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PNEUMOTHORAX
by

Kevin T. Martin
BVE, RRT, RCP

RC Educati onal Consulti ng Servi ces, Inc.
16781 Van Buren Blvd, Sui te B, Ri versi de, CA 92504-5798
(800) 441-LUNG / (877) 367-NURS
www. RCECS. c om
PNEUMOTHORAX
This material is copyrighted by RC Educational Consulting Services, Inc. Unauthorized duplication is prohibited by law.
2
BEHAVIORAL OBJECTIVES

UPON COMPLETION OF THE READING MATERIAL, THE PRACTITIONER WILL BE
ABLE TO:

1. For each of the following types of pneumothoraces, site the incidence, etiology, clinical
manifestations, diagnosis and treatment:

Primary spontaneous pneumothorax

Secondary spontaneous pneumothorax

Catamenial pneumothorax

Iatrogenic pneumothorax

Traumatic pneumothorax

Tension pneumothorax

2. Define re-expansion pulmonary edema.

3. Describe the steps to take to prevent re-expansion pulmonary edema.

4. Briefly outline the procedure for needle aspiration.

5. Briefly outline the procedure for chest tube insertion.

6. Briefly describe how to apply a pleural chest drainage system.

7. Apply the knowledge gained in this course during a clinical practice exercise.

COPYRIGHT 1992 By RC Educational Consulting Services, Inc.
COPYRIGHT April, 2000 By RC Educational Consulting Services, Inc.

(# TX 3 380 057)

Authored 1992 by Kevin T. Martin, BVE, RRT, RCP
Revised 1994, 1997 by Kevin T. Martin, BVE, RRT, RCP
Revised 2001 by Susan Jett Lawson, RRT, RCP
Revised 2004 by Michael R. Carr, BA, RRT, RCP
Revised 2007 by Michael R. Carr, BA, RRT, RCP

PNEUMOTHORAX
3

ALL RIGHTS RESERVED

This course is for reference and education only. Every effort is made to ensure that the clinical
principles, procedures and practices are based on current knowledge and state of the art
information from acknowledged authorities, texts and journals. This information is not intended
as a substitution for a diagnosis or treatment given in consultation with a qualified health care
professional.

PNEUMOTHORAX
4
TABLE OF CONTENTS

INTRODUCTION.............................................................................................................. 7

GENERAL INFORMATION............................................................................................. 7

COMMON CAUSES OF PNEUMOTHORAX. ................................................................ 9

PRIMARY SPONTANEOUS PNEUMOTHORAX.......................................................... 9

INCIDENCE.................................................................................................................. 9

ETIOLOGY................................................................................................................... 9

CLINICAL MANIFESTATIONS ............................................................................... 10

DIAGNOSIS................................................................................................................ 10

TREATMENT ............................................................................................................. 11

SECONDARY SPONTANEOUS PNEUMOTHORAX ..................................................18

INCIDENCE................................................................................................................ 18

ETIOLOGY - COPD................................................................................................... 18


DIAGNOSIS................................................................................................................ 18

TREATMENT ............................................................................................................. 19

CATAMENIAL PNEUMOTHORAX.............................................................................. 19

INCIDENCE AND ETIOLOGY................................................................................. 19


IATROGENIC PNEUMOTHORAX ................................................................................19

INCIDENCE................................................................................................................ 19

ETIOLOGY................................................................................................................. 20

PNEUMOTHORAX
5
DIAGNOSIS................................................................................................................ 20

TREATMENT ............................................................................................................. 20

TRAUMATIC PNEUMOTHORAX .................................................................................21

INCIDENCE AND ETIOLOGY................................................................................. 22

TREATMENT ............................................................................................................. 22

TENSION PNEUMOTHORAX .......................................................................................23


DIAGNOSIS................................................................................................................ 24

TREATMENT ............................................................................................................. 24

RE- EXPANSION PULMONARY EDEMA.....................................................................25

INCIDENCE................................................................................................................ 25

PATHOPHYSIOLOGY............................................................................................... 26


PREVENTION............................................................................................................. 26

WORKUP FOR ALL SUPECTED PNEUMOTHORACES ............................................26

NEEDLE ASPIRATION PROCEDURE (THORACENTESIS) ......................................27

CHEST TUBE / TUBE THORACOSTAOMY PROCEDURE....................................... 28

PLEURAL DRAINAGE SYSTEMS................................................................................ 31

DESCRIPTION............................................................................................................ 31

INDICATIONS FOR USE.......................................................................................... 31

PRECAUTIONS.......................................................................................................... 31

CLINICAL PRACTICE EXERCISE............................................................................... 34

SUMMARY...................................................................................................................... 35

PNEUMOTHORAX
6
PRACTICE EXERCISE DISCUSSION........................................................................... 37

SUGGESTED READING AND REFERENCES ............................................................ 38

PNEUMOTHORAX
7
INTRODUCTION

pneumothorax is air in the pleural space. It results from an opening between the pleura
and the atmosphere. The opening may be in the chest wall or in the lungs.
Pneumothoraces are classified as spontaneous or traumatic, depending upon whether
there is an obvious cause of trauma. Either type can result in a tension pneumothorax. All of
these are discussed in the following course. Re-expansion pulmonary edema, as a result of rapid
inflation of an atelectatic lung due to pneumothorax, also is discussed.

GENERAL INFORMATION

ining the inside of the chest cavity is the parietal pleura. Lining the outside of the lungs is
the visceral pleura. Between the two is the pleural space. The pressure within the pleural
space is negative (about -5 cm H
2
O) in comparison to alveolar and atmospheric pressure.
During normal breathing, the negative intrapleural pressure decreases slightly on inspiration and
increases (approaches 0) on expiration. The outward pull of the chest cage on the parietal pleura
and the inward pull of the lung on the visceral pleura produce this negative pressure. The lung
volume at which the outward pull equals the inward pull is the functional residual capacity
(FRC).

If there is an opening made into the pleural space, air rapidly rushes in due to the negative
pressure. Air continues to enter the space until pressure equalizes or the opening closes.
Generally, pleural pressure simply rises from -5 cm H
2
O to atmospheric pressure (0 cm H
2
O).
However, in the case of tension pneumothorax, pressure continues to rise above 0 cm H
2
O.

