Sections View Full Chapter Figures Tables Videos Annotate Full Chapter Figures Tables Videos Supplementary Content + Download Section PDF Listen ++ For further information, see CMDT Part 9-37: Spontaneous Pneumothorax + Key Features Download Section PDF Listen +++ +++ 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 Primary: no prior lung disease Secondary: complicating preexisting lung disease Traumatic pneumothorax occurs as a result of penetrating or blunt trauma Iatrogenic pneumothorax may follow procedures such as Thoracentesis Pleural biopsy Subclavian or internal jugular vein catheter placement Percutaneous lung biopsy Bronchoscopy with transbronchial biopsy Positive-pressure mechanical ventilation 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 +++ Demographics ++ 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 Download Section PDF Listen +++ +++ 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 + Diagnosis Download Section PDF Listen +++ +++ 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 ++ Demonstration on chest radiograph of lucency without lung markings between the chest wall and lung, and visualization of the visceral pleura (a "pleural line") is diagnostic 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 + Treatment Download Section PDF Listen +++ +++ Medications ++ Symptomatic treatment is appropriate for cough and chest pain Supplemental oxygen may increase the rate of reabsorption of pleural air Reliable patients with small (< 15%) primary pneumothoraces may be observed +++ Surgery ++ 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 one-way Heimlich valve protects against development of a tension pneumothorax and may permit observation at home Chest tube placement (tube thoracostomy) may be indicated For secondary, large, or tension pneumothorax For severe symptoms or mechanically ventilated patients Thoracoscopy or open thoracotomy for removal of blebs or pleurodesis may be indicated in recurrent primary pneumothorax or with failed tube thoracostomy +++ Therapeutic Procedures ++ Pleurodesis is indicated in recurrent or refractory cases + Outcome Download Section PDF Listen +++ +++ Follow-Up ++ Serial chest radiographs should be obtained at 24-hour intervals Chest tubes may be removed when the air leak subsides +++ Complications ++ Tension pneumothorax, which may be life-threatening Pneumomediastinum and subcutaneous emphysema +++ Prognosis ++ 50% recurrence rate in smokers 30% risk of recurrence in spontaneous pneumothorax treated with observation or chest tube placement Recurrence after surgical therapy is less common +++ When to Admit ++ Large, severely symptomatic, or progressive primary pneumothorax Secondary pneumothorax +++ Prevention ++ Smokers should be counseled to quit Future exposure to high altitudes, unpressurized flight, and scuba diving should be avoided + References Download Section PDF Listen +++ + +Gil Y et al. Diagnosis and treatment of catamenial pneumothorax: a systematic review. J Minim Invasive Gynecol. 2020 Jan;27(1):48–53. [PubMed: 31401265] + +Imran JB et al. JAMA Patient Page. Pneumothorax. JAMA. 2017 Sep 12;318(10):974. [PubMed: 28898380] + +Novoa NM et al. When to remove a chest tube. Thorac Surg Clin. 2017 Feb;27(1):41–6. [PubMed: 27865326] + +Plojoux J et al. New insights and improved strategies for the management of primary spontaneous pneumothorax. Clin Respir J. 2019 Apr;13(4):195–201. [PubMed: 30615303] + +Pompili C et al. Chest tube management after surgery for pneumothorax. Thorac Surg Clin. 2017 Feb;27(1):25–8. [PubMed: 27865323] + +Thelle A et al. Randomised comparison of needle aspiration and chest tube drainage in spontaneous pneumothorax. Eur Respir J. 2017 Apr 12;49(4). [PubMed: 28404647]