Você está na página 1de 39

Practice Essentials

Pneumothorax is defined as the presence of air or gas in the pleural cavity (ie, the potential space
between the visceral and parietal pleura of the lung), which can impair oxygenation and/or
ventilation. The clinical results are dependent on the degree of collapse of the lung on the
affected side. If the pneumothorax is significant, it can cause a shift of the mediastinum and
compromise hemodynamic stability. Air can enter the intrapleural space through a
communication from the chest wall (ie, trauma) or through the lung parenchyma across the
visceral pleura. See the image below.

Radiograph of a patient with a complete


right-sided pneumothorax due to a stab wound.

Signs and symptoms


The presentation of patients with pneumothorax varies depending on the following types of
pneumothorax and ranges from completely asymptomatic to life-threatening respiratory distress:

Spontaneous pneumothorax: No clinical signs or symptoms in primary spontaneous


pneumothorax until a bleb ruptures and causes pneumothorax; typically, the result is
acute onset of chest pain and shortness of breath, particularly with secondary spontaneous
pneumothoraces

Iatrogenic pneumothorax: Symptoms similar to those of spontaneous pneumothorax,


depending on patients age, presence of underlying lung disease, and extent of
pneumothorax

Tension pneumothorax: Hypotension, hypoxia, chest pain, dyspnea

Catamenial pneumothorax: Women aged 30-40 years with onset of symptoms within 48
hours of menstruation, right-sided pneumothorax, and recurrence

Pneumomediastinum: Must be differentiated from spontaneous pneumothorax; patients


may or may not have symptoms of chest pain, persistent cough, sore throat, dysphagia,
shortness of breath, or nausea/vomiting

See Clinical Presentation for more detail.

Diagnosis
History and physical examination remain the keys to making the diagnosis of pneumothorax.
Examination of patients with this condition may reveal diaphoresis and cyanosis (in the case of
tension pneumothorax). Affected patients may also reveal altered mental status changes,
including decreased alertness and/or consciousness (a rare finding).
Findings on lung auscultation vary depending on the extent of the pneumothorax. Respiratory
findings may include the following:

Respiratory distress (considered a universal finding) or respiratory arrest

Tachypnea (or bradypnea as a preterminal event)

Asymmetric lung expansion: Mediastinal and tracheal shift to contralateral side (large
tension pneumothorax)

Distant or absent breath sounds: Unilaterally decreased/absent lung sounds common, but
decreased air entry may be absent even in advanced state of pneumothorax

Minimal lung sounds transmitted from unaffected hemithorax with auscultation at


midaxillary line

Hyperresonance on percussion: Rare finding; may be absent even in an advanced state

Decreased tactile fremitus

Adventitious lung sounds: Ipsilateral crackles, wheezes

Cardiovascular findings may include the following:

Tachycardia: Most common finding; if heart rate is faster than 135 beats/min, tension
pneumothorax likely

Pulsus paradoxus

Hypotension: Inconsistently present finding; although typically considered a key sign of


tension pneumothorax, hypotension can be delayed until its appearance immediately
precedes cardiovascular collapse

Jugular venous distention: Generally seen in tension pneumothorax; may be absent if


hypotension is severe

Cardiac apical displacement: Rare finding

Common findings among the types of pneumothoraces include the following:

Spontaneous and iatrogenic pneumothorax: Tachycardia most common finding;


tachypnea and hypoxia may be present

Tension pneumothorax: Variable findings; respiratory distress and chest pain;


tachycardia; ipsilateral air entry on auscultation; breath sounds absent on affected
hemithorax; trachea may deviate from affected side; thorax may be hyperresonant;
jugular venous distention and/or abdominal distention may be present

Pneumomediastinum: Variable or absent findings; subcutaneous emphysema is the most


consistent sign; Hamman signa precordial crunching noise synchronous with the
heartbeat and often accentuated during expirationhas a variable rate of occurrence,
with one series reporting 10%

Lab and imaging studies


Although laboratory and imaging studies help determine a diagnosis, tension pneumothorax
primarily is a clinical diagnosis based on patient presentation. Suspicion of tension
pneumothorax, especially in late stages, mandates immediate treatment and does not require
potentially prolonged diagnostic studies.
Arterial blood gas (ABG) studies measure the degrees of acidemia, hypercarbia, and hypoxemia,
the occurrence of which depends on the extent of cardiopulmonary compromise at the time of
collection. ABG analysis does not replace physical diagnosis, nor should treatment be delayed
while awaiting results if symptomatic pneumothorax is suspected. However, ABG analysis may
be useful in evaluating hypoxia and hypercarbia and respiratory acidosis.

When pneumothorax is suspected, confirmation by chest radiography affords additional


information beyond confirmation, such as the extent of pneumothorax, potential causes, a
baseline study from which to go forward, and assistance with the therapeutic plan.
The following radiologic studies may be used to evaluate suspected pneumothorax:

Chest radiography: Anteroposterior and/or lateral decubitus films

Contrast-enhanced esophagography: If emesis/retching is the precipitating event

Chest computed tomography scanning: Most reliable imaging study for diagnosis of
pneumothorax but not recommended for routine use in pneumothorax

Chest ultrasonography

See Workup for more detail.

Management
Although there is general agreement on the management of pneumothorax, a full consensus
about management of initial or recurrent pneumothorax does not exist. Rather, many clinicians
use a risk stratification framework as well as other approaches for choosing among options to
restore lung volume and an air-free pleural space and to prevent recurrences.[1]
The range of medical therapeutic options for pneumothorax includes the following:

Watchful waiting, with or without supplemental oxygen

Simple aspiration

Tube drainage, with or without medical pleurodesis

Surgery
If the patient has had repeated episodes of pneumothorax or if the lung remains unexpanded after
5 days with a chest tube in place, operative therapy such as the following may be necessary:

Thoracoscopy: Video-assisted thoracoscopic surgery (VATS)

Electrocautery: Pleurodesis or sclerotherapy

Laser treatment

Resection of blebs or pleura

Open thoracotomy

Pharmacotherapy
The following medications may be used to aid in the management of patients with
pneumothorax:

Local anesthetics (eg, lidocaine hydrochloride)

Opioid anesthetics (eg, fentanyl citrate, morphine)

Benzodiazepines (eg, midazolam, lorazepam)

Antibiotics (eg, doxycycline, cefazolin)

Background

Pneumothorax is defined as the presence of air or gas in the pleural cavity (ie, the
potential space between the visceral and parietal pleura of the lung). The clinical results
are dependent on the degree of collapse of the lung on the affected side. Pneumothorax
can impair oxygenation and/or ventilation. If the pneumothorax is significant, it can cause
a shift of the mediastinum and compromise hemodynamic stability. Air can enter the
intrapleural space through a communication from the chest wall (ie, trauma) or through
the lung parenchyma across the visceral pleura.
Among the topics this article will discuss are several areas of new information in the
medical literature: (1) studies comparing aspiration and tube drainage for treatment of
primary spontaneous pneumothorax, (2) long-term follow-up of surgical treatment of
pneumothorax, (3) assessment of the impact of pleurodesis on transplantation outcomes
in patients with lymphangiomyomatosis, (4) demonstrated utility of ultrasonography in
the bedside diagnosis of iatrogenic pneumothorax, and (5) inability of ultrasonography to
distinguish between intrapulmonary bullae and pneumothorax.
See also Restoring an Air-Free Pleural Space in Pneumothorax.

Primary and secondary spontaneous pneumothorax

Spontaneous pneumothorax is a commonly encountered problem with approaches to


treatment that vary from observation to aggressive intervention. Primary spontaneous
pneumothorax (PSP) occurs in people without underlying lung disease and in the absence
of an inciting event (see the images below).[2] In other words, air enters into the
intrapleural space without preceding trauma and without an underlying history of clinical
lung disease. However, many patients whose condition is labeled as primary spontaneous
pneumothorax have subclinical lung disease, such as pleural blebs, that can be detected
by CT scanning. Patients are typically aged 18-40 years, tall, thin, and, often, are
smokers.

Radiograph of a patient with a small

spontaneous primary pneumothorax


Close radiographic view of patient with a small spontaneous primary pneumothorax
(same patient as from the previous image).

Expiratory radiograph of a patient


with a small spontaneous primary pneumothorax (same patient as in the previous
images).
Secondary spontaneous pneumothorax (SSP) occurs in people with a wide variety of
parenchymal lung diseases.[2] These individuals have underlying pulmonary pathology
that alters normal lung structure (see the image below). Air enters the pleural space via
distended, damaged, or compromised alveoli. The presentation of these patients may
include more serious clinical symptoms and sequelae due to comorbid conditions.