As pressure in the pleural space rises, lung tissue collapses. The amount of collapse is dependent
on the size of the pneumothorax. A very small pneumothorax (<25%) may be asymptomatic and
A
L
CHEST CAVITY
Parietal Pleura Visceral Pleura
Pleural Space
Interstitium
PNEUMOTHORAX
8
go completely unnoticed. A very large pneumothorax collapses the entire lung on the affected
side and produces numerous symptoms. In addition to dyspnea and hypoxia, there may be a
mediastinal shift to the opposite side, an enlarged hemithorax, and a depressed diaphragm.
When this occurs, it is termed tension pneumothorax.

The main physiological consequences of pneumothorax are a low V/Q ratio, shunting, and
possibly alveolar hypoventilation. The PaO
2
and vital capacity (VC) also decrease. Even if the
air is evacuated from the pleural space, it still may take several hours for the PaO
2
to return to
normal. Fortunately, most patients tolerate a simple, uncomplicated pneumothorax very well.
However, patients with underlying lung disease may find them life-threatening.

Pneumothoraces are classified as spontaneous or traumatic with subclassifications for each type.
Subclassifications for a spontaneous pneumothorax are primary or secondary. Subclassifications
for a traumatic pneumothorax are iatrogenic or noniatrogenic. Primary pneumothorax occurs in
an otherwise healthy person with no underlying lung disease. Secondary pneumothorax is a
complication of an underlying lung condition, usually emphysema, asthma or interstitial fibrosis.
Iatrogenic pneumothorax occurs as a result of a diagnostic or therapeutic maneuver.

Noniatrogenic pneumothorax occurs due to blunt or penetrating chest trauma. A discussion of
each type follows. Please note that treatment is discussed extensively under primary
spontaneous pneumothorax, but the principles discussed apply to all types.

There are many potential causes of pneumothorax. Some are idiopathic, occurring for no
apparent reason. These are generally presumed to be rupture of a bleb, cyst, or bulla. A rupture
or tear of the esophagus or mediastinal structures can also produce a pneumothorax. Chronic
lung disease and positive pressure ventilation may result in numerous pneumothoraces. Many of
these are probably from rupture of a bleb, cyst, or bulla as with idiopathic causes.

Compliments of Adam, Inc.
PNEUMOTHORAX
9
Infections, tumors, or foreign bodies may produce a bronchopleural connection. This can cause
air to leak into the pleural space. Lastly, trauma, thoracentesis, pleural biopsy, or insertion of
central venous catheters can produce a pneumothorax.

COMMON CAUSES OF PNEUMOTHORAX

Alveolar or airway rupture:

Idiopathic (probable rupture of bleb, cyst, or bulla)

Esophageal or mediastinal rupture

Chronic lung disease

Positive pressure ventilation (particularly with PEEP)

Infection, tumor, or foreign body producing a bronchopleural connection

Chest wall rupture:

Trauma

Thoracentesis or pleural biopsy

CVP insertion

PRIMARY SPONTANEOUS PNEUMOTHORAX

NCIDENCE - There are approximately 8600 reported cases of primary spontaneous
pneumothorax in the United States each year. The actual incidence is probably higher than
this because many are not reported. A small spontaneous pneumothorax may cause no
symptoms serious enough to seek medical help. The patient may notice a slight pain on deep
inspiration afterward, but this disappears quickly. Activities of daily living are not impaired so
no medical report is made. In reported cases, primary spontaneous pneumothorax (age adjusted)
is more prevalent in males, occurring in about 7.4 per 100,000 per year. In females, the
prevalence is 1.2 per 100,000 persons per year. Marfans syndrome is associated with an
increased risk of pneumothorax.

ETIOLOGY - The etiology of primary spontaneous pneumothorax is believed to be rupture of a
subpleural emphysematous bleb, usually in the apex. Blebs may be a result of a congenital
abnormality, inflammation of the bronchioles, or a disturbance of collateral ventilation. There is
a very strong association of spontaneous pneumothorax with cigarette smoking. Approximately
92% of the cases are past or present smokers. Smoking increases the risk of pneumothorax 22-
fold in males and 9-fold in females. For primary, spontaneous pneumothorax, the peak age is in
the early twenties and rarely occurs after age forty.
I
PNEUMOTHORAX
10
Patients who develop spontaneous pneumothorax tend to be tall, thin, and have a familial
tendency to pneumothorax. The increased length of the chest in tall, thin individuals probably
contributes to the formation of blebs. Increased length causes a greater pleural pressure gradient
from the base of the lung to the apex. Therefore, alveoli at the apex are subject to greater mean
distending pressures in tall individuals. Over an extended period, this leads to formation of
blebs, particularly in those genetically predisposed to bleb formation.

There is also a greater frequency of occurrence of primary spontaneous pneumothorax when
there are abrupt changes in atmospheric pressure. A drop in pressure of 10 millibars or more
within the preceding 48 hours increases spontaneous pneumothorax more than 40%. The risk of
pneumothorax also increases when there are four or more atmospheric pressure fluctuations
within 48 hours. Repeated exposure to atmospheric pressure variations probably subject
subpleural blebs to additional stress. The result is rupture and a pneumothorax.

CLINICAL MANIFESTATIONS - Primary spontaneous pneumothorax usually develops at
rest. Less than 10% occur during exercise. Patients usually do not seek immediate medical
advice. Some wait a week or more if there is no serious disability. The disadvantage of the wait
for the patient is that the incidence of re-expansion pulmonary edema increases for patients with
pneumothoraces that have been present for three or more days.

Symptoms:

Dyspnea and chest pains are the main symptoms, if any. The patient may complain of general
malaise. Pain is of acute onset and localized to the side of the pneumothorax. The pain often
changes from sharp and knifelike to a steady ache after several hours.

Physical:

Vital signs are usually normal, except for tachycardia. If the heart rate exceeds 140 per minute
or if hypotension, cyanosis, or electromechanical dissociation (EMD) is present, suspect a
tension pneumothorax. Hypoxia via pulse oximetry may be noted.

The side with the pneumothorax may appear larger and have less movement than the unaffected
side. There is decreased tactile fremitus, a hyperresonant percussion note, and absent or
decreased breath sounds on the involved side. A right-sided pneumothorax also may shift the
lower edge of the liver anteriorly. A large pneumothorax shifts the trachea to the opposite side.

