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Key Features

Essentials of Diagnosis

  • Acute onset of unilateral chest pain and dyspnea

  • Minimal physical findings in mild cases

  • Tension pneumothorax

    • Unilateral chest expansion

    • Decreased tactile fremitus

    • Hyperresonance

    • Diminished breath sounds

    • Mediastinal shift

    • Cyanosis

    • Hypotension

  • Pleural air on chest radiograph

General Considerations

  • Spontaneous pneumothorax occurs without trauma and is classified as

    • Secondary—complicating preexisting lung disease

    • Primary—no prior lung disease

  • Traumatic pneumothorax occurs as a result of penetrating or blunt trauma

  • Iatrogenic pneumothorax may follow procedures such as central line placement and transbronchial biopsy

  • Risk factors for secondary pneumothorax include

    • Chronic obstructive pulmonary disease (COPD)

    • Asthma

    • Cystic fibrosis

    • Tuberculosis

    • Prior Pneumocystis pneumonia

    • Menstruation (catemenial pneumothorax)

    • Many interstitial lung diseases

  • Tension pneumothorax usually occurs in the setting of

    • Penetrating trauma

    • Lung infection

    • Cardiopulmonary resuscitation

    • Positive pressure ventilation


  • Primary pneumothorax affects mainly tall, thin males between 10 and 30 years of age

  • Family history and smoking may be contributing factors in primary spontaneous pneumothorax

Clinical Findings

Symptoms and Signs

  • Chest pain ranges from minimal to severe

  • Dyspnea is almost always present

  • Symptoms usually begin at rest and resolve within 24 hours, even if the pneumothorax persists

  • In the setting of COPD or asthma, patients may present with life-threatening respiratory failure

  • Often seen with large pneumothoraces

    • Unilateral chest expansion

    • Hyperresonance

    • Diminished breath sounds

    • Decreased tactile fremitus

    • Decreased movement of the chest

  • Physical findings may be absent in small (< 15%) pneumothoraces

  • Tension pneumothorax should be suspected if marked tachycardia, mediastinal or tracheal shift, or hypotension is present

  • Crepitus may be found over the chest wall and adjacent structures

Differential Diagnosis

  • Emphysematous bleb mimicking loculated pneumothorax

  • Myocardial infarction

  • Pneumonia

  • Pulmonary embolism

  • Pneumomediastinum caused by rupture of the esophagus or bronchus

  • Upper respiratory tract infection

  • Rib fracture

  • Pericarditis

  • Mesothelioma


Laboratory Tests

  • Arterial blood gas usually reveals hypoxemia and acute respiratory alkalosis

  • Electrocardiogram: QRS axis and precordial T-wave changes may mimic acute myocardial infarction in left-sided pneumothorax

Imaging Studies

  • A visceral pleural line on chest radiograph is diagnostic; an expiratory film will increase sensitivity

  • Secondary pleural effusion can occur

  • Supine patients may demonstrate the "deep sulcus sign"—an abnormally radiolucent costophrenic angle

  • Large amounts of subpleural air with contralateral mediastinal shift are present in tension pneumothorax



  • Symptomatic treatment for cough and chest pain is appropriate

  • Supplemental oxygen may increase the rate of reabsorption of pleural air

  • Reliable patients with small (< 15%) primary pneumothoraces may be observed


  • Simple aspiration of pleural air through a small-bore catheter can be performed for large or progressive pneumothoraces

  • Placement of a small-bore chest tube (7F–14F) attached to a ...

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