidence of 1
pneumothorax in 5000 cases was documented.[28]
Pneumomediastinum
The following factors may result in pneumomediastinum:
Asthma
Parturition
Emesis
Severe cough
Mechanical ventilation
Athletic competition
Epidemiology
Primary spontaneous pneumothoraces (PSPs) occur in people aged 20-30 years, with a peak
incidence is in the early twenties.PSP is rarely observed in people older than 40 years. The ageadjusted incidence of PSP is 7.4-18 cases per 100,000 persons per year for men and 1.2-6 cases
per 100,000 persons per year for women.[29] The male-to-female ratio of age-adjusted rates is
6.2:1.
Secondary spontaneous pneumothoraces (SSPs) occur more frequently in patients aged 60-65
years. The age-adjusted incidence of SSP is 6.3 cases per 100,000 persons per year for men and
2.0 cases per 100,000 persons per year for women. The male-to-female ratio of age-adjusted
rates is 3.2:1. Chronic obstructive pulmonary disease (COPD) is a common cause of secondary
spontaneous pneumothorax that carries an incidence of 26 cases per 100,000 persons.[30]
Smoking increases the risk of a first spontaneous pneumothorax by more than 20-fold in men
and by nearly 10-fold in women compared with risks in nonsmokers.[31] Increased risk of
pneumothorax and recurrence appears to rise proportionally with number of cigarettes smoked.
In men, the risk of spontaneous pneumothorax is 102 times higher in heavy smokers than in
nonsmokers. Spontaneous pneumothorax most frequently occurs in tall, thin men aged 20-40
years.
Iatrogenic and traumatic pneumothorax
Catamenial pneumothorax is a rare phenomenon that generally occurs in women aged 30-50
years. It frequently begins 1-3 days after menses onset. The risk of thoracic endometriosis cannot
be predicted from the site of peritoneal lesions.[15]
Pneumomediastinum
Recurrences are more common among patients who smoke, patients with chronic obstructive
pulmonary disease (COPD), and patients with acquired immunodeficiency syndrome (AIDS).
Predictors of recurrence include pulmonary fibrosis, younger age, and increased height-to-weight
ratio. In a retrospective study of 182 consecutive patients with a newly diagnosed first episode of
pneumothorax, a higher rate of recurrence was noted in taller patients, thin patients, and patients
with SSP.
Patients who underwent bedside chest tube pleurodesis had cumulative rates of recurrence of
13% at 6 months, 16% at 1 year, and 27% at 3 years compared with 26%, 33%, and 50%,
respectively. The agent used (tetracycline or gentamicin) did not have any significant impact on
the recurrence rate.
Bullous lesions found on computed tomography (CT) scan or at thoracoscopy and the presence
of emphysematouslike changes in PSP are also not predictive of recurrence. However,
contralateral blebs were seen by CT scanning in higher frequency in the patients with
contralateral recurrence (33 patients; 14%) than those without a contralateral recurrence in a
retrospective study of 231 patients with PSP. Primary bilateral spontaneous pneumothorax
(PBSP) was significantly more common in patients with lower body mass index (BMI) and
among smokers.[32] In this series, all patients with contralateral recurrence were treated surgically.
Although some authors view PSP as more of a nuisance than a major health threat, deaths have
been reported. SSPs are more often life threatening, depending on the severity of the underlying
disease and the size of the pneumothorax (1-17% mortality rate). In particular, compared with
similar patients without pneumothorax, age-matched patients with COPD have a 3.5-fold
increase in relative mortality when a spontaneous pneumothorax occurs, and their risk of
recurrence rises with each occurrence. One study indicated that 5% of patients with COPD died
before a chest tube was placed.
Patients with AIDS also have a high inpatient mortality rate of 25% and a median survival of 3
months after the pneumothorax. These data derive from an era before highly active antiretroviral
therapy (HAART) was available.
Tension pneumothorax
Tension pneumothorax arises from numerous causes and rapidly progresses to respiratory
insufficiency, cardiovascular collapse, and, ultimately, death if not recognized and treated.
Therefore, if the clinical picture fits a tension pneumothorax, it must be emergently treated
before it results in hemodynamic instability and death.