Computed tomography scan


demonstrating secondary spontaneous pneumothorax (SSP) from radiation/chemotherapy
for lymphoma.

Iatrogenic and traumatic pneumothorax

Iatrogenic pneumothorax is a traumatic pneumothorax that results from injury to the


pleura, with air introduced into the pleural space secondary to diagnostic or therapeutic
medical intervention (see the following image). Half a century ago, iatrogenic
pneumothorax was predominantly the result of deliberate injection of air into the pleural
space for the treatment of tuberculosis (TB). The terminology evolved to the preference
for "induced" or "artificial" pneumothorax to indicate pulmonary TB treatment, before
arriving at the current classification. Pulmonary TB remains a significant cause of
secondary pneumothorax.

Radiograph of an older man


who was admitted to the intensive care unit (ICU) postoperatively. Note the right-sided
pneumothorax induced by the incorrectly positioned small-bowel feeding tube in the
right-sided bronchial tree. Marked depression of the right hemidiaphragm is noted, and
mediastinal shift is to the left side, suggestive of tension pneumothorax. The endotracheal
tube is in a good position.
Traumatic pneumothorax results from blunt trauma or penetrating trauma that disrupts the
parietal or visceral pleura (see the images below). Management steps for traumatic
pneumothoraces are similar to those for other, nontraumatic causes. If hemodynamic or
respiratory status is compromised or an open (communicating to the atmosphere) and/or
hemothorax are also present, tube thoracostomy is performed to evacuate air and allow
re-expansion of the lung. There is a subset of traumatic pneumothoraces classified as
occult; that is, they cannot be seen on chest radiographs but can be seen on CT scans. In
general, these can be observed and treated if they become symptomatic.

Illustration depicting multiple fractures of


the left upper chest wall. The first rib is often fractured posteriorly (black arrows). If
multiple rib fractures occur along the midlateral (red arrows) or anterior chest wall (blue
arrows), a flail chest (dotted black lines) may result, which may result in pneumothorax.

Radiograph of a patient with a


complete right-sided pneumothorax due to a stab wound.

Tension pneumothorax

A tension pneumothorax is a life-threatening condition that develops when air is trapped


in the pleural cavity under positive pressure, displacing mediastinal structures and
compromising cardiopulmonary function. Prompt recognition of this condition is life
saving, both outside the hospital and in a modern ICU. Because tension pneumothorax
occurs infrequently and has a potentially devastating outcome, a high index of suspicion
and knowledge of basic emergency thoracic decompression procedures are important for
all healthcare personnel. Immediate decompression of the thorax is mandatory when
tension pneumothorax is suspected. This should not be delayed for radiographic
confirmation. Note the image below.

This chest radiograph has 2


abnormalities: (1) tension pneumothorax and (2) potentially life-saving intervention
delayed while waiting for x-ray results. Tension pneumothorax is a clinical diagnosis
requiring emergent needle decompression, and therapy should never be delayed for x-ray
confirmation.

Pneumomediastinum

Pneumomediastinum is the presence of gas in the mediastinal tissues occurring


spontaneously or following procedures or trauma (see the following images). A
pneumothorax may occur secondary to pneumomediastinum.

Pneumomediastinum from
barotrauma may result in tension pneumothorax and obstructive shock.

This chest radiograph shows


pneumomediastinum (radiolucency noted around the left heart border) in this patient who
had a respiratory and circulatory arrest in the emergency department after experiencing
multiple episodes of vomiting and a rigid abdomen. The patient was taken immediately to
the operating room, where a large rupture of the esophagus was repaired.
Anatomy

The inner surface of the thoracic cage (parietal pleura) is contiguous with the outer surface of the
lung (visceral pleura); this space contains a small amount of lubricating fluid and is normally
under negative pressure compared to the alveoli. Determinants of pleural pressure are the
opposing recoil forces of the lung and chest wall.

Pathophysiology
The underlying pathophysiology of pneumothorax is reviewed in this section.

Spontaneous pneumothorax
Spontaneous pneumothorax in most patients occurs from the rupture of blebs and bullae.
Although primary spontaneous pneumothorax (PSP) is defined as occurring in patients without
underlying pulmonary disease, these patients have asymptomatic blebs and bullae detected on
computed tomography scans or during thoracotomy. PSP is typically observed in tall, young
people without parenchymal lung disease and is thought to be related to increased shear forces in
the apex.
Although PSP is associated with the presence of apical pleural blebs, the exact anatomic site of
air leakage is often uncertain. Fluorescein-enhanced autofluorescence thoracoscopy (FEAT) is a
novel method to examine the site of air leak in PSP. FEAT-positive lesions can be detected that
appear normal when viewed under normal white-light thoracoscopy.[3]
In normal respiration, the pleural space has a negative pressure. As the chest wall expands
outward, the surface tension between the parietal and visceral pleura expands the lung outward.
The lung tissue intrinsically has an elastic recoil, tending to collapse inwards. If the pleural space
is invaded by gas from a ruptured bleb, the lung collapses until equilibrium is achieved or the
rupture is sealed. As the pneumothorax enlarges, the lung becomes smaller. The main
physiologic consequence of this process is a decrease in vital capacity and partial pressure of
oxygen.
Lung inflammation and oxidative stress are hypothesized to be important to the pathogenesis of
PSP.[4] Current smokers, at increased risk for PSP, have increased numbers of inflammatory cells
in the small airways. Bronchoalveolar lavage (BAL) studies in patients with PSP reveal that the
degree of inflammation correlates with the extent of emphysematouslike changes (ELCs). One
hypothesis is that ELCs result from degradation of lung tissue due to imbalances of enzymes and
antioxidants released by innate immune cells.[5] In one study, erythrocyte superoxide dismutase
activity was significantly lower and plasma malondialdehyde levels higher in patients with PSP
than in normal control subjects.[4]
A growing body of evidence suggests that genetic factors may be important in the pathogenesis
of many cases of PSP. Familial clustering of this condition has been reported. Genetic disorders
that have been linked to PSP include Marfan syndrome, homocystinuria, and Birt-Hogg-Dube
(BHD) syndrome.
Birt-Hogg-Dube syndrome is an autosomal dominant disorder that is characterized by benign
skin tumors (hair follicle hamartomas), renal and colon cancer, and spontaneous pneumothorax.
Spontaneous pneumothorax occurs in about 22% of patients with this syndrome. The gene
responsible for this syndrome is a tumor suppressor gene located on band 17p11.2. The gene
encoding folliculin (FLCN) is thought to be the etiology of Birt-Hogg-Dube syndrome. Multiple
mutations have been found, and phenotypic variation is recognized. In one study, 8 patients

without skin or renal involvement had lung cysts and spontaneous pneumothorax.[6] A germ-line
mutation to this gene has been found in 5 patients, and genetic testing is now available.

Tension pneumothorax
Tension pneumothorax occurs anytime a disruption involves the visceral pleura, parietal pleura,
or the tracheobronchial tree. This condition develops when injured tissue forms a 1-way valve,
allowing air inflow with inhalation into the pleural space and prohibiting air outflow. The volume
of this nonabsorbable intrapleural air increases with each inspiration because of the 1-way valve
effect. As a result, pressure rises within the affected hemithorax. In addition to this mechanism,
the positive pressure used with mechanical ventilation therapy can cause air trapping.
As the pressure increases, the ipsilateral lung collapses and causes hypoxia. Further pressure
increases cause the mediastinum to shift toward the contralateral side and impinge on and
compress both the contralateral lung and impair the venous return to the right atrium. Hypoxia
results as the collapsed lung on the affected side and the compressed lung on the contralateral
side compromise effective gas exchange. This hypoxia and decreased venous return caused by
compression of the relatively thin walls of the atria impair cardiac function. Kinking of the
inferior vena cava is thought to be the initial event restricting blood to the heart. It is most
evident in trauma patients who are hypovolemic with reduced venous blood return to the heart.
Arising from numerous causes, this condition rapidly progresses to respiratory insufficiency,
cardiovascular collapse, and, ultimately, death if unrecognized and untreated.