DIAGNOSIS - The clinical history and physical raises the suspicion of pneumothorax. A chest
X-ray taken at full-expiration (when the lungs are smallest) establishes the actual diagnosis. One
should look for a thin (< 1 mm thick) visceral pleural line displaced away from the chest wall. In
approximately 15% there is also a small pleural effusion.

PNEUMOTHORAX
11

Pneumothorax

A 15% pneumothorax appears as a 1 cm or less pleural separation. A 30% pneumothorax
appears as a 2 to 2.5 cm separation. A complete pneumothorax decreases the lung to a 3 to 4 cm
diameter opacity at the hilum. A small pneumothorax can be mistaken for a large bullae.
However, the edge of a bullae is convex to the chest wall. The edge of a pneumothorax (the
pleural line) is concave to the chest wall.

Over 50% of patients with spontaneous pneumothorax have another in the years following.
Recurrent pneumothoraces occur on the same side as the previous pneumothorax. The average
interval between the first and second pneumothorax is around 2.3 years. If there is a second or
third pneumothorax without a thoracotomy being done for investigation and treatment, the
incidence of recurrence increases. Therefore, the diagnosis of pneumothorax should always be
suspected in a patient with a previous history of primary spontaneous pneumothorax. There is
some evidence that spontaneous pneumothorax may be due to primary pulmonary histiocytosis
X. This is a disease characterized by eosinophilic and histiocytic infiltration of lung tissue. It
primarily affects young smokers and usually presents with symptoms of cough, dyspnea ad chest
pain. Successful treatment may be thoracoscopic stapling of bullae ad pleural abrasion.

TREATMENT - Treatment is aimed at two goals: getting rid of air in the pleural space and
decreasing the possibility of recurrence. It should be remembered that rarely is a primary
spontaneous pneumothorax life-threatening. For many, once the hole causing the pneumothorax
has closed, simple observation is all that is necessary. The air in the pleural space is gradually
reabsorbed. Reabsorption is slow, taking approximately 16 days for a 20% pneumothorax. (Air
is absorbed from the pleural space at the rate of 1.25% of the hemithorax volume per 24 hours).

Pneumothoraces less than 15% are generally left untreated. No treatment is required if:

1. It is a primary pneumothorax.

PNEUMOTHORAX
12
2. There are no other chest X-ray abnormalities.

2. There are no symptoms and normal vital signs.

4. The patient is less than 40 years old.

5. The history suggests a recent (less than 24 hours) occurrence.

6. There is no progression on the chest X-ray after 6 hours.

Some may choose to administer low-flow oxygen. Oxygen administration may speed the
reabsorption process by flushing nitrogen from the lung. This creates a pressure gradient
between the alveolar and pleural air for nitrogen. Nitrogen-rich air from the pleural space then
diffuses into the alveoli. A pneumothorax can be reabsorbed 4 to 6 times faster with a high FIO
2
.
(However, oxygen toxicity can develop with prolonged use of greater than 60% oxygen).

More active treatment consists of catheter aspiration, tube thoracostomy, tube thoracostomy with
instillation of a sclerosing agent (chemical pleurodesis), or open thoracostomy. The first,
catheter (or needle) aspiration requires insertion of a 16-gauge needle with an internal
polyethylene catheter. The procedure is performed under local anesthesia. The needle is
inserted in the second anterior intercostal space at the midclavicular line. Generally, air rises so
one aspirates from the upper pleural space. An alternate site may be necessary if the
pneumothorax is localized or adhesions are present. (Pleural adhesions prevent air from rising so
another site may be necessary).

PNEUMOTHORAX
13

The needle is extracted after insertion, leaving the catheter in place. A 3-way stopcock and 50-cc
syringe are attached and air is manually withdrawn until there is no more. If greater than 4 liters
are withdrawn and no resistance is felt, one should assume there has been no lung re-expansion
or there is a persistent air leak. An alternate procedure (chest tubes) is then necessary. The
catheter is removed after aspiration. Simple aspiration is useful in the vast majority of patients
with primary spontaneous pneumothorax greater than 15%. It is less useful for recurrent
pneumothorax and unnecessary for a small pneumothorax. There is minimal morbidity
associated with the procedure.

Compliments of Adam, Inc.
PNEUMOTHORAX
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TIME TO REVIEW

1. What is the most common cause of hemothorax?

A. Chest trauma
B. Malignancy
C. Surgery
D. Pulmonary embolism

2. What is the most sensitive test for the detection of a small pneumothorax?

A. Lateral decubitus chest film
B. Computed tomography
C. Ultrasonography
D. Upright anteriorposterior (AP) chest film

3. Primary spontaneous pneumothorax occurs in a patient with no previous underlying lung
disease.

A. True
B. False

PNEUMOTHORAX
15

If aspiration is ineffective, tube thoracostomy (chest tubes) are necessary. Chest tubes are
indicated for primary spontaneous pneumothorax with severe dyspnea, chest pain, hypoxemia, or
those who fail simple catheter aspiration. Chest tubes also are indicated for secondary
spontaneous pneumothorax greater than 15% and traumatic pneumothoraces, especially if due to
positive pressure ventilation. Evacuation of air and re-expansion of the lung are generally rapid
with tube thoracostomy.

Suction applied to the tubes is rarely necessary and is associated with an increased incidence of
re-expansion pulmonary edema. Reserve suction for those who have no lung expansion within
24 hours of chest tubes. Large bore chest tubes are used to minimize the possibility of occlusion.
As with needle aspiration, chest tubes are generally inserted in the upper pleural space and
directed anteriorly for pneumothorax. They are inserted in the lower pleural space and directed
posteriorly for liquid evacuation of pleural material.

CHEST TUBES
Attach chest tube to underwater
seal drainage system.
PNEUMOTHORAX
16
Indications for the insertion of a chest tube include:

Pleural space
Hemothorax
Empyema
Pleural effusion
Chylothorax
Tension pneumothorax
> 10-20% simple pneumothorax

Mediastinal space
Free air
Free blood or other fluid

Pericardial space
Cardiac tamponade
Pneumopericardium

There is a high rate of recurrent collapse if chest tubes are removed too soon. They should be
left in place for 24 hours after the air leak stops and the lung is re-expanded. They should be
clamped in place for an additional 24 hours. Remove the tubes only if the lung does not re-
collapse after this time.