Pneumomediastinum
Two important concerns that clinicians should educate patients with pneumothorax/resolving
pneumothorax about are avoidance of air travel/travel to remote regions and prohibition of
smoking. Patients should also be advised to wear safety belts and passive restraint devices while
driving.
Avoid traveling by air or to remote areas
Patients should not travel by air or travel to remote sites until radiography shows complete
resolution. Although commercial air travel achieves minimal change in gas volumes due to
pressurization of the cabin, spontaneous pneumothorax has been described during commercial
travel.
Patients with previous spontaneous pneumothoraces are at risk for recurrence and are advised not
to dive unless thoracotomy or pleurodesis has been performed.[34] Ascent from deep-sea diving
causes gases to expand and can lead to pneumothorax in patients with bullae and blebs.
Stop smoking
Smoking cessation is strongly advised for all patients. They should be assessed as to readiness to
quit, to be educated about smoking cessation, and be provided with pharmacotherapy if ready to
quit. Direct patients indicating a readiness to quit smoking to their primary care physician or
offer referral for cessation management. This may include nicotine replacement and non-nicotine
pharmacotherapy such as bupropion or varenicline.
Whether primary or secondary pneumothorax, smoking increases the likelihood of bleb rupture
and recurrence, and it does so in a predictable, dose-related manner. Relative risk of bleb rupture
and recurrence rises by up to a factor of 20.
For patient education information, see the Lung and Airway Center and Breathing Difficulties
Center, as well as Collapsed Lung (Pneumothorax) and Chest Pain.
Diagnostic Considerations
This section reviews some important points to consider in the diagnosis of pneumothoraces.
Spontaneous pneumothorax
Because patients with primary spontaneous pneumothorax (PSP) will have apical
emphysematous pulmonary disease on computed tomography (CT) scanning or thoracoscopy,
they can be thought to have a congenital syndrome of mild acinar emphysema, whose expression
is enhanced by environmental factors (eg, smoking) just as it is in patients with alpha-1antitrypsin deficiency and "typical" emphysema.
Folliculin gene disorders have been described in familial spontaneous pneumothorax.[4] These
patients may have pneumothorax as the presenting symptom of Birt-Hogg-Dube disease.[5] Some
authors recommend screening patients with a family history of pneumothorax for the benign skin
tumors and renal cancers that arise from the disease.
Catamenial pneumothorax is a rare cause of recurrent pneumothorax in women. Prior to
recurrence, this condition may initially be diagnosed as PSP.
Pneumonia is a possible cause of pneumothorax; in the patient with human immunodeficiency
virus infection (HIV), Pneumocystis jiroveci pneumonia (PCP) , toxoplasmosis, and Kaposi
sarcoma need to be considered . A patient with HIV can have spontaneous pneumothorax as the
presenting symptom of their illness: HIV carries a lifetime risk of 6% for pneumothorax, and
about 85% of that number is related to PCP pneumonia.
The rare event of spontaneous pneumothorax leading to tension pneumothorax may be
misdiagnosed as an asthma crisis or exacerbation of chronic obstructive pulmonary disease
(COPD) in the patient presenting with tachycardia, subcutaneous emphysema, dyspnea, and
shock.
Traumatic pneumothorax
Always consider pneumothorax in the differential diagnosis of major trauma. In the patient with
blunt trauma and mental status changes, hypoxia, and acidosis, symptoms of a tension
pneumothorax may be masked by associated and similarly potentially lethal injuries.
When assessing the trauma patient, be aware that clinical presentations of tension pneumothorax
and cardiac tamponade may be similar.
Tension pneumothorax
The diagnosis of a tension pneumothorax should largely be made based on the history and
physical examination findings. Ultrasonography in the emergency setting is being increasingly
used as an adjunct to the physical examination when there is doubt regarding the diagnosis.
Chest radiography or CT scanning should be used only in those instances when the clinician is in
doubt regarding the diagnosis and when the patient's clinical condition is hemodynamically
stable. Obtaining such imaging studies when the diagnosis of tension pneumothorax is not in
question causes an unnecessary and potentially lethal delay in treatment.