Pneumomediastinum
With pneumomediastinum, excessive intra-alveolar pressures lead to rupture of alveoli bordering
the mediastinum. Air escapes into the surrounding connective tissue and dissects further into the
mediastinum. Esophageal trauma or elevated airway pressures may also allow air to dissect into
the mediastinum. Air may then travel superiorly into the visceral, retropharyngeal, and
subcutaneous spaces of the neck. From the neck, the subcutaneous compartment is continuous
throughout the body; thus, air can diffuse widely. Mediastinal air can also pass inferiorly into the
retroperitoneum and other extraperitoneal compartments. If the mediastinal pressure rises
abruptly or if decompression is not sufficient, the mediastinal parietal pleura may rupture and
cause a pneumothorax (in 10-18% of patients).
A wide variety of disease states and circumstances may result in a pneumothorax.

Primary and secondary spontaneous pneumothorax


Risks factors for primary spontaneous pneumothorax (PSP) include the following:

Smoking

Tall, thin stature in a healthy person

Marfan syndrome

Pregnancy

Familial pneumothorax

Blebs and bullae (sometimes called emphysematouslike changes or ELCs) are related to the
occurrence of primary spontaneous pneumothorax. Thoracic computerized tomography (CT)
scans of patients with PSP shows ipsilateral ELC in 89% and contralateral changes in 80%
compared with a rate of 20% among control subjects matched for age and smoking.[2]
Nonsmokers with PSP had CT scan ELC abnormalities of 80% compared with a rate of 0%
among nonsmoker controls without PSP.[2]
Although patients with PSP do not have overt parenchymal disease, this condition is heavily
associated with smoking80-90% of primary spontaneous pneumothorax (PSP) cases occur in
smokers or former smokers, and the relative risk of PSP increases as the number of cigarettes
smoked per day increases; that is, the risk of PSP is related to the intensity of smoking, with 102times higher incidence rates in males who smoke heavily (ie, >22 cigarettes/d), compared with a
7-fold increase in males who smoke lightly (1-12 cigarettes/d). This incremental risk with
increasing number of cigarettes smoked per day is much more pronounced in female smokers.
Typical PSP patients also tend to have a tall and thin body habitus. Whether height affects
development of subpleural blebs or whether more negative apical pleural pressures cause
preexisting blebs to rupture is unclear.
Pregnancy is an unrecognized risk factor, as suggested by a 10-year retrospective series in which
5 of 250 spontaneous pneumothorax cases were in pregnant women.[7] The cases were all
managed successfully with simple aspiration or vacuum-assisted thoracostomy (VATS), and no
harm occurred to mother or fetus.[7]
Other associations with pneumothorax include increased intrathoracic pressure with Valsalva,
although results contrary to popular belief, most spontaneous pneumothoraces occur while the
patient is at rest. Changes in atmospheric pressure, proximity to loud music, and low frequency
noises are other reported factors.
Familial associations have been noted in more than 10% of patients. Some are due to rare
connective tissue diseases, but mutations in the gene encoding folliculin (FLCN) have been
described. These patients may represent an incomplete penetrance of an autosomal dominant
genetic disorder. Birt-Hogg-Dube syndrome is characterized by benign skin growths, pulmonary
cysts, and renal cancers and is caused by mutations in the FLCN gene. In one family study, 9
ascertained cases of spontaneous pneumothorax were reported among 54 members. A review of
the literature summarized 61 reports of familial spontaneous pneumothorax among 22 families.
Up to 10% patients with spontaneous pneumothorax report a positive family history.[8]
Although rare, spontaneous pneumothorax occurring bilaterally and progressing to tension
pneumothorax has been documented.

Diseases and conditions associated with secondary spontaneous pneumothorax include the
following:

Chronic obstructive lung disease (COPD) or emphysema: Increased pulmonary pressure


due to coughing with a bronchial plug of mucus or phlegm bronchial plug may play a
role.

Asthma

Human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) with


PCP infection

Necrotizing pneumonia

Tuberculosis

Sarcoidosis

Cystic fibrosis

Bronchogenic carcinoma or metastatic malignancy

Idiopathic pulmonary fibrosis

Inhalational and intravenous drug use (eg, marijuana, cocaine) [9]

Interstitial lung diseases associated with connective tissue diseases

Lymphangioleiomyomatosis

Langerhans cell histiocytosis

Severe acute respiratory syndrome (SARS): A reported 1.7% of SARS patients developed
spontaneous pneumothorax. [10]

Thoracic endometriosis and catamenial pneumothorax

Collagen vascular disease, including Marfan syndrome

Secondary spontaneous pneumothoraces (SSP) occur in the presence of lung disease, primarily
in the presence of COPD. Other diseases that may be present when SSPs occur include
tuberculosis, sarcoidosis, cystic fibrosis, malignancy, and idiopathic pulmonary fibrosis.

Pneumocystis jiroveci pneumonia (previously known as Pneumocystis carinii pneumonia [PCP])


was a common cause of SSP in patients with AIDS during the last decade. In fact, 77% of AIDS
patients with spontaneous pneumothorax had thin-walled cavities, cysts, and pneumothorax from
PCP infection.[11] With the advent of highly active antiretroviral therapy (HAART) and
widespread use of trimethoprim-sulfamethoxazole (TMP-SMZ) prophylaxis, the incidence of
PCP and associated SSP has significantly declined.
PCP in other immunocompromised patients is seen only when TMP-SMZ prophylaxis is
withdrawn prematurely. For practical purposes, if the immunocompromised patient has been
taking TMP-SMZ prophylaxis reliably, PCP is reasonably excluded from the differential
diagnosis and should not be a causative factor for SSP.
In cystic fibrosis, up to 18.9% of patients have been reported to develop spontaneous
pneumothoraces, and they have a high incidence of recurrence on the same side after
conservative management (50%) or intercostal drainage (55.2%). The risk of SSP in these
patients increases with Burkholderia cepacia or Pseudomonas infections and allergic
bronchopulmonary aspergillosis (ABPA).[12] Pleurodesis increases the risk of bleeding associated
with lung transplantation but is not an absolute contraindication.
Many different types of malignancies are known to present with a pneumothorax, especially
sarcomas, but also genitourinary cancers and primary lung cancer; thus, pneumothorax in a
patient with malignancy should prompt a look for metastatic disease. Chemotherapeutic agents,
at times, can also induce SSP.[13]
Interstitial lung diseases are associated with connective-tissue diseases. Ankylosing spondylitis
may be noted when apical fibrosis is present; in fact, the typically low incidence of spontaneous
pneumothorax in patients with ankylosing spondylitis (0.29%) increases 45-fold (to 13%) when
apical fibrotic disease exists.[14]
Lymphangioleiomyomatosis (LAM) may present with spontaneous pneumothorax. This disease
is characterized by thin-walled cysts in women of childbearing age. Respiratory failure may lead
to a need for lung transplantation, and previous pleurodesis is no longer an absolute
contraindication for lung transplantation.
Thoracic endometriosis is a rare cause of recurrent pneumothorax (catamenial pneumothorax) in
women that is thought to arise from endometriosis reaching the chest wall across the diaphragm
(ie, its etiology may be primarily related to associated diaphragmatic defects). In a case series of
229 patients, catamenial pneumothorax caused by thoracic endometriosis was localized to the
visceral pleura in 52% of patients and to the diaphragm in 39% of patients.[15] Before recurrence,
this condition may be initially diagnosed as primary spontaneous pneumothorax.

Iatrogenic and traumatic pneumothorax


Causes of iatrogenic pneumothorax include the following:

Transthoracic needle aspiration biopsy of pulmonary nodules (most common cause,


accounting for 32-37% of cases)

Transbronchial or pleural biopsy

Thoracentesis

Central venous catheter insertion, usually subclavian or internal jugular [16]

Intercostal nerve block

Tracheostomy

Cardiopulmonary resuscitation (CPR): Consider the possibility of a pneumothorax if


ventilation becomes progressively more difficult.

Acute respiratory distress syndrome ( ARDS) and positive pressure ventilation in the
ICU: High peak airway pressures can translate into barotrauma in up to 3% of patients on
a ventilator and up to 5% of patients with ARDS. [17]

Nasogastric feeding tube placement

Iatrogenic pneumothorax is a complication of medical or surgical procedures. It most commonly


results from transthoracic needle aspiration. Other procedures commonly causing iatrogenic
pneumothorax are therapeutic thoracentesis, pleural biopsy, central venous catheter insertion,
transbronchial biopsy, positive pressure mechanical ventilation, and inadvertent intubation of the
right mainstem bronchus. Therapeutic thoracentesis is complicated by pneumothorax 30% of the
time when performed by inexperienced operators in contrast to only 4% of the time when
performed by experienced clinicians.
The routine use of ultrasonography during diagnostic thoracentesis is associated with lower rates
of pneumothorax (4.9% vs 10.3%) and need for tube thoracostomy (0.7% vs 4.1%). Similarly, in
patients who are mechanically ventilated, thoracentesis guided by bedside ultrasonography
without radiology support results in a relatively lower rate of pneumothorax.
Causes of traumatic pneumothorax include the following:

Trauma: Penetrating and nonpenetrating injury

Rib fracture

High-risk occupation (eg, diving, flying)

Traumatic pneumothoraces can result from both penetrating and nonpenetrating lung injuries.
Complications include hemopneumothorax and bronchopleural fistula. Traumatic

pneumothoraces often can create a 1-way valve in the pleural space (only letting in air without
escape) and can lead to a tension pneumothorax.

