Acute Pneumothorax Evaluation and Treatment


Article Author:
Karima Sajadi-Ernazarova
Jennifer Martin


Article Editor:
Nagendra Gupta


Editors In Chief:
David Wood
Andrew Wilt
Hajira Basit


Managing Editors:
Avais Raja
Orawan Chaigasame
Khalid Alsayouri
Kyle Blair
Radia Jamil
Erin Hughes
Patrick Le
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Hassam Zulfiqar
Navid Mahabadi
Hussain Sajjad
Steve Bhimji
Muhammad Hashmi
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Abbey Smiley
Sarosh Vaqar
Mark Pellegrini
James Hughes
Beenish Sohail
Hajira Basit
Phillip Hynes
Sandeep Sekhon


Updated:
8/12/2019 3:29:38 PM

Introduction

Pneumothorax - is an accumulation of air or gas in the pleural space (the space between visceral and parietal pleura of the chest cavity), which can impair with ventilation, oxygenation, or both. This condition can vary in its presentation from asymptomatic to life-threatening.[1][2]

Pneumothorax can subdivide into three broad categories according to the etiology:

1. Traumatic - resulting from blunt or penetrating chest trauma. Majority of all pneumothoraces are traumatic in origin

2. Iatrogenic - caused by manipulation by a healthcare provider, such as the insertion of central lines, etc

3. Spontaneous - a pneumothorax without any apparent cause or inciting event.

Pneumothorax can also be classified based on their physiology into the following types:

1. Simple - when the air in the pleural space does not communicate with an outside atmosphere, and there is no shift in mediastinum or hemidiaphragm. An example is a pleural laceration from a fractured rib.

2. Communicating - when there is a defect in a chest wall, such as from a gunshot wound, that causes open communication with an outside atmosphere. This loss of the chest wall integrity can create an air sucking and a paradoxical lung collapse, thus causing significant ventilatory problems.

3. Tension - progressive accumulation of air in the pleural cavity causing the shift of mediastinum to the opposite side, resulting in compression of vena cava and other great vessels, decreased diastolic filling, and ultimately compromised cardiac output. It occurs when a chest injury causes a one-valve situation when the air gets into the pleural cavity but is unable to escape freely and thus gets trapped. 

Etiology

Causes:

1. Traumatic - results from blunt or penetrating injuries to the chest wall. 

2. Spontaneous - primary spontaneous pneumothorax occurs in people with no underlying lung disease or inciting event, secondary spontaneous pneumothorax occurs in people with significant underlying parenchymal lung disease and results from some inciting incident, such as a bleb rupture.[3]

3. Iatrogenic - is a subtype of traumatic pneumothorax, where an injury occurs as a result of a diagnostic or therapeutic medical intervention (i.e., insertion of a central line, etc.)

4. Catamenial - is a non-traumatic pneumothorax that occurs in women in conjunction with their menstrual period. Although not entirely understood, the cause is believed to be endometriosis of the pleura.

Epidemiology

The incidence of non-traumatic pneumothorax is 7.4 to 18 per 100000 people per year. [4] It is much higher in smokers (12% vs. 0.1% lifetime risk)[5]

Primary spontaneous pneumothorax often affects young males, tall and thin built, often smokers. The incidence of recurrence is 20 to 60% in the first 3 years after the first episode. 

Secondary spontaneous pneumothoraces also occur in patients with underlying lung disease; thus epidemiology varies greatly. 

Catamenial pneumothorax affects young women of childbearing age. 

History and Physical

The clinical presentation varies depending on the etiology and the size of the pneumothorax. Some patients may be asymptomatic, and pneumothorax is diagnosed as an incidental finding during the workup for another condition. 