A tension pneumothorax is a life-threatening condition and requires immediate action (eg, needle
thoracostomy or chest tube insertion). However, the clinician should be wary of prematurely
diagnosing a tension pneumothorax in a patient without respiratory distress, hypoxia,
hypotension, or cardiopulmonary compromise. If the patient's clinical presentation is
questionable and if the patient appears stable, the clinician should reexamine the patient and use
bedside ultrasonography or request immediate portable chest radiography (or reexamine the
chest radiographs if they have already been obtained) to confirm the diagnosis.
A high index of suspicion for tension pneumothorax is recommended in patients on mechanical
ventilation with acute onset of hemodynamic instability, difficult ventilation with high
inspiratory pressures, and worsening hypoxemia and/or hypercapnia, even with a functioning
chest tube in place. Patients at greatest risk of a pneumothorax and/or tension pneumothorax
include those with COPD who are using ventilators; those with acute respiratory distress
syndrome (ARDS); and those receiving a tidal volume greater than 12 mL/kg, a peak airway
pressure greater than 60 cm H2 O, or a positive end-expiratory pressure greater than 15 cm H2 O.
Portable chest radiograph may fail to show the pneumothorax; CT scanning may be required for
diagnosis.
Avoid assuming that a patient with a chest tube does not have a tension pneumothorax if he or
she has respiratory or hemodynamic instability. Chest tubes can become plugged or
malpositioned and cease to function. In addition, improper attachment of a 1-way valve to the
chest tube may produce tension pneumothorax.
Other conditions to consider include the following:
Asthma
Costochondritis
Diaphragmatic Injuries
Esophageal Spasm
Mediastinitis
Myocardial Ischemia
Myocarditis
Pericarditis
Pleurodynia
Tuberculosis
Differential Diagnoses
Acute Pericarditis
Heart Failure
Myocardial Infarction
Pulmonary Embolism
Rib Fracture
Approach Considerations
includes watchful waiting with or without supplemental oxygen, simple aspiration, tube drainage
with or without medical pleurodesis, vacuum-assisted thoracostomy (VATS) with pleurodesis
and/or closure of leaks and bullectomy, and open surgical procedures such as thoracotomy for
pleurectomy or pleurodesis.
Selection between the various management options requires an understanding of the natural
history of pneumothorax, the risk of recurrent pneumothorax, and the benefits and limitations of
each treatment option and discussion with the patient.
See also Restoring an Air-Free Pleural Space in Pneumothorax.
Pharmacotherapy
Medication may be necessary to treat a pulmonary disorder that causes the pneumothorax. For
example, intravenous antibiotics are included in the treatment of a pneumothorax that developed
as a sequela of staphylococcal pneumonia. In addition, studies suggest that the administration of
prophylactic antibiotics during chest tube insertion may reduce the incidence of complications
such as emphysema. Clearly, the use of analgesics can provide patient comfort until the
thoracostomy tube is removed. Some authors advocate the use of intercostal nerve blocks to
increase patient comfort and decrease the need for narcotic analgesics.
In patients with repeated pneumothoraces who are not good candidates for surgery, sclerotherapy
with talc or doxycycline may be necessary.
Patient presentation
The following are possible presentations of patients with pneumothorax:
Asymptomatic (incidental finding): Treatment decisions are guided by estimate of longterm recurrence risk.
Clinically fragile: Treatment is guided by local practice patterns for air evacuation and
observation. Comorbid conditions may preclude observation because of decreased
cardiopulmonary reserve.
Likelihood of resolution
The likelihood of a pneumothorax resolving is classified as follows:
Will not resolve, could be fatal: Tension pneumothorax; unrecognized air leak
Likelihood of recurrence
The following categories of pneumothorax recurrence likelihood should be assessed:
May recur and the patient may be clinically unstable, but emergency care is readily
accessible
Outpatient care: This can occur in asymptomatic patients or those with a small
pneumothorax and reliable follow-up.
Emergency department (ED) care: Prolonged periods of observation are inefficient and
clinically suboptimal; efficacy studies of manual aspiration and placement of 1-way
valves performed in EDs are an attempt to address these practical issues.