Tension pneumothorax
The most common etiologies of tension pneumothorax are either iatrogenic or related to trauma,
such as the following:

Blunt or penetrating trauma: Disruption of either the visceral or parietal pleura occurs and
is often associated with rib fractures, although rib fractures are not necessary for tension
pneumothorax to occur.

Barotrauma secondary to positive-pressure ventilation, especially when using high


amounts of positive end-expiratory pressure (PEEP)

Pneumoperitoneum [18, 19]

Fiberoptic bronchoscopy with closed-lung biopsy [20]

Markedly displaced thoracic spine fractures

Acupuncture [21, 22, 23]

Preexisting Bochdalek hernia with trauma [24]

Colonoscopy [25] and gastroscopy have been implicated in case reports.

Percutaneous tracheostomy [26]

Conversion of idiopathic, spontaneous, simple pneumothorax to tension pneumothorax

Unsuccessful attempts to convert an open pneumothorax to a simple pneumothorax in


which the occlusive dressing functions as a 1-way valve

Tension pneumothorax occurs commonly in the ICU setting in patients who are ventilated with
positive pressure, and practitioners must always consider this when changes in respiratory or
hemodynamic status occur. Infants requiring ventilatory assistance and those with meconium
aspiration have a particularly high risk for tension pneumothorax. Aspirated meconium may
serve as a 1-way valve and produce a tension pneumothorax.
Any penetrating wound that produces an abnormal passageway for gas exchange into the pleural
spaces and that results in air trapping may produce a tension pneumothorax. Blunt trauma, with
or without associated rib fractures, and incidents such as unrestrained head-on motor vehicle
accidents, falls, and altercations involving laterally directed blows may also cause tension
pneumothoraces.

Significant chest injuries carry an estimated 10-50% risk of associated pneumothorax; in about
50% of these cases, the pneumothorax may not be seen on standard radiographs and are therefore
deemed occult. In one study, 12% of patients with asymptomatic chest stab wounds had a
delayed pneumothorax or hemothorax. McPherson et al analyzed data from the Vietnam Wound
Data and Munitions Effectiveness Team study and determined that tension pneumothorax was
the cause of death in 3-4% of fatally wounded combat casualties.[27]
Acupuncture is a traditional Chinese medicine technique used worldwide by alternative medical
practitioners. Acupuncture's most frequently reported serious complication is pneumothorax; in
one Japanese report of 55,291 acupuncture treatments, an approximate incidence of 1
pneumothorax in 5000 cases was documented.[28]

Pneumomediastinum
The following factors may result in pneumomediastinum:

Acute generation of high intrathoracic pressures (often as a result of inhalational drug


use, such smoking marijuana or inhalation of cocaine)

Asthma

Respiratory tract infection

Parturition

Emesis

Severe cough

Mechanical ventilation

Trauma or surgical disruption of the oropharyngeal, esophageal, or respiratory mucosa

Athletic competition

Epidemiology

The epidemiologic data vary among the pneumothorax classifications.


Primary, secondary, and recurring spontaneous pneumothorax

It is likely that the incidence for spontaneous pneumothorax is underestimated. Up to 10% of


patients may be asymptomatic, and others with mild symptoms may not present to a medical
provider.

Primary spontaneous pneumothoraces (PSPs) occur in people aged 20-30 years, with a peak
incidence is in the early twenties.PSP is rarely observed in people older than 40 years. The ageadjusted incidence of PSP is 7.4-18 cases per 100,000 persons per year for men and 1.2-6 cases
per 100,000 persons per year for women.[29] The male-to-female ratio of age-adjusted rates is
6.2:1.
Secondary spontaneous pneumothoraces (SSPs) occur more frequently in patients aged 60-65
years. The age-adjusted incidence of SSP is 6.3 cases per 100,000 persons per year for men and
2.0 cases per 100,000 persons per year for women. The male-to-female ratio of age-adjusted
rates is 3.2:1. Chronic obstructive pulmonary disease (COPD) is a common cause of secondary
spontaneous pneumothorax that carries an incidence of 26 cases per 100,000 persons.[30]
Smoking increases the risk of a first spontaneous pneumothorax by more than 20-fold in men
and by nearly 10-fold in women compared with risks in nonsmokers.[31] Increased risk of
pneumothorax and recurrence appears to rise proportionally with number of cigarettes smoked.
In men, the risk of spontaneous pneumothorax is 102 times higher in heavy smokers than in
nonsmokers. Spontaneous pneumothorax most frequently occurs in tall, thin men aged 20-40
years.
Iatrogenic and traumatic pneumothorax

Traumatic and tension pneumothoraces occur more frequently than spontaneous


pneumothoraces, and the rate is undoubtedly increasing in US hospitals as intensive care
treatment modalities have become increasingly dependent on positive-pressure ventilation,
central venous catheter placement, and other causes that potentially induce iatrogenic
pneumothorax.
Iatrogenic pneumothorax may cause substantial morbidity and, rarely, death. The incidence of
iatrogenic pneumothorax is 5-7 per 10,000 hospital admissions, with thoracic surgery patients
excluded because pneumothorax may be a typical outcome following these surgeries.
Pneumothorax occurs in 1-2% of all neonates, with a higher incidence in infants with neonatal
respiratory distress syndrome. In one study, 19% of such patients developed a pneumothorax.
Tension pneumothorax

Tension pneumothorax is a complication in approximately 1-2% of the cases of idiopathic


spontaneous pneumothorax. Until the late 1800s, tuberculosis was a primary cause of
pneumothorax development. A 1962 study showed a frequency of pneumothorax of 1.4% in
patients with tuberculosis.

The actual incidence of tension pneumothorax outside of a hospital setting is impossible to


determine. Approximately 10-30% of patients transported to level-1 trauma centers in the United
States receive prehospital decompressive needle thoracostomies; however, not all of these
patients actually have a true tension pneumothorax. Although this occurrence rate may seem
high, disregarding the diagnosis would probably result in unnecessary deaths. A review of
military deaths from thoracic trauma suggests that up to 5% of combat casualties with thoracic
trauma have tension pneumothorax at the time of death.[27]
The overall incidence of tension pneumothorax in the intensive care unit (ICU) is unknown. The
medical literature provides only glimpses of the frequency. In one report, of 2000 incidents
reported to the Australian Incident Monitoring Study (AIMS), 17 involved actual or suspected
pneumothoraces, and 4 of those were diagnosed as tension pneumothorax.
Catamenial pneumothorax

Catamenial pneumothorax is a rare phenomenon that generally occurs in women aged 30-50
years. It frequently begins 1-3 days after menses onset. The risk of thoracic endometriosis cannot
be predicted from the site of peritoneal lesions.[15]
Pneumomediastinum

Spontaneous pneumomediastinum generally occurs in young, healthy patients without serious


underlying pulmonary disease, mostly in the second to fourth decades of life. A slight
predominance of pneumomediastinum exists for males. This condition occurs in approximately 1
case per 10,000 hospital admissions.
Prognosis

The prognosis varies among the pneumothorax classifications.


Primary, secondary, and recurring spontaneous pneumothorax

Complete resolution of an uncomplicated pneumothorax takes approximately 10 days. PSP is


typically benign and often resolves without medical attention. Many affected individuals do not
seek medical attention for days after symptoms develop. This trend is important, because the
incidence of reexpansion pulmonary edema increases in patients whose chest tubes have been
placed 3 or more days after the pneumothorax occurred.
Recurrences usually strike within the first 6 months to 3 years. The 5-year recurrence rate is 2832% for primary spontaneous pneumothorax (PSP) and 43% for secondary spontaneous
pneumothorax (SSP).