Chest drainage systems typically consist of three components; a collection bottle/chamber, a
water seal, and a water column suction control bottle/chamber. For a simple pneumothorax
requiring the evacuation of air only, the collection bottle is omitted. The collection bottle allows
measurement of fluid drainage and prevents drainage from entering the water seal. This is
unnecessary if there is no significant pleural effusion or fluid.

The water seal uses a tube submersed in water (usually 2 cm of water). The tube functions as a
one-way valve allowing air to leave the pleural space but not enter. On inspiration, a negative
intrapleural pressure causes water to rise in the tube. On expiration, a positive intrapleural
pressure forces air out of the tube. This produces bubbles in the water. (Bubbling means that air
is escaping the pleural space).

The third component, a water column suction control bottle, provides a controlled amount of
suction. A vent tube is submersed in a column of water corresponding to the maximum negative
pressure allowed. For example, a 20 cm column of water produces a pressure of 20 cm H
2
O.
The vent tube vents to the atmosphere. Should the wall suction exceed this pressure, air is pulled
in from the atmosphere. This prevents excessive negative pressure from acting on the lung. The
bottle is then connected to wall suction at the desired negative pressure.

Since approximately 50% of primary spontaneous pneumothorax patients have a recurrence,
injection of a sclerosing agent has been performed to reduce its likelihood. Various agents have
been used, with tetracycline being the current agent of choice. Tetracycline appears very
PNEUMOTHORAX
17
effective in creating adhesions between the visceral and parietal pleura (pleurodesis). Adhesions
glue the pleura together decreasing the possibility of rupture. There are no long-term studies
on possible adverse effects, so it is not recommended for patients on their first episode.
However, if there is a recurrence, it should be treated with intrapleural tetracycline. The
recommended dosage is 20-35 mg/kg injected into the pleural space at the time of the initial
pneumothorax. The higher dose is more effective in creating adhesions.

Other agents used for pleurodesis are silver nitrate, talc, varidase, 50% glucose, blood and
varidase, diacetyl phosphate, and doxycycline. (Some feel the pleural irritation of doxycycline is
more effective at pleurodesis than tetracycline). After injection of any agent, the patient must be
repositioned frequently to distribute the fluid. Injection of sclerosing agents do not cause or
affect underlying lung disease. They also do not produce a chest X-ray of pleural thickening.
Pleurodesis with all agents is very painful so the patient must be premedicated with lidocaine. A
dose of 1.5-3 mg/kg lidocaine is injected in the pleural space and flushed with 50 cc of normal
saline. (Dosage is 35 mg/kg doxycycline in 50-100 cc of 1% lidocaine). Large doses of
morphine or meperidine are necessary for up to 1-2 hours after injection.

Open thoracostomy (surgery) is used for oversewing of an air leak and scarification of the pleura.
There are several indications for surgical intervention:

1. A massive air leak is present and the lung does not re-expand within 24 hours
following insertion of two chest tubes attached to suction.

2. An excessive air leak is present after 7-10 days.

3. A third ipsilateral pneumothorax occurs.

4. A spontaneous hemopneumothorax occurs with blood loss more than 1000 cc.

5. Bilateral spontaneous pneumothorax occurs.

6. Large cysts are recognized on chest x-rays simultaneous with the spontaneous
pneumothorax.

7. The first spontaneous pneumothorax of a pilot, scuba diver, or a patient who lives in a
remote area.

Once the leak has been sewed the pleura is scarified to create adhesions. Various methods of
scarification have been used, ranging from pleurectomy to abrasion with dry sponges or gauze.
Abrasion with gauze is recommended because it is less traumatic than pleurectomy and will not
affect a future thoracotomy, if necessary. Dry abrasion can be followed by injection of
tetracycline or doxycycline for additional pleurodesis.

PNEUMOTHORAX
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SECONDARY SPONTANEOUS PNEUMOTHORAX

econdary spontaneous pneumothorax is often serious and frequently life-threatening.

INCIDENCE - Its incidence is similar to that of primary spontaneous pneumothorax, about
7500 per year in the United States and generally occurs in older patients. Frequency for
secondary spontaneous pneumothorax (age-adjusted) is 6.3/100,000 for men and 2/100,000 for
women annually. It is three times more common in males than females.

ETIOLOGY - COPD (asthma, interstitial fibrosis and emphysema) is the primary etiology in
the majority of patients. Cystic fibrosis patients also have a high incidence.

CLINICAL MANIFESTATIONS

Symptoms:

The clinical manifestations are the same as with primary spontaneous pneumothorax but much
more severe. (Since most patients are already compromised from an underlying lung condition,
symptoms are obviously more severe). The patient experiences shortness of breath and chest
pain (ipsilateral). The mortality rate is around 16%.

Physical:

Tachypnea, tachycardia, hypoxia, cyanosis and possibly hypotension may be present. Secondary
spontaneous pneumothorax should be considered in the COPD patient who experiences
increasing shortness of breath with associated chest pain. Pneumothorax can be difficult to
diagnose in these patients since they already have hyperexpanded lungs, tactile fremitus,
decreased breath sounds, and a hyperresonant percussion note. Many of the normal clinical
manifestations of COPD conceal the manifestations of a pneumothorax.

DIAGNOSIS - Diagnosis is again made by the presence of a pleural line on the chest x-ray.
This can be difficult to see on the COPD patient because the lungs are already hyperlucent from
airtrapping. In fact, there is little difference in radiodensity between a pneumothorax and an
emphysematous lung. The pneumothorax may be overlooked if the film is overexposed. It is
important to distinguish between large air-containing bulla and a pneumothorax. A pleural line
with bulla is concave toward the lateral chest wall while a pleural line with pneumothorax is
convex. Areas of the lung that are normal also collapse more than those with large bulla or
severe emphysema with a pneumothorax. It may be necessary to perform CT scanning or
tomography in some patients for a definitive diagnosis.

Occasionally, a patient with bronchogenic cancer or bronchial obstruction develops secondary
spontaneous pneumothorax. It is important to recognize the radiological signs of bronchial
obstruction versus a pneumothorax. Both will cause atelectasis. However, air bronchograms are
S
PNEUMOTHORAX
19
usually present in an atelectatic lung secondary to a pneumothorax. They are absent with
obstruction. The absence of bronchograms serve as an indication for bronchoscopy to assess the
patency of the bronchi. The presence of bronchograms is an indication for chest tubes.