Inpatient care: This site of care is generally selected when high-flow oxygen is needed,
the pneumothorax is larger but the patient is stable, or comorbidities increase concern
about risk or follow-up. The average hospital stay is 2.8 days.
Intensive care unit (ICU): ICU treatment and observation is appropriate for patients who
are unstable or intubated.
Interval of observation
No protocols regarding serial radiography or imaging exist; the clinician typically reviews serial
vital signs and clinical assessments, using the direction and rate of change in the patients clinical
status to select imaging frequency. Monitoring pneumothorax size during this time is important,
as follows:
At 1 month: Full lung reexpansion can occur, on average, 3 weeks after the initial event.
Several options are available to restore an air-free pleural space, including observation
without oxygen, administering supplemental oxygen, simple aspiration, chest tube
placement, 1-way valve insertion, and thoracostomy with continuous suction.
(See the video of chest tube insertion, below.)
Insertion of chest tube. Video courtesy of Therese Canares, MD, and Jonathan Valente,
MD, Rhode Island Hospital, Brown University.
Contou et al recommend that clinicians consider drainage via a small-bore catheter as a
first-line treatment for pneumothorax of any cause. The authors found that drainage via
catheter or via chest tube is similarly effective for the management for the management
Supplemental oxygen
Oxygen administration at 3 L/min nasal canula or higher flow treats possible hypoxemia
and is associated with a 4-fold increase in the rate of pleural air absorption compared
with room air alone.
Simple aspiration
A tube inserted into the pleural space is connected to a device with 1-way flow for air
removal. Examples of such devices are Heimlich valves or water seal canisters, and tubes
connected to wall suction devices.
The typical goal of inserting 1-way valve systems is to avoid hospital admission and still
treat the spontaneous pneumothorax. One-way valves may also expedite hospital
discharge and be used during transport of an injured patient.
A Heimlich valve is a 1-way, rubber flutter valve that allows for complete evacuation of
air that is not under tension. The proximal end attaches to the chest tube or catheter, and
the distal end connects to a suction device or is left open to the atmosphere.
Heimlich valves do not require suction and thus eliminate the chance of a tension
pneumothorax; they also allow greater mobility and less discomfort for the patient. By
decreasing the length of the hospital stay and allowing for outpatient care, medical costs
are reduced as well.
In a pilot study, Marquette et al determined that using a serial-steps approach with a
single system (small-caliber catheter/Heimlich valve) in patients with a first episode of
PSP was as effective as simple manual needle aspiration or a conventional chest tube
thoracotomy.[61] In 41 thin, young, smoking males, a 1-way Heimlich valve was connected
to the catheter, allowing the air to flow spontaneously outward for 24-48 hours;
thereafter, if the lung failed to re-expand, wall suction was applied. Patients with an air
leak persisting for more than 4 days were referred for surgery.
At 24 hours, the success rate was 61%, and at 1 week, it had risen to 85%; the actuarial 1year recurrence rate was 24%.[61] When 24-hour and 1-week success rates and recurrence
at 12 months were taken as end points, the method described above was effective as
simple manual needle aspiration or a conventional chest tube thoracotomy.[61]
Heimlich valves are widely used in the care of patients with acquired immunodeficiency
syndrome (AIDS) who have a median length of 20 days of chest tube placement to
facilitate care and mobility.
Prehospital Care
Assess the ABCs (airway, breathing, circulation), and evaluate the possibility of a tension
pneumothorax. Assess the vital signs, and perform pulse oximetry. A tension pneumothorax is
almost always associated with hypotension.
Administer oxygen to the patient, ventilate the patient, and establish an intravenous (IV) line.
Tension pneumothorax
Failure of the emergency medical service personnel (EMS) and medical control physician to
make a correct diagnosis of tension pneumothorax and to promptly perform needle
decompression in the prehospital setting can result in rapid clinical deterioration and cardiac
arrest. Most paramedics are trained and protocolized to perform needle decompression for
immediate relief of a tension pneumothorax.
However, if an incorrect diagnosis of tension pneumothorax is made in the prehospital setting,
the patient's life may be endangered by unnecessary invasive procedures. Close cooperation and
accurate communication between the emergency department (ED) and the EMS personnel is of
paramount importance.