Recurrences are more common among patients who smoke, patients with chronic obstructive
pulmonary disease (COPD), and patients with acquired immunodeficiency syndrome (AIDS).
Predictors of recurrence include pulmonary fibrosis, younger age, and increased height-to-weight
ratio. In a retrospective study of 182 consecutive patients with a newly diagnosed first episode of
pneumothorax, a higher rate of recurrence was noted in taller patients, thin patients, and patients
with SSP.
Patients who underwent bedside chest tube pleurodesis had cumulative rates of recurrence of
13% at 6 months, 16% at 1 year, and 27% at 3 years compared with 26%, 33%, and 50%,
respectively. The agent used (tetracycline or gentamicin) did not have any significant impact on
the recurrence rate.
Bullous lesions found on computed tomography (CT) scan or at thoracoscopy and the presence
of emphysematouslike changes in PSP are also not predictive of recurrence. However,
contralateral blebs were seen by CT scanning in higher frequency in the patients with
contralateral recurrence (33 patients; 14%) than those without a contralateral recurrence in a
retrospective study of 231 patients with PSP. Primary bilateral spontaneous pneumothorax
(PBSP) was significantly more common in patients with lower body mass index (BMI) and
among smokers.[32] In this series, all patients with contralateral recurrence were treated surgically.
Although some authors view PSP as more of a nuisance than a major health threat, deaths have
been reported. SSPs are more often life threatening, depending on the severity of the underlying
disease and the size of the pneumothorax (1-17% mortality rate). In particular, compared with
similar patients without pneumothorax, age-matched patients with COPD have a 3.5-fold
increase in relative mortality when a spontaneous pneumothorax occurs, and their risk of
recurrence rises with each occurrence. One study indicated that 5% of patients with COPD died
before a chest tube was placed.
Patients with AIDS also have a high inpatient mortality rate of 25% and a median survival of 3
months after the pneumothorax. These data derive from an era before highly active antiretroviral
therapy (HAART) was available.
Tension pneumothorax

Tension pneumothorax arises from numerous causes and rapidly progresses to respiratory
insufficiency, cardiovascular collapse, and, ultimately, death if not recognized and treated.
Therefore, if the clinical picture fits a tension pneumothorax, it must be emergently treated
before it results in hemodynamic instability and death.
Pneumomediastinum

Pneumomediastinum is generally a benign, self-limited condition. Malignant


pneumomediastinum, or tension pneumomediastinum (unvented mediastinal or pulmonary
adventitial air causing pressure so high that circulatory or ventilatory failure occurs), was first
described in 1944; however, all patients described in this report had serious comorbid conditions,
often related to trauma or in association with Boerhaave syndrome.
No reports of fatal outcomes in patients with spontaneous pneumomediastinum in the absence of
underlying disease exist in the more recent literature. The mortality rate is as high as 70% in
patients with pneumomediastinum secondary to Boerhaave syndrome, even with surgical
intervention. Traumatic mediastinum, although present in up to 6% of patients does not portend
serious injury.[33]
Patient Education

Two important concerns that clinicians should educate patients with pneumothorax/resolving
pneumothorax about are avoidance of air travel/travel to remote regions and prohibition of
smoking. Patients should also be advised to wear safety belts and passive restraint devices while
driving.
Avoid traveling by air or to remote areas

Patients should not travel by air or travel to remote sites until radiography shows complete
resolution. Although commercial air travel achieves minimal change in gas volumes due to
pressurization of the cabin, spontaneous pneumothorax has been described during commercial
travel.
Patients with previous spontaneous pneumothoraces are at risk for recurrence and are advised not
to dive unless thoracotomy or pleurodesis has been performed.[34] Ascent from deep-sea diving
causes gases to expand and can lead to pneumothorax in patients with bullae and blebs.
Stop smoking

Smoking cessation is strongly advised for all patients. They should be assessed as to readiness to
quit, to be educated about smoking cessation, and be provided with pharmacotherapy if ready to
quit. Direct patients indicating a readiness to quit smoking to their primary care physician or
offer referral for cessation management. This may include nicotine replacement and non-nicotine
pharmacotherapy such as bupropion or varenicline.
Whether primary or secondary pneumothorax, smoking increases the likelihood of bleb rupture
and recurrence, and it does so in a predictable, dose-related manner. Relative risk of bleb rupture
and recurrence rises by up to a factor of 20.

For patient education information, see the Lung and Airway Center and Breathing Difficulties
Center, as well as Collapsed Lung (Pneumothorax) and Chest Pain.

Diagnostic Considerations
This section reviews some important points to consider in the diagnosis of pneumothoraces.
Spontaneous pneumothorax
Because patients with primary spontaneous pneumothorax (PSP) will have apical
emphysematous pulmonary disease on computed tomography (CT) scanning or thoracoscopy,
they can be thought to have a congenital syndrome of mild acinar emphysema, whose expression
is enhanced by environmental factors (eg, smoking) just as it is in patients with alpha-1antitrypsin deficiency and "typical" emphysema.
Folliculin gene disorders have been described in familial spontaneous pneumothorax.[4] These
patients may have pneumothorax as the presenting symptom of Birt-Hogg-Dube disease.[5] Some
authors recommend screening patients with a family history of pneumothorax for the benign skin
tumors and renal cancers that arise from the disease.
Catamenial pneumothorax is a rare cause of recurrent pneumothorax in women. Prior to
recurrence, this condition may initially be diagnosed as PSP.
Pneumonia is a possible cause of pneumothorax; in the patient with human immunodeficiency
virus infection (HIV), Pneumocystis jiroveci pneumonia (PCP) , toxoplasmosis, and Kaposi
sarcoma need to be considered . A patient with HIV can have spontaneous pneumothorax as the
presenting symptom of their illness: HIV carries a lifetime risk of 6% for pneumothorax, and
about 85% of that number is related to PCP pneumonia.
The rare event of spontaneous pneumothorax leading to tension pneumothorax may be
misdiagnosed as an asthma crisis or exacerbation of chronic obstructive pulmonary disease
(COPD) in the patient presenting with tachycardia, subcutaneous emphysema, dyspnea, and
shock.
Traumatic pneumothorax
Always consider pneumothorax in the differential diagnosis of major trauma. In the patient with
blunt trauma and mental status changes, hypoxia, and acidosis, symptoms of a tension
pneumothorax may be masked by associated and similarly potentially lethal injuries.
When assessing the trauma patient, be aware that clinical presentations of tension pneumothorax
and cardiac tamponade may be similar.
Tension pneumothorax

The diagnosis of a tension pneumothorax should largely be made based on the history and
physical examination findings. Ultrasonography in the emergency setting is being increasingly
used as an adjunct to the physical examination when there is doubt regarding the diagnosis.
Chest radiography or CT scanning should be used only in those instances when the clinician is in
doubt regarding the diagnosis and when the patient's clinical condition is hemodynamically
stable. Obtaining such imaging studies when the diagnosis of tension pneumothorax is not in
question causes an unnecessary and potentially lethal delay in treatment.
A tension pneumothorax is a life-threatening condition and requires immediate action (eg, needle
thoracostomy or chest tube insertion). However, the clinician should be wary of prematurely
diagnosing a tension pneumothorax in a patient without respiratory distress, hypoxia,
hypotension, or cardiopulmonary compromise. If the patient's clinical presentation is
questionable and if the patient appears stable, the clinician should reexamine the patient and use
bedside ultrasonography or request immediate portable chest radiography (or reexamine the
chest radiographs if they have already been obtained) to confirm the diagnosis.
A high index of suspicion for tension pneumothorax is recommended in patients on mechanical
ventilation with acute onset of hemodynamic instability, difficult ventilation with high
inspiratory pressures, and worsening hypoxemia and/or hypercapnia, even with a functioning
chest tube in place. Patients at greatest risk of a pneumothorax and/or tension pneumothorax
include those with COPD who are using ventilators; those with acute respiratory distress
syndrome (ARDS); and those receiving a tidal volume greater than 12 mL/kg, a peak airway
pressure greater than 60 cm H2 O, or a positive end-expiratory pressure greater than 15 cm H2 O.
Portable chest radiograph may fail to show the pneumothorax; CT scanning may be required for
diagnosis.
Avoid assuming that a patient with a chest tube does not have a tension pneumothorax if he or
she has respiratory or hemodynamic instability. Chest tubes can become plugged or
malpositioned and cease to function. In addition, improper attachment of a 1-way valve to the
chest tube may produce tension pneumothorax.
Other conditions to consider include the following:

Aspiration, Bacterial, Mycoplasmal, and Viral Pneumonia

Asthma

Costochondritis

Diaphragmatic Injuries

Esophageal Spasm

Foreign Bodies, Trachea

Mediastinitis

Myocardial Ischemia

Myocarditis

Pericarditis

Pleurodynia

Pulmonary Empyema and Abscess

Tuberculosis

Differential Diagnoses

Acute Aortic Dissection

Acute Coronary Syndrome

Acute Pericarditis

Esophageal Rupture and Tears in Emergency Medicine

Heart Failure

Myocardial Infarction

Pediatric Acute Respiratory Distress Syndrome

Pulmonary Embolism

Rib Fracture

Approach Considerations

Despite general agreement on the management of pneumothorax, a full consensus about


management of initial or recurrent pneumothorax does not exist. Professional societies differ in
their approach to management and hospitalization.[39, 54]
This section presents a risk stratification framework as well as other approaches for choosing
among options to restore lung volume and an air-free pleural space and to prevent recurrences.[1]
These goals are applicable across diverse clinical presentations. The range of therapeutic options

includes watchful waiting with or without supplemental oxygen, simple aspiration, tube drainage
with or without medical pleurodesis, vacuum-assisted thoracostomy (VATS) with pleurodesis
and/or closure of leaks and bullectomy, and open surgical procedures such as thoracotomy for
pleurectomy or pleurodesis.
Selection between the various management options requires an understanding of the natural
history of pneumothorax, the risk of recurrent pneumothorax, and the benefits and limitations of
each treatment option and discussion with the patient.
See also Restoring an Air-Free Pleural Space in Pneumothorax.
Pharmacotherapy

Medication may be necessary to treat a pulmonary disorder that causes the pneumothorax. For
example, intravenous antibiotics are included in the treatment of a pneumothorax that developed
as a sequela of staphylococcal pneumonia. In addition, studies suggest that the administration of
prophylactic antibiotics during chest tube insertion may reduce the incidence of complications
such as emphysema. Clearly, the use of analgesics can provide patient comfort until the
thoracostomy tube is removed. Some authors advocate the use of intercostal nerve blocks to
increase patient comfort and decrease the need for narcotic analgesics.
In patients with repeated pneumothoraces who are not good candidates for surgery, sclerotherapy
with talc or doxycycline may be necessary.

Treatment Based on Risk Stratification


The decision to observe or to treat with an immediate intervention should be guided by a risk
stratification that considers the patient's presentation and the likelihood of spontaneous resolution
and recurrence.

Patient presentation
The following are possible presentations of patients with pneumothorax:

Asymptomatic (incidental finding): Treatment decisions are guided by estimate of longterm recurrence risk.

Symptomatic but clinically stable: Treatment is guided by local resources and


conventions for the site of care. The British Thoracic Society (BTS) advocates for simple
aspiration and deferring hospitalization in primary spontaneous pneumothorax (PSP) as
initial management if the patient is stable. [54] A small bore catheter or chest tube
placement is recommended by the American College of Chest Physicians (ACCP) Delphi
consensus statement. [39]

Clinically fragile: Treatment is guided by local practice patterns for air evacuation and
observation. Comorbid conditions may preclude observation because of decreased
cardiopulmonary reserve.

Life threatening: Pneumothorax that causes hemodynamic instability is life-threatening


and must be treated immediately with tube thoracostomy. All documents and
recommendations call for intervention if a patient is unstable.

Likelihood of resolution
The likelihood of a pneumothorax resolving is classified as follows:

Very likely to resolve: Small pneumothorax in a hemodynamically stable patient without


significant parenchymal lung disease; small iatrogenic pneumothorax

May resolve: Large pneumothorax in a normal lung (eg, PSP or iatrogenic


pneumothorax)

Unlikely to resolve: Secondary pneumothorax, enlarging pneumothorax (suggests a


continuing air leak)

Will not resolve, could be fatal: Tension pneumothorax; unrecognized air leak

Likelihood of recurrence
The following categories of pneumothorax recurrence likelihood should be assessed:

Unlikely to recur: Iatrogenic pneumothorax in normal lung

May recur, but patient will likely be clinically stable

May recur and the patient may be clinically unstable, but emergency care is readily
accessible

Very likely to recur: Diffuse and progressive pulmonary pathology (eg,


lymphangioleiomyomatosis [LAM])

Recurrence could be life-threatening: Poor cardiopulmonary reserve, limited access to


emergency medical care

Selection of site of patient care


The following is a suggested guideline on determining where to administer care in a patient with
a pneumothorax:

Outpatient care: This can occur in asymptomatic patients or those with a small
pneumothorax and reliable follow-up.

Emergency department (ED) care: Prolonged periods of observation are inefficient and
clinically suboptimal; efficacy studies of manual aspiration and placement of 1-way
valves performed in EDs are an attempt to address these practical issues.

Inpatient care: This site of care is generally selected when high-flow oxygen is needed,
the pneumothorax is larger but the patient is stable, or comorbidities increase concern
about risk or follow-up. The average hospital stay is 2.8 days.

Intensive care unit (ICU): ICU treatment and observation is appropriate for patients who
are unstable or intubated.

Interval of observation
No protocols regarding serial radiography or imaging exist; the clinician typically reviews serial
vital signs and clinical assessments, using the direction and rate of change in the patients clinical
status to select imaging frequency. Monitoring pneumothorax size during this time is important,
as follows:

At 0-6 hours: The ACCP Delphi consensus statement recommends observation in an ED


for 6 hours, and discharge to home if a follow-up chest radiograph shows no enlargement
of the lesion, in reliable patients. [39] Emergency room observation with a repeat
radiograph 6 hours later used to be common but may be used less often now.

At 24-96 hours: Additional follow up in 2 days is recommended, with preference given to


a 24-48 hour follow-up radiograph in the outpatient setting. Outpatient follow-up during
the 96-hour (4-d) window is essential to distinguish between a resolved pneumothorax
and one that needs evacuation. A computed tomography (CT) scan at this time
distinguishes between PSP and secondary spontaneous pneumothorax (SSP).

At 1 month: Full lung reexpansion can occur, on average, 3 weeks after the initial event.

Restoring an Air-Free Pleural Space

Several options are available to restore an air-free pleural space, including observation
without oxygen, administering supplemental oxygen, simple aspiration, chest tube
placement, 1-way valve insertion, and thoracostomy with continuous suction.
(See the video of chest tube insertion, below.)
Insertion of chest tube. Video courtesy of Therese Canares, MD, and Jonathan Valente,
MD, Rhode Island Hospital, Brown University.
Contou et al recommend that clinicians consider drainage via a small-bore catheter as a
first-line treatment for pneumothorax of any cause. The authors found that drainage via
catheter or via chest tube is similarly effective for the management for the management

of pneumothoraces, including primary spontaneous pneumothorax, secondary


spontaneous pneumothorax, and traumatic and iatrogenic pneumothoraces.[55]
See also Restoring an Air-Free Pleural Space in Pneumothorax.

Observation without oxygen

Simple observation is appropriate for asymptomatic patients with a minimal


pneumothorax (< 15-20% by Light criteria; 2-3 cm from apex to cupola by alternate
criteria) with close follow-up, ensuring no enlargement (see Estimating the size of the
pneumothorax under Chest Radiography). Air is reabsorbed spontaneously by 1.25% of
size pneumothorax per day.[56]
An interesting multicenter, prospective, observational study reported on more than 500
trauma patients with occult pneumothorax identified on CT scan, with an initially normal
chest radiograph. Controversy exists in the literature on the treatment of all patients with
occult pneumothorax, whether to closely observe patients with occult pneumothorax or
whether to place a chest tube. It is even more controversial in patients on positive
pressure ventilation. It is generally accepted after trauma to treat pneumothorax seen on
chest radiographs with chest tube thoracostomy. Conversion to tension pneumothorax is
the worst feared complication if left untreated.
The study arms included observation versus chest tube thoracostomy. Only 6% of
patients failed observation and developed pneumothorax, including only 15% failed
observation on positive pressure ventilation. In multivariate regression analysis, failure of
observation was seen in patients with chest radiographic evidence of pneumothorax
progression and symptoms of respiratory distress. According to this study, it is safe to
closely observe trauma patients with occult pneumothorax on chest radiographs, even if
receiving mechanical ventilation.[57]

Supplemental oxygen

Oxygen administration at 3 L/min nasal canula or higher flow treats possible hypoxemia
and is associated with a 4-fold increase in the rate of pleural air absorption compared
with room air alone.

