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Pneumothorax

Pneumothorax refers to a condition in which there is air in the pleural cavity. The pleural cavity is a very thin space between the visceral and parietal pleura of the lungs that usually contains minimal fluid. This abnormal air impairs normal ventilation and oxygenation giving a myriad of symptoms seen in pneumothorax.


Presentation

Very common presentations are sudden chest pain and shortness of breath. The pain is often said to be stabbing, radiates to the ipsilateral shoulder and is worse on inspiration. In primary spontaneous pneumothorax, there is usually resolution in the first 24 hours although it might take up to 12 weeks to resolve. Other symptoms of pneumothorax are cough, anxiety and general feeling of malaise. Hypoxia and hypotension are characteristic of tension pneumothorax.

Physical signs include respiratory distress, tachypnea, absent breath sounds, decreased tactile fremitus, tachycardia, hypotension, pulsus paradoxus and jugular venous distension [7].

Tall Stature
  • statur e ) (e.g., in Marfan syndrome ) Smoking : 90% of cases ; up to 20-fold increase in risk (risk increases with cumulative number of cigarettes smoked) Homocystinuria Secondary (pneumothorax as a complication of underlying lung disease) Catamenial[amboss.com]
  • Tall stature and low body mass index are also associated with higher rates of PSP. It is hypothesised that the RB develops in smokers and leads to the development of ELC in patients predisposed to this process.[web.archive.org]
Dyspnea
  • We present a case of trapped lung caused by a pneumothorax that occurred some 14 years before the patient presented to our hospital with a complaint of incapacitating dyspnea.[ncbi.nlm.nih.gov]
  • However, unusual symptoms and signs, such as dyspnea and subcutaneous emphysema, which are less likely to be related with complicating colonoscopy, may obscure correct clinical diagnosis.[ncbi.nlm.nih.gov]
  • We describe a 36-year-old patient who was admitted to the emergency ward for acute dyspnea due to a spontaneous pneumothorax.[ncbi.nlm.nih.gov]
  • Presentation is variable and may range from no symptoms to severe dyspnea with tachycardia and hypotension.[radiopaedia.org]
Tracheal Deviation
  • Note the tracheal deviation to the left. Prognosis If the pneumothorax was an isolated event and treatment was initiated early, the prognosis is excellent.[emedicine.medscape.com]
  • deviation Hyper-resonance to percussion Decreased breath sounds In tension pneumothorax: Raised JVP, pulsus paradoxus, marked tracheal deviation, Tachycardia 135, hypotension, distended neck veins Differential diagnosis of a pneumothorax Pleural effusion[oxfordmedicaleducation.com]
  • CXR FINDINGS Supine Hyperlucency in anteromedial and subpulmonic recesses Visualisation of visceral pleural Deep sulcus sign Tension (radiological) increased volume of hemithorax depressed hemidiaphragm tracheal deviation MANAGEMENT tension: decompress[lifeinthefastlane.com]
  • deviation (usually in tension pneumothoraces) decreased or absent tactile fremitus Evaluation CXR diagnostic gold standard best observed in upright, end-expiration films will show collapsed lung may show broken ribs or other signs of associated trauma[step2.medbullets.com]
Hyperresonance
  • […] penetrating trauma non- penetrating trauma blunt trauma is most common cause severe coughing can also cause Presentation Symptoms sudden-onset, unilateral, pleuritic chest pain dyspnea acute respiratory distress Physical exam decreased or absent breath sounds hyperresonance[step2.medbullets.com]
  • […] symptoms (e.g. general malaise, fatigue) are less commonly observed Signs General appearances may be normal Sweating, tachypnoea, tachycardia (most common finding) Splinting of the chest wall to relieve pleuritic pain Decreased or absent breath sounds Hyperresonance[rch.org.au]
  • Patients with pneumothorax present with sudden-onset dyspnea , ipsilateral chest pain , diminished breath sounds, and hyperresonant percussion on the affected side.[amboss.com]
  • Physical findings classically consist of absent tactile fremitus, hyperresonance to percussion, and decreased breath sounds on the affected side.[merckmanuals.com]
  • Physical exam findings for a pneumothorax are unequal breath sounds, hyperresonance with percussion over the chest wall, and decreased wall movement on the affected side of the chest.[cdemcurriculum.com]
Tachypnea
  • Vital signs frequently demonstrate tachycardia, tachypnea and, depending on the severity, hypoxia and hypotension.[cdemcurriculum.com]
  • Physical signs include respiratory distress, tachypnea, absent breath sounds, decreased tactile fremitus, tachycardia, hypotension, pulsus paradoxus and jugular venous distension.[symptoma.com]