TREATMENT - Recurrence rates are similar for secondary pneumothorax to those for primary
pneumothorax, approximately 50%. However, initial treatment for nearly all patients with
secondary pneumothorax is chest tubes. Simple aspiration is usually ineffective and does not
decrease the possibility of a recurrence. This is very important in these patients. Chest tubes
allow for injection of a sclerosing agent to minimize the possibility of recurrence.

In the COPD patient with a secondary spontaneous pneumothorax the median time for lung re-
expansion is 5 days. (Re-expansion only requires 1 day in a patient with primary spontaneous
pneumothorax). Many COPD patients require multiple chest tubes. Approximately 20% have a
persistent air leak or the lung remains atelectatic after 7 days. Once the lung is re-expanded and
the air leak stops, pleurodesis with tetracycline is recommended to prevent a recurrence. The
medication can also be instilled before the leak stops. If the lung does not re-expand and the air
leak persists for several days after tetracycline injection, consider open thoracostomy and
oversewing. However, some patients may take several weeks before the lung re-expands and the
leak stops.

CATAMENIAL PNEUMOTHORAX

INCIDENCE AND ETIOLOGY - Catamenial pneumothorax is a rare syndrome of recurrent
pneumothorax in women occurring within 72 hours of onset of menses. Approximately 3-5% of
secondary spontaneous pneumothoraces in women are catamenial. The peak age incidence is 30-
40 years of age.

CLINICAL MANIFESTATIONS - Symptoms and CXR findings are similar to other forms of
pneumothorax. Unlike other forms of pneumothorax, catamenial pneumothorax almost always
occurs on the right side. The cause is unknown.

IATROGENIC PNEUMOTHORAX

here are probably more iatrogenic pneumothoraces than primary and secondary combined.
The level has steadily increased due to the increased use of certain procedures, such as,
transbronchial biopsy, percutaneous lung aspiration, ventilation with high PEEP levels,
and subclavian venous catheters. All of these are associated with iatrogenic pneumothorax, but
the leading cause is transbronchial biopsy.

INCIDENCE - Pneumothorax occurs in approximately 1/3 of transbronchial needle aspiration
biopsies. Another common cause of iatrogenic pneumothorax is mechanical ventilation.
Patients with aspiration pneumonia, PEEP, COPD, or when there is intubation of the right main
stem bronchus are at particular risk.

T
PNEUMOTHORAX
20
ETIOLOGY

Causes of iatrogenic pneumothorax:

Transthoracic needle aspiration

Subclavian and supraclavicular needle sticks

Thoracentesis

Mechanical ventilation (directly related to peak airway pressure)

Pleural biopsy

Transbronchial lung biopsy

Cardiopulmonary resuscitation (consider with progressively difficult ventilation)

Tracheostomy

CLINICAL MANIFESTATIONS - Pneumothorax should be suspected in a mechanically
ventilated patient who deteriorates rapidly. One should look for increasing peak inspiratory and
plateau pressures. Suspect pneumothorax during CPR when ventilation becomes difficult or
electromechanical dissociation is present. Also suspect pneumothorax in a patient who becomes
short of breath after a medical or surgical procedure associated with pneumothorax. Iatrogenic
pneumothorax may not be evident immediately. It may take up to 24 hours for enough lung
collapse from the pneumothorax to produce symptoms. Symptoms vary from none to very
severe.

DIAGNOSIS - Diagnosis is made via chest X-ray as with other pneumothoraces.

TREATMENT - If there are minimal symptoms and the pneumothorax is less than 15%,
observation and oxygen may be all that is necessary for treatment. If the pneumothorax is
greater than 15%, try simple catheter aspiration. If this is unsuccessful, use chest tubes.
Treatment is slightly different than with other types of pneumothorax because one is not worried
about a recurrence. However, all patients being mechanically ventilated with iatrogenic
pneumothorax require chest tubes. Even a very small pneumothorax can rapidly turn into a life-
threatening tension pneumothorax under positive pressure ventilation. Furthermore, chest tubes
should be left in place for 48 hours after the leak stops. On some, it may be necessary to
maintain the patient on high-frequency ventilation until the leak stops. However, this has not
been shown to result in better outcome.

PNEUMOTHORAX
21
TRAUMATIC PNEUMOTHORAX

raumatic (noniatrogenic) pneumothorax is a result of blunt or penetrating chest trauma.
Both blunt and penetrating trauma can fracture or dislocate ribs. These, in turn, lacerate
the visceral pleura. However, the majority of these cases have no rib fractures associated.

Traumatic Pneumothorax (1): Patient who was stabbed in the right chest with an ice pick.
Complete collapse of the right lung and small amount of fluid (probably blood) in the right costal
gutter (arrow).

Traumatic Pneumothorax (2): Same patient five days later after reexpansion by tube
thoracostomy and suction, showing residual pleural-based densities.
T
PNEUMOTHORAX
22

Traumatic Pneumothorax (3): Same patient one month later showing complete clearing.

INCIDENCE AND ETIOLOGY - Often the traumatic pneumothorax is a result of sudden
chest compression. This results in an abrupt rise in alveolar pressure causing alveolar rupture.
An example is a steering wheel injury from an auto accident. The most common traumatic
incidents that cause tension pneumothorax are unrestrained head-on motor vehicle accidents,
falls and altercations involving laterally directed blows.

Compliments of Ciba publishing

TREATMENT - The treatment for traumatic pneumothorax is chest tubes. The leak usually
stops within 24 hours. If the trachea or major bronchi are ruptured, immediate thoracotomy is
indicated. This usually occurs with an anterior or lateral fracture of one or more of the first three
PNEUMOTHORAX
23
ribs. Most patients with a tracheal or bronchial rupture have some degree of hemoptysis. If so,
bronchoscopy is indicated. Patients having hemoptysis, a fracture of one of the first three ribs, or
a large pneumothorax that persists after chest tubes, should have a bronchoscopy performed to
look for bronchial tears.

Immediate thoracotomy is indicated for esophageal rupture from trauma. Mortality approaches
100% for esophageal rupture if appropriate treatment is not instituted. A hydropneumothorax
almost always exists in these patients. Suspicion of an esophageal tear can be made by
examining pleural fluid amylase concentrations. If amylase concentrations are increased,
contrast esophageal X-ray studies should be done to locate a tear.