The most common presenting symptoms are chest pain and shortness of breath (64 to 85%). Chest pain is usually severe, sharp/stabbing, pleuritic and radiates to ipsilateral shoulder/arm. Symptomatic onset is sudden, and in primary spontaneous pneumothorax can decrease after 24 hours, possibly due to gradual spontaneous resolution of the pneumothorax. Patients can also present with anxiety and cough, but these symptoms are less common. The patient may have a normal physical exam if the pneumothorax is small. However, with large enough pneumothorax, there may be absent breath sounds on the affected side. Many patients with first time spontaneous pneumothorax do not seek medical help for several days.

The signs and symptoms of tension pneumothorax are more severe, and timely diagnosis and treatment are crucial for the patient's survival. Tension pneumothorax, besides chest pain and shortness of breath, presents with hypoxia and hypotension. The gradual accumulation of air in the pleural space due to one-valve situation causes the shift of the mediastinum to the contralateral side and compression of vena cava and eventual compromise of the cardiac output, producing life-threatening hypotension and hypoxia. On physical exam, the patient has absent breath sounds on the affected hemithorax, tracheal deviation to the contralateral side, tachycardia, and jugular venous distention — undiagnosed and untreated tension pneumothorax results in hemodynamic collapse and death. 

Evaluation

Traumatic pneumothorax must be a suspected diagnosis in any blunt or penetrating chest trauma. Adequate history, physical exam and chest X-rays are the mainstays of the diagnosis. However, small pneumothoraces are often missed on physical exam and chest X-ray and may be present on CT chest during a diagnostic workup for other injuries.[6][1]

In patients who present with sudden onset of sharp pleuritic chest pain and shortness of breath, spontaneous pneumothorax should always be on a differential diagnosis list.[3] 

The diagnosis is made by upright chest radiograph, except tension pneumothorax which is a clinical diagnosis. With the recent advent of bedside ultrasonography, the diagnosis of pneumothorax can be made quickly at the bedside in the hands of an experienced operator. 

The definition of large vs. small pneumothorax is by the distance between the lung margin and chest wall[7]:

  • Small pneumothorax: the presence of a visible rim of less than 2 cm between the lung margin and the chest wall
  • Large pneumothorax: the presence of a visible rim of greater than 2 cm between the lung margin and the chest wall

The chest radiograph is thought to underestimate the size of pneumothorax.

Treatment / Management

The management is guided by the etiology, clinical presentation, and risk stratification.[3][6]

The principles of treatment of pneumothorax: air elimination, reduction of air leakage, healing of pleural fistula, promoting re-expansion of the lung, prevention of future recurrences.[8]

Asymptomatic patients with pneumothorax as an incidental finding may not need any intervention unless an estimated risk of recurrence is high. Typically this decision is not made initially in the emergency department, and a patient must obtain a referral to a pulmonologist for further evaluation and care.

Symptomatic patients with stable vital signs may require needle aspiration or small bore catheter insertion (pigtail catheter) in the emergency department. Evidence suggests that in a primary spontaneous pneumothorax needle aspiration is as safe and effective as tube thoracostomy.[9] These patients require admission for high flow oxygen and observation with interval repeat of the chest radiograph. 

Generally, traumatic pneumothoraces with stable or unstable vital signs require the insertion of large vs. small bore thoracostomy catheter. Most of them can be treated with small bore pigtail catheters, although very large pneumothoraces may require treatment with large bore chest tubes.[10] If there is a concomitant hemothorax, a thoracostomy with a large bore chest tube insertion is necessary. 

Pharmacotherapy:

In the treatment of pneumothorax, the pharmacotherapy is mainly focused on an adequate control of pain from the pneumothorax itself and/or from procedures to restore lung volumes and air-free pleural space (thoracostomy or needle aspiration). Pain control is achievable through local infiltration of an anesthetic at the thoracostomy site, as well as intravenous and oral pain medication administration, or both. Typically, a thoracostomy requires IV opiates to manage the pain, since the procedure itself is painful, and indwelling thoracostomy catheter leads to much discomfort to the patient. Some authors advocate for regional anesthesia for these patients, such as intercostal nerve blocks. Prophylactic antibiotics should be considered in patients during the chest tube insertion to prevent infection at the site of insertion and later complications, such as emphysema. 