  • The clinician will know a patient has tension pneumothorax if the patient has progressive, unexplained hypotension, tachycardia, hypoxia and/or tachypnea in the setting of a physical examination with unilateral decreased breath sounds, distended neck[clinicaladvisor.com]
  • […] situations such as ventilation, resuscitation, trauma, or in people with lung disease.The most common findings in people with tension pneumothorax are chest pain and respiratory distress, often with an increased heart rate (tachycardia) and rapid breathing (tachypnea[en.wikipedia.org]
  • Patients with a pneumothorax, regardless of type, will present with respiratory distress, including dyspnea and tachypnea, and tachycardia. They may also have decreased or absent breath sounds on the side of the chest with a pneumothorax.[web.archive.org]
Pleuritic Pain
  • pain Decreased or absent breath sounds Hyperresonance on percussion Asymmetric lung expansion, mediastinal and tracheal shift with large pneumothorax Signs of tension pneumothorax Deviation of the trachea to the contralateral side, tachycardia, hypotension[rch.org.au]
  • Chest pain : a pleuritic pain may give a sensation of breathlessness. Examples include pleurodynia and Bornholm disease. Pulmonary embolism may produce haemoptysis and a few rales over the affected area.[patient.info]
Chest Pain
  • Shortly thereafter, she was admitted to the hospital with chest pain and required chest drain insertion.[ncbi.nlm.nih.gov]
  • The patient visited our department with chest pain and was diagnosed with left pneumothorax based on a chest X-ray. Thoracic computed tomography (CT) showed multiple cysts in both lungs.[ncbi.nlm.nih.gov]
  • Patients with this condition usually present with chest pain and dyspnoea, and the presentation can mimic acute coronary syndrome. We present a case of a woman aged 58 years who presented with progressive dyspnoea and cough.[ncbi.nlm.nih.gov]
  • When to Seek Medical Care for a Collapsed Lung A doctor should be seen after any symptoms of chest pain are experienced, because of the possibility of other equally or more serious causes of chest pain.[emedicinehealth.com]
Cyanosis
  • In tension pneumothorax, patients are distressed with rapid laboured respirations, cyanosis, profuse diaphoresis, and tachycardia.[bestpractice.bmj.com]
  • Decreased or absent breath sounds Hyperresonance on percussion Asymmetric lung expansion, mediastinal and tracheal shift with large pneumothorax Signs of tension pneumothorax Deviation of the trachea to the contralateral side, tachycardia, hypotension, cyanosis[rch.org.au]
  • Tension pneumothorax is more likely in this group Intubation and ventilation Especially with high pressures used Presentation of a pneumothorax Pleuritic chest pain and shortness of breath (but note may be asymptomatic) Signs: Tachycardia and tachypnoea Cyanosis[oxfordmedicaleducation.com]
  • Cyanosis or blueness of the skin will occur as the tissues lose their oxygen. Decreased levels of consciousness may occur because of the low blood pressure , decreased brain perfusion, and low oxygenation.[emedicinehealth.com]
Decompression Sickness
  • An additional problem in these cases is that those with other features of decompression sickness are typically treated in a diving chamber with hyperbaric therapy; this can lead to a small pneumothorax rapidly enlarging and causing features of tension[en.wikipedia.org]
Shoulder Pain
  • Common symptoms of a collapsed lung include: Sharp chest or shoulder pain, made worse by a deep breath or a cough Shortness of breath Nasal flaring (from shortness of breath) A larger pneumothorax causes more severe symptoms, including: Bluish color of[nlm.nih.gov]
  • Symptoms Common symptoms of a collapsed lung include: Sharp chest or shoulder pain, made worse by a deep breath or a cough Shortness of breath Nasal flaring (from shortness of breath) A larger pneumothorax causes more severe symptoms, including: Bluish[mountsinai.org]
  • […] pleura usually do not separate from each other in obstructive atelectasis Pathophysiology Either from disruption of visceral pleura Or, trauma to parietal pleura Clinical findings Acute onset of Pleuritic chest pain Dyspnea (in 80-90%) Cough Back or shoulder[learningradiology.com]
Facial Swelling
  • CASE REPORT: A 75-year-old woman and a 65-year-old man presented with dyspnea, and facial swelling and abdominal pain, respectively. In the first case, symptoms occurred during polypectomy, whereas they occurred after polypectomy in the second case.[ncbi.nlm.nih.gov]

Workup

The mainstay in diagnosis of pneumothorax remains a thorough history and physical examination. In the case of tension pneumothorax, valuable time could be wasted if treatment is not instituted immediately the clinical diagnosis is made. However, investigations still have a role to play in determining the extent of the damage and the extent of the effect of the pneumothorax.