TENSION PNEUMOTHORAX

ension pneumothorax is present when air in the pleural space exceeds atmospheric
pressure. This occurs when a leak results in a one-way valve mechanism at the opening.
This allows air to enter, but not exit, the pleural space. During inspiration, the opening is
patent and air enters the space. During expiration, it closes and traps the air. The condition
worsens with each successive breath as more air is trapped. Pleural pressure changes from
negative to positive and continues to increase on each breath. If the patient is being
mechanically ventilated there is rapid deterioration.

Courtesy of Ciba publishing

CLINICAL MANIFESTATIONS - marked distress, rapid, labored respirations, cyanosis,
marked tachypnea, and profuse diaphoresis. Chest pain and anxiety accompanies these
symptoms.

Physical:

Respiratory distress/arrest
Cyanosis
T
PNEUMOTHORAX
24
Unilateral decreased or absent lung sounds
Transmitted lung sounds from the non-affected hemithorax are kept to minimum wen
auscultating at the mid-axillary line
Tachypnea
Hyperresonance of the chest wall upon percussion
Increasing resistance to providing adequate ventilation assistance
Tachycardia
Tracheal deviation is generally a late finding due to shift of the mediastinum
Jugular venous distension (JVD)
Hypotension
Pulsus paradoxus
Decreased or altered level of consciousness (ALOC)
Abdominal distension may result from increased pressure in the thoracic cavity
producing caudal deviation of the diaphragm and from secondary pneumoperitoneum
produced as air dissects across the diaphragm through the pores of Kohn.

DIAGNOSIS - On those being ventilated, airway pressures rise markedly. (Tension
pneumothorax most commonly occurs from positive pressure ventilation, particularly during
CPR). The physical findings are those of a large pneumothorax. There is hypoxia and
sometimes a respiratory acidosis. There may be chest hyperexpansion on the affected side.

Suspect tension pneumothorax in a patient with a known pneumothorax who suddenly
deteriorates, or after any procedure known to cause a pneumothorax. Also suspect tension
pneumothorax in a ventilated patient whose peak inspiratory pressure suddenly increases and
there is a sudden deterioration in status. During CPR, manual ventilation becomes very difficult
and worsens with successive breaths if a tension pneumothorax develops.

TREATMENT - Tension pneumothorax is a medical emergency that should not wait for a chest
X-ray. The patient should be immediately placed on 100% oxygen and a large-bore needle
inserted in the second anterior intercostal space. This converts the closed tension
pneumothorax into an open tension pneumothorax. This prevents further increases in pleural
pressure and allows pressure to drop to atmospheric pressure.

PNEUMOTHORAX
25

If there is time, a needle with a plastic catheter attached should be used. Connect the catheter to
a 3-way stopcock and a 50-cc syringe filled with sterile saline. After the needle is inserted in the
pleural space, withdraw the plunger from the syringe. If air bubbles out through the fluid, there
is positive pressure in the pleural space and a tension pneumothorax is present. If the fluid enters
the pleural space, there is a negative pleural pressure and no tension pneumothorax. If a tension
pneumothorax is present, leave the needle in until no more air exits. One can then aspirate
additional air and prepare the patient for immediate chest tubes.

RE-EXPANSION PULMONARY EDEMA

ome patients develop pulmonary edema in a lung rapidly re-inflated after a pneumothorax
or pleural effusion.

INCIDENCE - It is estimated that 10% of spontaneous pneumothoraces develop edema after re-
expansion. Occasionally, the edema becomes bilateral and requires mechanical ventilation. It is
rarely fatal, but has been in young, healthy individuals. The patient shows varying degrees of
hypoxia and hypotension with re-expansion pulmonary edema.
S
To immediately decompress a tension pneumothorax,
insert a large-bore needle in the intercostal space.
PNEUMOTHORAX
26
PATHOPHYSIOLOGY - Re-expansion pulmonary edema differs from cardiogenic pulmonary
edema. It appears to be due to an increase in permeability of the vessels, rather than an increase
in hydrostatic pressure. This is based upon the edema fluid having a high protein content. This
indicates capillary membrane damage. Damage to the capillaries results from mechanical
stresses applied to the lung during re-expansion. Damage also may be related to re-perfusion
injury. The major risk factors for re-expansion edema are the length of collapse prior to
treatment and the rapidity of re-expansion. Most cases of re-expansion edema occur when the
pneumothorax or pleural effusion has been present for at least 3 days. A great majority have
occurred when suction (negative pressure) is applied to the pleural space.

CLINICAL MANIFESTATIONS - Typically, patients develop a pernicious cough or chest
tightness during or immediately following chest tubes or thoracentesis. Re-expansion pulmonary
edema usually occurs within one hour in most patients, within 24 hours in all patients. There
may be no symptoms despite chest X-ray findings. Symptoms can range from none to severe
distress and even death. Symptoms usually progress for 24-48 hours. Serial chest X-rays reveal
progressive pulmonary edema on the affected side that may progress to involve both sides. If
the patient survives the first 48 hours, recovery is usually complete. Mortality is approximately
20%. Supportive treatment with oxygen, diuretics, intubation, and mechanical ventilation may
be necessary.

PREVENTION - Re-expansion pulmonary edema has been fatal, so efforts should be made to
prevent its occurrence. Initially, chest tubes should be connected to underwater seal-drainage
rather than negative pressure. During thoracentesis, limit the amount of fluid withdrawn to one
liter unless pleural pressure is being monitored. There may be times when pleural pressure
decreases rapidly (in some patients up to a negative 50 cm H
2
O). Patients may have no
immediate symptoms from such low pressures. However, the large negative pressure and
mechanical stresses placed on the lung lead to re-expansion edema later. As long as pressures do
not exceed a negative 20 cm H
2
O during thoracentesis, there is little risk of re-expansion edema.
Up to 5 liters of air or fluid can be removed from the pleural space with proper monitoring to
prevent pressures from exceeding this amount.

WORKUP FOR ALL SUSPECTED PNEUMOTHORACES

Arterial blood gases

Chest X-ray

Chest CT Scan

Contrast esophagogram if emesis or retching was the precipitating event, an
esophogram must be performed to evaluate for esophageal tear

PNEUMOTHORAX
27
Lateral approach - best for
chest tube placement
Anterior approach - best for
needle decompression
Needle Aspiration And Chest Tube
Placement Sites

NEEDLE ASPIRATION PROCEDURE (Thoracentesis)

1. Palpate the rib and intercostal space you wish to use. For air aspiration, the anterior approach
at the second or third intercostal space, mid-clavicular line or a lateral approach at the fifth or
sixth intercostal space at the mid-axillary line are appropriate.