In patients with recurrent pneumothoraces, chemical pleurodesis, or sclerotherapy with talc may be a treatment consideration.  

Differential Diagnosis

Differential diagnosis of non-traumatic spontaneous pneumothorax includes: pneumonia, acute asthma exacerbation, bronchitis, pulmonary embolism, aortic dissection, costochondritis, acute coronary syndrome, anxiety or panic attack, diaphragmatic injuries, GERD, esophageal spasm, Mallory-Weiss tear, Boerhaave's syndrome, mediastinitis, myocarditis, pericarditis, pleurodynia, tuberculosis, pulmonary empyema, lung abscess.

In traumatic pneumothoraces, tension pneumothorax and concomitant hemothorax must always be considered. There is a high association of other traumatic injuries in the chest and abdomen in patients with traumatic pneumothorax, and an appropriate full trauma workup must be done by ED physicians and trauma surgeons to exclude other injuries.

Prognosis

Spontaneous pneumothorax has a recurrence rate close to 20 to 60% in the next 3 years after the initial episode.[11]

Complications

Misdiagnosis is a frequent complication of pneumothorax. Multiple factors, such as incomplete or inadequate history or physical exam, low index of clinical suspicion, failure to obtain a chest radiograph, or failure to recognize a pneumothorax on a chest radiograph, can contribute to misdiagnosis. Misdiagnosis leads to failure to treat the pneumothorax, and in some cases can lead to devastating consequences such as[8][12][13][14][15][14][13]:

  1. Conversion to tension pneumothorax
  2. Hypoxemic Respiratory Failure
  3. Shock
  4. Respiratory arrest
  5. Cardiac arrest
  6. Empyema
  7. Re-expansion pulmonary edema
  8. Iatrogenic complications from the needle decompression or thoracostomy procedure - the failure of the lung to re-expand, lung laceration, infection of the insertion site and pleural space, laceration of intercostal vessels or internal mammary artery, hemothorax, persistent air leak, damage to the intercostal neurovascular bundle, etc
  9. Chest tube-induced arrhythmia

Enhancing Healthcare Team Outcomes

The management of a pneumothorax is with an interdisciplinary team that includes an emergency department physician, general surgeon, thoracic surgeon, critical care specialist, radiologist, and specialty-trained emergency or critical care nurse. After assisting with chest tube placement, the monitoring of these patients is performed by the nurses. Nurses must assess the wound site, breath sounds, and patency of the drainage system and report to the team any abnormalities. Further, sudden development of a tension pneumothorax can cause a rapid deterioration in a patient's overall clinical status. Hence prompt identification by the nurse followed by treatment by the interprofessional team is essential. The nurse is usually the first to identify the condition and must be prepared to contact the clinical team immediately and then assist in any rapid intervention. It is a prevalent condition with over 5 million patients admitted to the ICUs each year in the United States with pneumothorax. While a chest x-ray remains the standard modality for diagnosing a pneumothorax, numerous enhancements in radiology software have taken place over the last few years enabling easier diagnosis, especially for less experienced practitioners.[16] Having a trained interdisciplinary team managing the evaluation and treatment of a pneumothorax will result in the best outcomes. Lines of communication must be open and rapid. [Level V]


Interested in Participating?

We are looking for contributors to author, edit, and peer review our vast library of review articles and multiple choice questions. In as little as 2-3 hours you can make a significant contribution to your specialty. In return for a small amount of your time, you will receive free access to all content and you will be published as an author or editor in eBooks, apps, online CME/CE activities, and an online Learning Management System for students, teachers, and program directors that allows access to review materials in over 500 specialties.

