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For further information, see CMDT Part 9-38: Pneumothorax
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Essentials of Diagnosis
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Acute onset of unilateral chest pain and dyspnea
Minimal physical findings in mild cases
Tension pneumothorax
Pleural air on chest radiograph
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General Considerations
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Spontaneous pneumothorax occurs without trauma and is classified as
Traumatic pneumothorax occurs as a result of penetrating or blunt trauma and includes iatrogenic pneumothorax following procedures such as
Thoracentesis
Pleural biopsy
Subclavian or internal jugular vein catheter placement
Percutaneous lung biopsy
Bronchoscopy with transbronchial biopsy
Positive-pressure mechanical ventilation
Secondary pneumothorax occurs as a complication of
Chronic obstructive pulmonary disorder (COPD)
Interstitial lung disease
Asthma
Cystic fibrosis
Tuberculosis
Pneumocystis jirovecii pneumonia
Necrotizing bacterial pneumonia
Menstruation (catamenial pneumothorax)
Cystic lung diseases, including
Lymphangioleiomyomatosis
Tuberous sclerosis
Langerhans cell histiocytosis
Birt-Hogg-Dube syndrome (a hereditary condition with multiple benign skin tumors, lung cysts, and increased risk of both benign and malignant kidney tumors)
Tension pneumothorax usually occurs in the setting of
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Primary pneumothorax is more likely among tall, thin, young (ages < 45 years) individuals, more commonly men
Occurrence of primary spontaneous pneumothorax is correlated with
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Chest pain ranges from minimal to severe
Dyspnea is almost always present
Cough is commonly reported
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
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Differential Diagnosis
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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 primary pneumothorax
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Chest radiography
Demonstration of lucency without lung markings between the chest wall and lung, and visualization of the visceral pleura (a "pleural line") is diagnostic
A characteristic air-fluid level is seen in a few patients with secondary pleural effusion
In supine patients, abnormally radiolucent costophrenic sulcus (the "deep sulcus" sign) may appear
In patients with a tension pneumothorax, there ...