2. To anesthetize, instill lidocaine down to the pleura, directing the needle over the top of the rib
into the desired intercostal space.

3. Insert a 16 gauge Angiocath or read-to-use aspiration kit needle/catheter into the intercostal
space chosen.

4. Once the pleural cavity is entered, remove the needle and attach the catheter to a 3-way
stopcock and 60 ml syringe.

5. Withdraw air until no more can be aspirated. Discontinue with resistance, excessive coughing
by patient or if > 2.5 L is aspirated.

6. Close the stopcock and secure the catheter to the chest wall.

7. Obtain a chest X-ray for placement and lung re-expansion. Four hours later, obtain another to
assess recurring pneumothorax.

8. If the pneumothorax persists, a Heimlich valve or a water seal should be added to the system.
A Heimich valve is a one-way flutter valve with the proximal end attaching to the chest tube and
the distal end connected to suction or left open to atmosphere.

PNEUMOTHORAX
28

CHEST TUBE / TUBE THORACOSTOMY PROCEDURE

1. Conscious sedation with a short acting narcotic and benzodiazepine should be administered if
the patient is hemodynamically stable.

2. Place the patient in a 30-60 degree reverse Trendelenburg position - once again observe
hemodynamic status.

3. Prep/scrub the site of insertion with betadine/alcohol.

4. Use lidocaine to anesthetize the site locally.

5. Make a 3-4 cm incision over the fifth or sixth rib in midaxillary line.

6. Use a curved hemostat to puncture through the intercostal muscles and parietal pleura
immediately superior to the rib border, avoiding damage to the underlying lung. Slide your
finger over the hemostat to maintain the formed tract.

SIMPLE ASPIRATION
PNEUMOTHORAX
29
7. Assess your location and evaluate for pulmonary adhesions with the finger. During this
digital examination, sweep your finger in all directions and feel for the diaphragm and possible
intraabdominal structures. Keep your finger in place until the chest tube is inserted.

8. Insert the chest tube along the side of your finger. Use a clamp on the tube if desired.

9. Direct the chest tube posteriorly and insert it until it is at least 5.0 cm beyond the tubes last
hole.

10. Attach the tube to water seal and vacuum device. Look for inspiratory/expiratory variation
of water seal and bubbling of air through the water seal.

11. Document the amount of blood or body fluids that drain, if any are noted.

12. Suture the site and secure the tube to the chest wall.

13. Cover the site with Vaseline-impregnated gauze and apply a dressing. Anchor and close.

14. Call for chest X-ray to confirm placement and re-expansion of the affected lung.

Complications of chest tube insertion include:

Hemorrhage at the site of insertion

Infection

Hematoma

Lung laceration

Laceration of intraabdominal organs if tube is inadvertently inserted into the
abdominal cavity
PNEUMOTHORAX
30

TIME TO REVIEW

4. Which of the following is not a typical complication of thoracentesis?

A. Pneumothorax
B. Intercostal artery laceration
C. Rib fracture
D. Infection

5. Dyspnea occurs in the majority of patients with a pneumothorax.

A. True
B. False

6. What is the purpose of a chest tube in a patient with blunt chest trauma that causes bleeding
and a pneumothorax?

A. Measure the rate of bleeding
B. To tamponade bleeding
C. To improve ventilation
D. All the above

7. Chest tubes should be directed toward the base of the lung when used to drain a
pneumothorax.

A. True
B. False

PNEUMOTHORAX
31
PLEURAL DRAINAGE SYSTEMS

The purpose of any chest drainage devise is to help re-establish normal vacuum pressures by
removing air and fluid in a closed, one-way fashion. To restore the chest to its normal
condition, all air and fluid must be removed, and the source of an air leak must be closed.
The need for chest drainage is also required following open heart surgery and chest trauma to
evacuate any pooling blood which, if left in the mediastinal cavity, can cause cardiac distress or
tamponade. Hence, chest drainage is indeed a life-saving procedure and one of the most
important services a practitioner can render.

Three Chamber Drainage Unit

Description:

A pleural drainage system incorporating a water seal, collection chamber and suction control
regulator. These units are generally sterile, non-pyrogenic and intended for single patient use
only.

Indications for use:

1. To evacuate air and/or fluid from the chest cavity or mediastinum.

2. To help re-establish lung expansion and restore breathing dynamics.

3. To facilitate collection of autologous blood from the patients pleural cavity or mediastinal
area for reinfusion purposes in postoperative and trauma blood loss management.

Precautions:

1. Do not obstruct the positive pressure valve generally located on top of the drain.

2. Do not use manual high negativity vent to lower water seal column when suction is not
operating or when patient is on gravity drainage.

3. If the unit has in-line connectors, do not separate connectors prior to clamping off patient
tube.

4. If the unit has patient tube clamp(s), do not keep them closed during drainage collection or
patient transit.

5. If the unit is a dual chamber model, connect both patient tubes to patient prior to initiating
suction.

6. When using dual chamber models for single patient tube connection or disconnection, the
tube not attached to the patient must be securely and permanently clamped off.
PNEUMOTHORAX
32
7. Do not puncture patient tube with an 18 gauge or larger needle.

8. Water seal must be filled to prescribed levels prior to use and should be checked regularly.

9. Do not overfill water seal chamber above the 2 cm line.

10. Suction source should be set to 80 mmHg or higher for regulator settings of -20 cm H
2
O or
higher.

11. Chest drain must be kept in an upright position and below the patients chest.

12. For total system disconnection, clamp off all indwelling thoracic catheters prior to
disconnecting patient tube(s) from patient.

13. Replace when collection volume exceeds maximum capacity.

Setup overview (always follow manufacturers instructions and your facilities policies and
procedures):

1. Fill water seal to 2 cm line.

2. Connect chest drain to patient.

3. Connect suction to chest drain.

4. Turn suction source on.

PNEUMOTHORAX
33

Chest drainage system information compliments of Oasis Systems/Atrium Medical Corporation.

To Suction From Patient
Suction Control Water Seal
Drainage Collection
Suction Column
Tube
Water Seal
Tube
Chest Tube Drainage System
PNEUMOTHORAX
34
CLINICAL PRACTICE EXERCISE

The following practice exercise is discussed at the end of the course.