Simple aspiration

Simple aspiration in 131 cases of small spontaneous pneumothorax yielded successful


results up to 87%.[58] Other studies have described more limited success in up to 70%
cases.[59] A more recent emergency department (ED) study supports needle aspiration as
safe and effective as chest tube placement for primary spontaneous pneumothorax (PSP),
conferring the additional benefits of shorter length of stay and fewer hospital admissions.
[60]

Chest tube placement

A tube inserted into the pleural space is connected to a device with 1-way flow for air
removal. Examples of such devices are Heimlich valves or water seal canisters, and tubes
connected to wall suction devices.

One-way valve insertion (portable system)

The typical goal of inserting 1-way valve systems is to avoid hospital admission and still
treat the spontaneous pneumothorax. One-way valves may also expedite hospital
discharge and be used during transport of an injured patient.

A Heimlich valve is a 1-way, rubber flutter valve that allows for complete evacuation of
air that is not under tension. The proximal end attaches to the chest tube or catheter, and
the distal end connects to a suction device or is left open to the atmosphere.
Heimlich valves do not require suction and thus eliminate the chance of a tension
pneumothorax; they also allow greater mobility and less discomfort for the patient. By
decreasing the length of the hospital stay and allowing for outpatient care, medical costs
are reduced as well.
In a pilot study, Marquette et al determined that using a serial-steps approach with a
single system (small-caliber catheter/Heimlich valve) in patients with a first episode of
PSP was as effective as simple manual needle aspiration or a conventional chest tube
thoracotomy.[61] In 41 thin, young, smoking males, a 1-way Heimlich valve was connected
to the catheter, allowing the air to flow spontaneously outward for 24-48 hours;
thereafter, if the lung failed to re-expand, wall suction was applied. Patients with an air
leak persisting for more than 4 days were referred for surgery.
At 24 hours, the success rate was 61%, and at 1 week, it had risen to 85%; the actuarial 1year recurrence rate was 24%.[61] When 24-hour and 1-week success rates and recurrence
at 12 months were taken as end points, the method described above was effective as
simple manual needle aspiration or a conventional chest tube thoracotomy.[61]
Heimlich valves are widely used in the care of patients with acquired immunodeficiency
syndrome (AIDS) who have a median length of 20 days of chest tube placement to
facilitate care and mobility.

Thoracostomy with continuous wall suction

First-time secondary spontaneous pneumothorax (SPS) (including chronic obstructive


pulmonary disease [COPD]) and traumatic pneumothorax typically require this approach.
A small-bore catheter (eg, 7-14F) is safe to use in most patients, whereas a larger chest
tube (24F) is also appropriate initially, and increasing suction pressure can be used if the
lung fails to inflate.
A larger tube (eg, 28F) can reduce resistance in patients who are ventilated and at greater
risk for air leaks. Air leaks resolve within 7 days of treatment 80% of the time, with an
average hospital stay of 5 days. Keep the tube in place for 24 hours after the air leak
ceases.

Prehospital Care

Assess the ABCs (airway, breathing, circulation), and evaluate the possibility of a tension
pneumothorax. Assess the vital signs, and perform pulse oximetry. A tension pneumothorax is
almost always associated with hypotension.
Administer oxygen to the patient, ventilate the patient, and establish an intravenous (IV) line.
Tension pneumothorax

Failure of the emergency medical service personnel (EMS) and medical control physician to
make a correct diagnosis of tension pneumothorax and to promptly perform needle
decompression in the prehospital setting can result in rapid clinical deterioration and cardiac

arrest. Most paramedics are trained and protocolized to perform needle decompression for
immediate relief of a tension pneumothorax.
However, if an incorrect diagnosis of tension pneumothorax is made in the prehospital setting,
the patient's life may be endangered by unnecessary invasive procedures. Close cooperation and
accurate communication between the emergency department (ED) and the EMS personnel is of
paramount importance.
To prevent reentry of air into the pleural cavity after needle thoracostomy and decompression in
the prehospital setting, a 1-way valve should be attached to the distal end of the Angiocath. If
available, a Heimlich valve may be used. If a commercially prepared valve is not available,
attach a finger condom or the finger of a rubber glove with its tip removed to serve as a
makeshift 1-way valve device.
Clothing covering a wound that communicates with the chest cavity can play a role in producing
a 1-way valve effect, allowing air to enter the pleural cavity but hindering its exit. Removing
such clothing items from the wound may facilitate decompression of a tension pneumothorax.
A tension pneumothorax is a contraindication to the use of military antishock trousers.
Prehospital ultrasonography

In a preliminary 2006 study from Norway, Busch evaluated the feasibility of using portable
ultrasound in an air rescue setting, concluding that prehospital ultrasonography could provide
diagnostic and therapeutic benefit when conducted by a proficient examiner who used goaldirected and time-sensitive protocols.[43] Further study in this area may help to determine the
indications and role of prehospital ultrasonography.
Hospital Management

Immediate attention to the ABCs (airway, breathing, circulation) while assessing vital signs and
oxygen saturation is paramount, particularly in patients with thoracic trauma. Evaluate the
patency of the airway and the adequacy of the ventilatory effort. Assess the circulatory status and
the integrity of the chest wall. Carefully evaluate the cardiovascular system, because a tension
pneumothorax and pericardial tamponade can cause similar findings.
Emergency department (ED) care depends on the hemodynamic stability of the patient. All
patients should receive supplemental oxygen to increase oxygen saturation and to enhance the
reabsorption of free air.
Note that ultrasonography is the only radiographic modality that allows patients with
nonarrhythmogenic cardiac arrest to continue undergoing resuscitation while clinicians search

for easily reversible causes of asystole or pulseless electrical activity (PEA).[62] A protocol (using
the acronym CAUSE for cardiac arrest ultrasound exam) in which cardiac arrest patients,
concurrent with resuscitation, receive bedside ultrasonography to look for cardiac tamponade,
massive pulmonary embolus, severe hypovolemia, and tension pneumothorax has been proposed
for further investigation. It is possible that the eventual adoption of ultrasonography in this
setting may allow increased "real-time" diagnostic acumen, decreasing the time required to
receive appropriate condition-related therapy.
Primary and secondary spontaneous pneumothorax

If the primary spontaneous pneumothorax (PSP) is smaller than 15% (or estimated as small) (see
Estimating the size of the pneumothorax under Chest Radiography), and the patient is
symptomatic but hemodynamically stable, needle aspiration is the treatment of choice.
If the PSP is smaller than 15% and if the patient is asymptomatic, many consider observation to
be the treatment of choice. (If the patient is admitted, administer oxygen, as this has been shown
to speed resolution of the pneumothorax.)
If the PSP is greater than 15% (or estimated as large) aspiration using a pigtail catheter left to
low suction or water seal is recommended. Strong suction should not be used with a spontaneous
pneumothorax because of an often-delayed presentation and, thus, an increased risk of
reexpansion pulmonary edema (see Complications).
Spontaneous pneumothorax is a life-threatening condition in patients with severe underlying
lung disease; thus, tube thoracostomy is the procedure of choice in secondary spontaneous
pneumothorax (SSP).
Pleurodesis decreases the risk of recurrence, as does thoracotomy or video-assisted thoracoscopy
(VAT) to excise the bullae.
Iatrogenic and traumatic pneumothorax

Aspiration is the technique of choice for iatrogenic pneumothoraces, because recurrence is


usually not a factor. Tube thoracostomy is reserved for very symptomatic patients.
In general, traumatic pneumothoraces should be treated with insertion of a chest tube,
particularly if the patient cannot be closely observed. Chest tubes are attached to a one-way valve
apparatus that uses a water chamber to avoid a direct connection to atmospheric pressure (so that
during inspiration, when negative pressure is generated, air does not rush into the pleural space)
and allows for the continuous removal air from the pleural cavity during respiration. Changing
the pressure above the water seal allows for below atmospheric suction to further remove air
from the pleural space. The collapsed lung reexpands and heals, thereby preventing continued air

leakage. After air leaks have ceased for 24 hours, the vacuum may be decreased and the chest
tube removed.
The process of lung reexpansion and healing is not immediate and may be complicated by
pulmonary edema; therefore, a chest tube is usually left in place until the clinical conditions are
met; any complications warrant longer placement.
A subset of patients who have a small (< 15-20%), minimally symptomatic pneumothorax may
be admitted, observed closely, and monitored by using serial chest radiographs. In these patients,
administration of 100% oxygen promotes resolution by speeding the absorption of gas from the
pleural cavity into the pulmonary vasculature.
Although commonly used, few data exist in the medical literature showing the efficacy of the
procedure or reviewing the field-use and incidence of the needle decompression.
Tension pneumothorax