Improve Content - Become an Author or Editor

This is an academic project designed to provide inexpensive peer-reviewed Apps, eBooks, and very soon an online CME/CE system to help students identify weaknesses and improve knowledge. We would like you to consider being an author or editor. Please click here to learn more. Thank you for you for your interest, the StatPearls Publishing Editorial Team.

Acute Pneumothorax Evaluation and Treatment - Questions

Take a quiz of the questions on this article.

Take Quiz
A 26-year-old male presents to the emergency department complaining of right-sided chest discomfort for the past one day. He elaborates that the pain was sudden in onset and describes it as sharp. He denies any history of trauma. His vital signs include a blood pressure of 110/74 mmHg, a heart rate of 84 beats per minute, a respiratory rate of 18 breaths per minute, a temperature of 98 degrees Fahrenheit, and oxygen saturation of 98% on room air. On physical examination, his chest auscultation reveals diminished breath sounds on the right side. An electrocardiogram is performed and is normal. Further evaluation with a chest x-ray demonstrates an apical pneumothorax on the right. Which of the following would be the next step in management for this patient?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A 17-year-old with a left lung pneumothorax is seen in the emergency department. The physician decides to place a needle in the mid-axillary line and 3rd intercostals rib space. Which of the following is being accessed?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
What condition is associated with Hamman sign?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A trauma victim has fractures of four ribs anteriorly on the right. He also has a small pneumothorax. Diagnostic peritoneal lavage reveals the presence of blood and the patient is booked for a celiotomy. What is the most important step prior to celiotomy?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A 16-year-old male sustains a stab wound to the right chest. He arrives profoundly dyspneic with a respiratory rate of 38 breaths per minute, heart rate of 134 beats per minute, blood pressure of 80/40 mmHg, and oxygen saturation of 80% on room air. Physical examination reveals decreased breath sounds on the side of the injury, crepitus, and soft tissue swelling on the anterior chest wall and neck, but the cardiac examination is unremarkable. He is awake and complains of pain at the wound site. After the patency of the airway is assured, what is the next best step in this patient's management?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
Which of the following is not an absolute indication for a chest tube?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A 35-year-old man is ventilated in the intensive care unit for pneumonia. He suddenly decompensates after a right-sided central venous catheter is inserted in the internal jugular vein. His vital signs include a blood pressure of 60/40 mmHg and oxygen saturation of 82% on 100% oxygen. On further physical examination, the patient has absent breath sounds on the right hemithorax, tracheal deviation to the left, and jugular venous distension. What is the best next step in the management of this patient?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up

