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Pneumothorax

  • Pneumothorax is the presence of air within the pleural space
  • Due to disruption of parietal, visceral or mediastinal pleura
  • May also occur from spontaneous rupture of subpleural bleb
  • A tension pneumothorax occurs when pleura form a one-way flap valve
  • Tension pneumothorax is a medical emergency

Classification

  • Spontaneous pneumothorax
    • Primary - no identifiable pathology
    • Secondary - underlying pulmonary disorder
    • Catamenial
  • Traumatic
    • Blunt or penetrating thoracic trauma
    • Iatrogenic
      • Postoperative
      • Mechanical ventilation
      • Thoracocentesis
      • Central venous cannulation

Primary spontaneous pneumothorax

  • Usually occurs in young healthy adult men
  • 85% patients are less than 40 years old
  • Male : female ratio is 6:1
  • Bilateral in 10% of cases
  • Occurs as result of rupture of an acquired subpleural bleb
  • Blebs have no epithelial lining and arise from rupture of the alveolar wall
  • Apical blebs found in 85% of patients undergoing thoracotomy
  • Frequency of spontaneous pneumothorax increases after each episode
  • Most recurrences occur within 2 years of the initial episode

Secondary spontaneous pneumothorax

  • Accounts for 10-20% of spontaneous pneumothoraces
  • can be due to:
    • Chronic obstructive pulmonary disease with bulla formation
    • Interstitial lung disease
    • Primary and metastatic neoplasms
    • Ehlers-Danlos syndrome
    • Marfan's syndrome

Traumatic pneumothorax

  • Can result from either blunt or penetrating trauma
  • Tracheobronchial and oesophageal injuries can cause both mediastinal emphysema and pneumothorax
  • Iatrogenic pneumothorax is common
  • Occurs after
    • Pneumonectomy
    • Thoracocentesis
    • High-pressure mechanical ventilation
    • Subclavian venous cannulation

Clinical features

  • Predominant symptom is acute pleuritic chest pain
  • Dyspnoea results form pulmonary compression
  • Symptoms are proportional to the size of the pneumothorax
  • Also depend on the degree of pulmonary reserve
  • Physical signs include
    • Tachypnoea
    • Increased resonance
    • Absent breath sounds
  • In a tension pneumothorax
    • The patient is hypotensive with acute respiratory distress
    • The trachea may be shifted away from the affected side
    • Neck veins may be engorged
  • Diagnosis can be confirmed with a chest x-ray

Right pneumothorax

Management

Spontaneous pneumothorax

  • Depends symptoms and the radiological size of the pneumothorax
  • Small asymptomatic pneumothoraces (<20%) may simply be followed with serial chest x-rays
  • If drainage required a chest drain should be inserted
    • Through the 5th intercostal space
    • Just above the upper border of the rib
    • Blunt insertion (rather than using the trocar) should be used
    • Position should be checked with a chest x-ray
    • Should be connected to an underwater seal placed below the level of the patient

Tension pneumothorax

  • Prophylactic chest drains should be inserted in patients with rib fractures prior to ventilation
  • Tension pneumothorax requires immediate needle aspiration
  • Inserted anteriorly through the 2nd intercostal space
  • Chest drain can then be inserted

Tension pneumothorax

Picture provided by Abid Majeed, Services Hospital, Lahore, Pakistan

Surgery

  • Surgery is required for
    • Air leak persisting for more than 10 days
    • Failure of lung re-expansion
    • Recurrent spontaneous pneumothorax
  • Surgical options include
    • Partial pleurectomy
    • Operative abrasion of pleural lining
    • Resection of pulmonary bullae
  • Poor-risk patients may benefit from chemical pleurodesis with tetracycline

Bibliography

Devanand A, Koh M S, Ong T H et al. Simple aspiration versus chest-tube insertion in the management of primary spontaneous pneumothorax: a systematic review.  Respir Med 2004;  98:  579-590.

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