To prevent reentry of air into the pleural cavity after needle thoracostomy and decompression in
the prehospital setting, a 1-way valve should be attached to the distal end of the Angiocath. If
available, a Heimlich valve may be used. If a commercially prepared valve is not available,
attach a finger condom or the finger of a rubber glove with its tip removed to serve as a
makeshift 1-way valve device.
Clothing covering a wound that communicates with the chest cavity can play a role in producing
a 1-way valve effect, allowing air to enter the pleural cavity but hindering its exit. Removing
such clothing items from the wound may facilitate decompression of a tension pneumothorax.
A tension pneumothorax is a contraindication to the use of military antishock trousers.
Prehospital ultrasonography
In a preliminary 2006 study from Norway, Busch evaluated the feasibility of using portable
ultrasound in an air rescue setting, concluding that prehospital ultrasonography could provide
diagnostic and therapeutic benefit when conducted by a proficient examiner who used goaldirected and time-sensitive protocols.[43] Further study in this area may help to determine the
indications and role of prehospital ultrasonography.
Hospital Management
Immediate attention to the ABCs (airway, breathing, circulation) while assessing vital signs and
oxygen saturation is paramount, particularly in patients with thoracic trauma. Evaluate the
patency of the airway and the adequacy of the ventilatory effort. Assess the circulatory status and
the integrity of the chest wall. Carefully evaluate the cardiovascular system, because a tension
pneumothorax and pericardial tamponade can cause similar findings.
Emergency department (ED) care depends on the hemodynamic stability of the patient. All
patients should receive supplemental oxygen to increase oxygen saturation and to enhance the
reabsorption of free air.
Note that ultrasonography is the only radiographic modality that allows patients with
nonarrhythmogenic cardiac arrest to continue undergoing resuscitation while clinicians search
for easily reversible causes of asystole or pulseless electrical activity (PEA).[62] A protocol (using
the acronym CAUSE for cardiac arrest ultrasound exam) in which cardiac arrest patients,
concurrent with resuscitation, receive bedside ultrasonography to look for cardiac tamponade,
massive pulmonary embolus, severe hypovolemia, and tension pneumothorax has been proposed
for further investigation. It is possible that the eventual adoption of ultrasonography in this
setting may allow increased "real-time" diagnostic acumen, decreasing the time required to
receive appropriate condition-related therapy.
Primary and secondary spontaneous pneumothorax
If the primary spontaneous pneumothorax (PSP) is smaller than 15% (or estimated as small) (see
Estimating the size of the pneumothorax under Chest Radiography), and the patient is
symptomatic but hemodynamically stable, needle aspiration is the treatment of choice.
If the PSP is smaller than 15% and if the patient is asymptomatic, many consider observation to
be the treatment of choice. (If the patient is admitted, administer oxygen, as this has been shown
to speed resolution of the pneumothorax.)
If the PSP is greater than 15% (or estimated as large) aspiration using a pigtail catheter left to
low suction or water seal is recommended. Strong suction should not be used with a spontaneous
pneumothorax because of an often-delayed presentation and, thus, an increased risk of
reexpansion pulmonary edema (see Complications).
Spontaneous pneumothorax is a life-threatening condition in patients with severe underlying
lung disease; thus, tube thoracostomy is the procedure of choice in secondary spontaneous
pneumothorax (SSP).
Pleurodesis decreases the risk of recurrence, as does thoracotomy or video-assisted thoracoscopy
(VAT) to excise the bullae.
Iatrogenic and traumatic pneumothorax
leakage. After air leaks have ceased for 24 hours, the vacuum may be decreased and the chest
tube removed.
The process of lung reexpansion and healing is not immediate and may be complicated by
pulmonary edema; therefore, a chest tube is usually left in place until the clinical conditions are
met; any complications warrant longer placement.
A subset of patients who have a small (< 15-20%), minimally symptomatic pneumothorax may
be admitted, observed closely, and monitored by using serial chest radiographs. In these patients,
administration of 100% oxygen promotes resolution by speeding the absorption of gas from the
pleural cavity into the pulmonary vasculature.
Although commonly used, few data exist in the medical literature showing the efficacy of the
procedure or reviewing the field-use and incidence of the needle decompression.