Investigations that may be carried out include blood tests to determine the degree of cardiopulmonary compromise. A chest radiograph would also be done to evaluate the extent of the condition and the effect on the mediastinum [8]. CT scan is the best imaging modality for use in pneumothorax but it is not routinely used. Ultrasound scan is also very useful when employed by a skilled sonologist.

Atelectasis
  • There is no air in the pleural space normally The introduction of air into the pleural space separates the visceral from the parietal pleura In contradistinction, the visceral and parietal pleura usually do not separate from each other in obstructive atelectasis[learningradiology.com]
  • These two conditions are known as pneumothorax and atelectasis. Commonly Confused Terms Let's face it. We all sometimes use an inappropriate word, like 'they're' instead of 'their,' by accident.[study.com]
  • The clinical term is atelectasis. This answer is based on source information from the National Cancer Institute. See All 3 Answers 2 Answers A For a small pneumothorax, no treatment may be needed as it will repair on its own.[sharecare.com]
  • Many things can cause atelectasis. Depending on the cause, atelectasis is categorized as either obstructive or nonobstructive. Causes of obstructive atelectasis Obstructive atelectasis happens when a blockage develops in one of your airways.[healthline.com]
  • Things that may cause false positives, especially in non-trauma, critically ill patients: Dyspnea causes interference above the pleural line Single lung intubation, or esophageal intubation can lead to secondary atelectasis Lung and pleura adhering together[rebelem.com]
Pneumothorax on Chest X-Ray
  • Diagnosis of pneumothorax A chest x-ray is used to diagnose a pneumothorax, though a CT scan is sometimes used.[healthdirect.gov.au]
  • While clinical signs and obvious things, like gaping holes in someone's chest, are clues to a pneumothorax, a chest X-ray (radiograph) should be taken as well.[study.com]
  • A chest x-ray should be ordered early in the evaluation of a patient with a suspected pneumothorax. If the patient is unstable, however, and a tension pneumothorax is suspected, proceed directly to treatment without waiting for the radiograph.[cdemcurriculum.com]
  • No lab values are of use in the diagnosis of tension pneumothorax. A chest x-ray will be diagnostic and will show collapse of the lung with contralateral deviation of the mediastinum.[clinicaladvisor.com]
  • There is hyperresonance (higher pitched sounds than normal) with percussion of the chest wall which is suggestive of pneumothorax diagnosis. Chest x- rays will then be used to confirm the diagnosis of the pneumothorax.[physio-pedia.com]

Treatment

The goal of treatment is to restore lung volume, get air out of the pleural space and to prevent recurrence. Procedures like simple aspiration, insertion of chest tube, insertion of a 1-way valve and thoracostomy with continuous suction will help to restore an air-free pleural space. Other procedures like video assisted thoracoscopic surgery and thoracotomy could be performed for pleurodesis or pleurectomy [9].

Drugs also have a role to play in pneumothorax caused by an underlying medical condition. Analgesics are used to relieve pain, benzodiazepines provide conscious sedation and antibiotics are used to reduce the risk of infection after a surgical procedure.

Prognosis

In patients who have uncomplicated pneumothorax, complete resolution occurs within 10 days. Primary spontaneous pneumothorax is usually benign and requires no medical intervention. Recurrence however occurs between 6 months to 3 years of the incident. It has a 5-year recurrence rate of 28 to 32% while the secondary type has a 5-year recurrence rate of 43%. Recurrence is commoner in smokers, patients with chronic obstructive pulmonary disease (COPD) and patients with AIDS. Deaths have been recorded in patients with the relatively benign primary spontaneous pneumothorax while the secondary type has a mortality rate of up to 17%. Tension pneumothorax is a rapidly evolving entity that quickly leads to death if intervention is not swift [6].

Etiology

During inflation of the lungs, there is negative pressure in the pleural space. When air enters this space, it causes an increase in pressure, leading to a collapse of the lung. One of the major causes of this is trauma which could be either be due to accidents or could be iatrogenic. Other causes are ruptured blebs. Blebs are air blisters which are found on the surface of the lungs, they are harmless if the remain intact. It could also be caused by a chronic lung disease like cystic fibrosis [2].

Epidemiology

The epidemiology is largely dependent on the type of pneumothorax. The primary spontaneous pneumothorax is more common in young adults between the ages of 20 years to 30 years, while the secondary type is more common in people aged between 60 years and 65 years. They are both commoner in men than in women and there is no recorded racial predilection. Smoking is also said to increase the risk of the secondary type spontaneous pneumothorax.

Iatrogenic pneumothorax occurs in 5 to 7 in every 100,000 hospital admissions largely due to the increased use of mechanical ventilation. A rare type, catamenial pneumothorax is seen only in women and occurs within 3 days after menstruation starts [3].