Tension pneumothorax remains a life-threatening condition diagnosed under difficult conditions,


with a simple emergency procedure as treatment (ie, needle decompression). Make sure no
contraindications exist for the placement of an emergency decompression catheter into the
thorax. Previous thoracotomy, previous pneumonectomy, and presence of a coagulation disorder,
for example, are relative contraindications, because failure to treat tension pneumothorax
expectantly can result in patient death.
Under emergent circumstances, place decompression catheters in the second rib interspace in the
midclavicular line. This site was confirmed by Wax and Leibowitz, who reviewed 100 thoracic
computed tomography (CT) scans by measuring the distance from the midline to the internal
mammary artery and the average thickness of the tissues.[63] This procedure punctures through the
skin and, possibly, through the pectoralis major muscle, external intercostals, internal
intercostals, and parietal pleura. Placement in the middle third of the clavicle minimizes the risk
of injury to the internal mammary artery during the emergency procedure.[63] Place the catheter
just above the cephalad border of the rib, because the intercostal vessels are largest on the lower
edge of the rib.
Harcke et al had similar results when they used CT scan analysis of deployed male military
personnel to determine that, at the second right intercostal space in the midclavicular line, the
mean horizontal thickness was 5.36 cm, and that an 8-cm angiocatheter would reach the pleural
space in 99% of the male soldiers in this series.[64]
Unfortunately, in a 2005 study of emergency physicians, 21 of whom had completed advanced
trauma and life support (ATLS) training, only 60% were able to correctly identify the second
intercostal space when attempting to locate the needle thoracostomy site on a human volunteer,

and all placed the thoracentesis needle medial to the midclavicular line.[62] In the same study, 8%
of participants inappropriately identified the site used for needle pericardiocentesis and 4%
inappropriately identified the fifth intercostal space in the anterior axillary line.[62]
A 2011 study by Sanchez et all suggests the anterior approach is typically more successful than
the lateral approach when it comes to angiocatheters, although the anterior approach is not
failsafe. Further, longer angiocatheters may increase the chances of decompression, but the risk
of damage to surrounding vital structures is higher.[65]
Related to the development of apparent life-threatening hemorrhage after decompression in the
second intercostal space at the anterior, midclavicular line in patients with no initial evidence of
hemothorax on presentation, it has been suggested that a potentially safer option is to
decompress a pneumothorax in the fifth intercostal space at the anterior axillary line, similar to
recommendations for chest drain insertion.
If a hemothorax is associated with the pneumothorax, additional chest tubes may be needed to
assist drainage of blood and clots. If the hemopneumothorax requires insertion of a second chest
tube, the second tube should be directed inferiorly and should be posterior to the apex of the
diaphragm.
Another point to take note of is that a significant number of patients have a larger chest wall than
can be penetrated by a catheter length of 5 cm. In particular, men undergoing treatment for
tension pneumothorax are more likely to have a larger body habitus with wider chest wall, such
that performing needle thoracostomy may need a catheter longer than 5 cm to reliably penetrate
into the pleural space.
In one study, a catheter length of patients at an American level 1 trauma center showed that a
catheter length of 5 cm would reliably penetrate the pleural space in only 75% of patients.[66] A
2008 study analyzing average chest wall thickness at the second intercostal space in the
midclavicular line concluded that a 4.5-cm catheter length may not penetrate the chest wall in
approximately 10-35% of trauma patients, depending on age and sex.[67]
Catamenial pneumothorax

Oral contraceptives carry a high success rate in the treatment of catamenial pneumothorax,
although this condition may also (rarely) be treated surgically. Most cases present during or
shortly after menses, and the spontaneous pneumothorax is usually right-sided.
Pneumomediastinum

Most patients with pneumomediastinum should be observed for signs of serious complications
(eg, pneumothorax, tension pneumothorax, mediastinitis). If the pneumomediastinum occurred

from the inhalation of cocaine or smoking of marijuana, observation in the ED for progression
may be indicated.
A follow-up chest radiograph should be obtained in 12-24 hours to detect any progression or
complication, such as pneumothorax. If no progression occurs at 24 hours and if no evidence of
mediastinitis exists, the patient may be discharged.

ndications for Surgical Assistance


If the patient has had repeated episodes of pneumothorax or if the lung remains unexpanded after
5 days with a chest tube in place, operative therapy may be necessary. The surgeon may use
treatment options such as thoracoscopy, electrocautery, laser treatment, resection of blebs or
pleura, or open thoracotomy. Other surgical indications are as follows:

Persistent air leak for longer than 7 days

Recurrent, ipsilateral pneumothorax

Contralateral pneumothorax

Bilateral pneumothorax

First-time presentation in a patient with a high-risk occupation (eg, diver, pilot)

Patients with acquired immunodeficiency syndrome (AIDS) (often because of extensive


underlying necrosis)

Unacceptable risk of recurrent pneumothorax for patients with plans for extended stays at
remote sites

Lymphangiomyomatosis, a condition causing a high risk of pneumothorax [68]

Thoracotomy

While thoracotomy is the criterion standard, video-assisted thoracoscopic surgery (VATS) has
been replacing thoracotomy in the treatment of chronic or persisting pneumothoraces due to the
aforementioned reasons. Recurrence rates with thoracotomy are as low as 4%.[70]
Talc is the preferred agent for pleurodesis. It can be administered by insufflation or as a slurry.
Insufflation of talc and thoracotomy has a recurrence rate of 0-7%.

Complications

Misdiagnosis is the most common complication of needle decompression. If a pneumothorax but


not a tension pneumothorax is present, needle decompression creates an open pneumothorax.
Alternatively, if no pneumothorax exists, the patient may develop a pneumothorax after the
needle decompression is performed. Additionally, the needle may lacerate a lung, which,
although rare, can cause significant pulmonary injury or hemothorax. If the needle is initially
placed too medially to the sternum, needle decompression may cause a hemothorax by lacerating
the inferior set of intercostal vessels or the internal mammary artery.
Damage to the intercostal neurovascular bundle and lung parenchymal injury can occur
following thoracostomy tube placement, especially if trocars are used for placement, and there is
an increased risk of postoperative bleeding after lung transplantation for medical pleurodesis and
surgery (length of hospital stay not affected).[68]
Accidental disconnection and malpositioning of Heimlich valves can complicate an attempted
outpatient treatment of pneumothorax via pigtail catheter.
Pneumothorax complications include the following:

Hypoxemic respiratory failure

Respiratory or cardiac arrest

Hemopneumothorax

Bronchopulmonary fistula

Pulmonary edema (following lung reexpansion)

Empyema

Pneumomediastinum

Pneumopericardium

Pneumoperitoneum

Pyopneumothorax

Complications of surgical procedures include the following:

Failure to cure the problem

Acute respiratory distress or failure

Infection of the pleural space

Cutaneous or systemic infection

Persistent air leak

Reexpansion pulmonary edema

Pain at the site of chest tube insertion

Prolonged tube drainage and hospital stay

Reexpansion pulmonary edema


Reexpansion pulmonary edema is a unilateral pulmonary edema that is seen after reinflation of a
collapsed lung. It can also occur in the opposite lung. The incidence, etiology, risks, and
mortality rates of this condition are controversial.
Findings from animal studies and several case reports in humans indicate that reexpansion
pulmonary edema may occur more often if a pneumothorax is present for longer than 3 days, if
the evacuation volume is greater than 2000 mL, and if suction is applied. This information is
important because in one study, 46% of patients waited more than 2 days after their symptoms
started to seek medical attention, and, in another study, 18% waited more than 7 days.

Tension pneumothorax
A worsening pneumothorax, usually with a 1-way valve phenomenon, can allow air into the
intrapleural space and prevent its escape, causing mediastinal shift, pulmonary shunting, and
circulatory collapse.
Treatment of tension pneumothorax is emergent and should be performed before confirmatory
radiologic studies. Needle decompression is performed before definitive treatment with tube
thoracostomy (see Tension pneumothorax under Hospital Management).
In mechanically ventilated patients, high pressures and air trapping place patients at risk for
tension pneumothorax if the thoracostomy is not functioning. Patients with smaller
pneumothoraces that would otherwise be managed with aspiration or observation sometimes
undergo thoracostomy because of the need for mechanical ventilation.

Você também pode gostar