Tension pneumothorax
and all placed the thoracentesis needle medial to the midclavicular line.[62] In the same study, 8%
of participants inappropriately identified the site used for needle pericardiocentesis and 4%
inappropriately identified the fifth intercostal space in the anterior axillary line.[62]
A 2011 study by Sanchez et all suggests the anterior approach is typically more successful than
the lateral approach when it comes to angiocatheters, although the anterior approach is not
failsafe. Further, longer angiocatheters may increase the chances of decompression, but the risk
of damage to surrounding vital structures is higher.[65]
Related to the development of apparent life-threatening hemorrhage after decompression in the
second intercostal space at the anterior, midclavicular line in patients with no initial evidence of
hemothorax on presentation, it has been suggested that a potentially safer option is to
decompress a pneumothorax in the fifth intercostal space at the anterior axillary line, similar to
recommendations for chest drain insertion.
If a hemothorax is associated with the pneumothorax, additional chest tubes may be needed to
assist drainage of blood and clots. If the hemopneumothorax requires insertion of a second chest
tube, the second tube should be directed inferiorly and should be posterior to the apex of the
diaphragm.
Another point to take note of is that a significant number of patients have a larger chest wall than
can be penetrated by a catheter length of 5 cm. In particular, men undergoing treatment for
tension pneumothorax are more likely to have a larger body habitus with wider chest wall, such
that performing needle thoracostomy may need a catheter longer than 5 cm to reliably penetrate
into the pleural space.
In one study, a catheter length of patients at an American level 1 trauma center showed that a
catheter length of 5 cm would reliably penetrate the pleural space in only 75% of patients.[66] A
2008 study analyzing average chest wall thickness at the second intercostal space in the
midclavicular line concluded that a 4.5-cm catheter length may not penetrate the chest wall in
approximately 10-35% of trauma patients, depending on age and sex.[67]
Catamenial pneumothorax
Oral contraceptives carry a high success rate in the treatment of catamenial pneumothorax,
although this condition may also (rarely) be treated surgically. Most cases present during or
shortly after menses, and the spontaneous pneumothorax is usually right-sided.
Pneumomediastinum
Most patients with pneumomediastinum should be observed for signs of serious complications
(eg, pneumothorax, tension pneumothorax, mediastinitis). If the pneumomediastinum occurred
from the inhalation of cocaine or smoking of marijuana, observation in the ED for progression
may be indicated.
A follow-up chest radiograph should be obtained in 12-24 hours to detect any progression or
complication, such as pneumothorax. If no progression occurs at 24 hours and if no evidence of
mediastinitis exists, the patient may be discharged.
Contralateral pneumothorax
Bilateral pneumothorax
Unacceptable risk of recurrent pneumothorax for patients with plans for extended stays at
remote sites
Thoracotomy
While thoracotomy is the criterion standard, video-assisted thoracoscopic surgery (VATS) has
been replacing thoracotomy in the treatment of chronic or persisting pneumothoraces due to the
aforementioned reasons. Recurrence rates with thoracotomy are as low as 4%.[70]
Talc is the preferred agent for pleurodesis. It can be administered by insufflation or as a slurry.
Insufflation of talc and thoracotomy has a recurrence rate of 0-7%.
Complications
Hemopneumothorax
Bronchopulmonary fistula
Empyema
Pneumomediastinum
Pneumopericardium
Pneumoperitoneum
Pyopneumothorax
Tension pneumothorax
A worsening pneumothorax, usually with a 1-way valve phenomenon, can allow air into the
intrapleural space and prevent its escape, causing mediastinal shift, pulmonary shunting, and
circulatory collapse.
Treatment of tension pneumothorax is emergent and should be performed before confirmatory
radiologic studies. Needle decompression is performed before definitive treatment with tube
thoracostomy (see Tension pneumothorax under Hospital Management).
In mechanically ventilated patients, high pressures and air trapping place patients at risk for
tension pneumothorax if the thoracostomy is not functioning. Patients with smaller
pneumothoraces that would otherwise be managed with aspiration or observation sometimes
undergo thoracostomy because of the need for mechanical ventilation.