Sex distribution
Age distribution

Pathophysiology

The pathophysiology varies with the cause of the pneumothorax. In spontaneuos pneumothorax, gas invades the pleural space usually from a ruptured bleb. This causes an increase in the pressure within the pleural space, so the lungs collapses within itself until the rupture is closed or equilibrium is reached. This reduces the size of the lungs equivalent to the amount of gas decreasing the vital capacity of the lung and reducing the partial pressure of oxygen [4].

Tension pneumothorax results as a consequence of disruption in the visceral or parietal pleura or the tracheobronchial tree. The injured tissue forms a one way valve so that there is inflow of air during inspiration but no outflow. The volume increases with each inspiratory movement and the pressure within the hemithorax builds. The affected lung then collapses and continued increase in pressure pushes the mediastinum to the opposite side. This shift impinges on the contralateral lung and also impairs venous return to the right atrium. The combination of the effects of the collapsed lung and the compressed one leads to hypoxia, which ultimately impairs cardiac function. This condition can rapidly progress to death if intervention is delayed [5].

Prevention

Smoking is a recognized risk factor, so avoiding cigarettes reduce the risk of developing a pneumothorax. Other medical preventive measures are geared towards reducing the risk of recurrence.

Summary

Individuals with pneumothorax usually have a collapse of the lung on the affected side. The degree of collapse usually determines the clinical consequence. Also, symptoms are dependent on the type of pneumothorax [1].

Patient Information

  • Definition: Pneumothorax is a condition that results from air entering the pleural space which causes the lung to collapse and this will affect breathing and heart function. It is a fairly common condition.
  • Cause: A number of risk factors are associated with this condition including smoking, chronic lung diseases, pregnancy, AIDS, trauma and some medical procedures.
  • Symptoms: The most common symptom is sudden chest pain, this pain feels like a stab and it radiates to the shoulder on the affected side. There is also sudden shortness of breath and you may notice the lips start to turn blue. There might also be cough, patients tend to feel anxious for their lives and have a general feeling of ill health.
  • Diagnosis: This is usually done by examination as a quick identification of the condition is necessary to improve prognosis. Some tests might however be carried out to know the extent of the damage to the lung and heart functions.
  • Treatment: For the milder cases, patients are observed and monitored for signs of worsening. The more severe cases involve the insertion of a chest tube to relieve the air pressure. If this fails, surgeries are carried out to obliterate the pleural space or remove part of the lungs [10].

References

Article

  1. Noppen M, Dekeukeleire T, Hanon S, Stratakos G, Amjadi K, Madsen P. Fluorescein-enhanced autofluorescence thoracoscopy in patients with primary spontaneous pneumothorax and normal subjects.Am J Respir Crit Care Med. Jul 1 2006;174(1):26-30.
  2. Gunji Y, Akiyoshi T, Sato T, Kurihara M, Tominaga S, Takahashi K. Mutations of the Birt Hogg Dube gene in patients with multiple lung cysts and recurrent pneumothorax. J Med Genet. Sep 2007;44(9):588-93.
  3. Feldman AL, Sullivan JT, Passero MA, Lewis DC. Pneumothorax in polysubstance-abusing marijuana and tobacco smokers: three cases. J Subst Abuse. 1993;5(2):183-6. 
  4. Flume PA, Strange C, Ye X, Ebeling M, Hulsey T, Clark LL. Pneumothorax in cystic fibrosis. Chest. Aug 2005;128(2):720-8.
  5. Lee CC, Lee SH, Chang IJ, et al. Spontaneous pneumothorax associated with ankylosing spondylitis.Rheumatology (Oxford). Dec 2005;44(12):1538-41. 
  6. Miller JS, Itani KM, Oza MD, Wall MJ. Gastric rupture with tension pneumoperitoneum: a complication of difficult endotracheal intubation. Ann Emerg Med. Sep 1997;30(3):343-6.
  7. Iannoli ED, Litman RS. Tension pneumothorax during flexible fiberoptic bronchoscopy in a newborn. Anesth Analg. Mar 2002;94(3):512-3; table of contents.
  8. Whale C, Hallam C. Tension pneumothorax related to acupuncture. Acupunct Med. Jun 2004;22(2):101; author reply 101-2.
  9. Hearnshaw SA, Oppong K, Jaques B, Thompson NP. Tension pneumothorax as a complication of colonoscopy. Endoscopy. Feb 2004;36(2):190.
  10. Melton LJ 3rd, Hepper NG, Offord KP. Incidence of spontaneous pneumothorax in Olmsted County, Minnesota: 1950 to 1974. Am Rev Respir Dis. Dec 1979;120(6):1379-82.

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Last updated: 2017-08-09 17:21