Acute Pneumothorax Evaluation and Treatment - References

References

Swierzy M,Helmig M,Ismail M,Rückert J,Walles T,Neudecker J, [Pneumothorax]. Zentralblatt fur Chirurgie. 2014 Sep     [PubMed]
Papagiannis A,Lazaridis G,Zarogoulidis K,Papaiwannou A,Karavergou A,Lampaki S,Baka S,Mpoukovinas I,Karavasilis V,Kioumis I,Pitsiou G,Katsikogiannis N,Tsakiridis K,Rapti A,Trakada G,Karapantzos I,Karapantzou C,Zissimopoulos A,Zarogoulidis P, Pneumothorax: an up to date "introduction". Annals of translational medicine. 2015 Mar     [PubMed]
Baumann MH, Management of spontaneous pneumothorax. Clinics in chest medicine. 2006 Jun     [PubMed]
McKnight CL,Burns B, Pneumothorax . 2018 Jan     [PubMed]
Larson R, Primary spontaneous pneumothorax presenting to a chiropractic clinic as undifferentiated thoracic spine pain: a case report. The Journal of the Canadian Chiropractic Association. 2016 Mar     [PubMed]
Idrees MM,Ingleby AM,Wali SO, Evaluation and management of pneumothorax. Saudi medical journal. 2003 May     [PubMed]
MacDuff A,Arnold A,Harvey J, Management of spontaneous pneumothorax: British Thoracic Society Pleural Disease Guideline 2010. Thorax. 2010 Aug     [PubMed]
Huang Y,Huang H,Li Q,Browning RF,Parrish S,Turner JF Jr,Zarogoulidis K,Kougioumtzi I,Dryllis G,Kioumis I,Pitsiou G,Machairiotis N,Katsikogiannis N,Courcoutsakis N,Madesis A,Diplaris K,Karaiskos T,Zarogoulidis P, Approach of the treatment for pneumothorax. Journal of thoracic disease. 2014 Oct     [PubMed]
Zehtabchi S,Rios CL, Management of emergency department patients with primary spontaneous pneumothorax: needle aspiration or tube thoracostomy? Annals of emergency medicine. 2008 Jan     [PubMed]
Tsai TM,Lin MW,Li YJ,Chang CH,Liao HC,Liu CY,Hsu HH,Chen JS, The Size of Spontaneous Pneumothorax is a Predictor of Unsuccessful Catheter Drainage. Scientific reports. 2017 Mar 15     [PubMed]
Sadikot RT,Greene T,Meadows K,Arnold AG, Recurrence of primary spontaneous pneumothorax. Thorax. 1997 Sep     [PubMed]
Eggeling S, [Complications in the therapy of spontaneous pneumothorax]. Der Chirurg; Zeitschrift fur alle Gebiete der operativen Medizen. 2015 May     [PubMed]
Slade M, Management of pneumothorax and prolonged air leak. Seminars in respiratory and critical care medicine. 2014 Dec     [PubMed]
Peyrin JC,Charlet JP,Duret J,Crepel N,Brichon PY, [Reexpansion pulmonary edema after pneumothorax. Apropos of a case. Review of the literature]. Journal de chirurgie. 1988 Mar     [PubMed]
Cardozo S,Belgrave K, A shocking complication of a pneumothorax: chest tube-induced arrhythmias and review of the literature. Case reports in cardiology. 2014     [PubMed]
Ley-Zaporozhan J,Shoushtari H,Menezes R,Zelovitzky L,Odedra D,Jimenez-Juan L,Brunet K,Karimzad Y,Paul NS, Enhanced pneumothorax visualization in ICU patients using portable chest radiography. PloS one. 2018     [PubMed]
Alrajab S,Youssef AM,Akkus NI,Caldito G, Pleural ultrasonography versus chest radiography for the diagnosis of pneumothorax: review of the literature and meta-analysis. Critical care (London, England). 2013 Sep 23;     [PubMed]

Disclaimer

The intent of StatPearls is to provide practice questions and explanations to assist you in identifying and resolving knowledge deficits. These questions and explanations are not intended to be a source of the knowledge base of all of medicine, nor is it intended to be a board or certification review of Pediatrics-Medical Student. The authors or editors do not warrant the information is complete or accurate. The reader is encouraged to verify each answer and explanation in several references. All drug indications and dosages should be verified before administration.

StatPearls offers the most comprehensive database of free multiple-choice questions with explanations and short review chapters ever developed. This system helps physicians, medical students, dentists, nurses, pharmacists, and allied health professionals identify education deficits and learn new concepts. StatPearls is not a board or certification review system for Pediatrics-Medical Student, it is a learning system that you can use to help improve your knowledge base of medicine for life-long learning. StatPearls will help you identify your weaknesses so that when you are ready to study for a board or certification exam in Pediatrics-Medical Student, you will already be prepared.

Our content is updated continuously through a multi-step peer review process that will help you be prepared and review for a thorough knowledge of Pediatrics-Medical Student. When it is time for the Pediatrics-Medical Student board and certification exam, you will already be ready. Besides online study quizzes, we also publish our peer-reviewed content in eBooks and mobile Apps. We also offer inexpensive CME/CE, so our content can be used to attain education credits while you study Pediatrics-Medical Student.