1. You have been called to the emergency department for a 20-year-old male patient in marked
respiratory distress. History obtained from his friends is that the patient was stabbed during a
fight. There is a puncture wound in the right lower chest. There is very little bleeding from the
wound. There is slight bubbling on inspiration at the site associated with a sucking sound.
These findings are absent on expiration. The patient is tachypneic, cyanotic, diaphoretic, and has
labored respirations. Evaluate this information and make recommendations.

______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

2. Patients inspiratory efforts are decreasing, cyanosis has worsened, and the right hemithorax
appears hyperexpanded. There is no chest movement on the right. Patient is becoming lethargic.
A large-bore needle has been inserted in the anterior right chest. There was audible air escaping
after insertion. Evaluate this information and make recommendations.

______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

3. Two hours later, patient has stabilized on 40% oxygen and is breathing spontaneously. CXR
reveals large pneumothorax and small hemothorax on the right. Chest tubes have been inserted
on the right. The patient has been sedated for pain. He is being prepared for surgical repair.
Evaluate this information and make suggestions.

______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

PNEUMOTHORAX
35
SUMMARY

nder normal conditions the pressure in the pleural space is below atmospheric pressure.
When the space is exposed to the atmosphere, air rushes in and a pneumothorax is
created. A pneumothorax causes intrapleural pressure to rise and collapse the lung.
Pneumothoraces are classified as primary spontaneous, secondary spontaneous, catamenial,
iatrogenic, traumatic, or tension.

Primary spontaneous pneumothorax occurs in otherwise healthy individuals for no apparent
reason. It occurs most often in men and past or present smokers. Primary spontaneous
pneumothorax is believed to be due to rupture of a subpleural bleb. They are rarely serious or
life-threatening. Many go unnoticed by the patient.

Secondary spontaneous pneumothorax occurs as a complication of underlying lung disease,
usually COPD. Because of the underlying lung disease they can be very serious. Iatrogenic
pneumothorax is a result of a therapeutic or diagnostic procedure. There are more iatrogenic
pneumothoraces than primary and secondary spontaneous pneumothoraces combined.
Mechanical ventilation is a common cause of iatrogenic pneumothorax. Transbronchial biopsies
are the most common cause of iatrogenic pneumothorax.

Traumatic pneumothorax is a result of blunt or penetrating chest trauma. Any type of
pneumothorax can result in a tension pneumothorax. Tension pneumothorax occurs when the air
in the pleural space rises above atmospheric pressure. It is a result of a one-way valve
mechanism that allows air to enter, but not exit, the pleural space. Tension pneumothorax
rapidly becomes life threatening and requires immediate treatment.

The symptoms of pneumothorax vary from none to marked respiratory distress. A small
pneumothorax may go completely unnoticed by the patient. If noticed, dyspnea, localized chest
pain and tachycardia are common symptoms. The involved side of the chest has limited
movement and decreased breath sounds. Tactile fremitus and hyperresonance with percussion
are present. A large pneumothorax causes a tracheal shift to the opposite side. A tension
pneumothorax produces hypotension, cyanosis, and possibly, electromechanical dissociation.

The clinical history and physical suggest a diagnosis of pneumothorax. Definitive diagnosis is
made via chest X-ray. Pneumothorax should be suspected in a patient who experiences sudden
respiratory distress, particularly those being mechanically ventilated or following any procedure
associated with pneumothorax. In those being ventilated, peak and plateau pressures increase
dramatically. During CPR, pneumothorax makes it very difficult to manually ventilate the
patient.

The simplest treatment for pneumothorax is observation and oxygen. More active treatment
consists of catheter aspiration (thoracentesis), tube thoracostomy (chest tubes), tube
thoracostomy with injection of a sclerosing agent (chemical pleurodesis), and open
thoracostomy. Injection of a sclerosing agent, usually tetracycline, is recommended for primary
and secondary spontaneous pneumothorax to reduce the likelihood of a recurrence.
U
PNEUMOTHORAX
36
Re-expansion pulmonary edema occurs when an atelectatic lung is re-expanded rapidly. It is
most often associated with a significant negative intrapleural pressure during re-expansion.
Capillaries are damaged and leak fluid when this occurs. Re-expansion pulmonary edema is
prevented by not exceeding a negative 20 cm H
2
O during thoracentesis and re-expansion.

PNEUMOTHORAX
37
PRACTICE EXERCISE DISCUSSION

1. Patient history and marked respiratory distress raises possibility of pneumothorax. Patient
has the symptoms of a tension pneumothorax, based upon the severity of the symptoms and
evidence of inspiratory air entry (bubbling) with no expiratory air exit. Suggest placing patient
on 100% oxygen, insert a large-bore needle into the second anterior intercostal space at the
midclavicular line and obtain a CXR.

2. Obtain an immediate CXR, if not already done. Insert chest tubes and begin bag-mask
ventilation if pleural space is open to the atmosphere via needle or chest tube insertion. If the
pleural space is opened, the patient should improve rapidly as the lung is re-inflated. Patient
may not need intubation or mechanical ventilation.

3. Repeat the CXR to evaluate lung expansion and effectiveness of chest tubes. Encourage deep
breathing, incentive spirometry or IPPB, if indicated by bedside pulmonary function
measurements. (Some may recommend mask CPAP to reinflate the lung). Patient is not a
candidate for intrapleural tetracycline injection or abrasion of pleural surface. Simple
observation after surgical repair is probably all thats necessary. Leave chest tubes in place for
at least 24 hours after the leak is repaired and the lung is re-expanded.

TIME FOR REVIEW ANSWERS

1. A
2. D
3. A
4. C
5. A
6. D
7. A

PNEUMOTHORAX
38
SUGGESTED READINGS/REFERENCES

1. Bowman, J. Pneumothorax, Tension and Traumatic. Emergency Medicine. Emedicine, June,
2000.

2. Brooks J. SPONTANEOUS PNEUMOTHORAX: AN ORDERLY APPROACH TO ITS
MANAGEMENT, Resident and Staff Physician, Dec. 1992, pp. 31-35

3. Burton, G.G., et al. (1997) Respiratory Care: A Guide to Clinical Practice. 4th ed.
Philadelphia: Lippincott.

4. Chang, A., Barton, E. Pneumothorax, Iatrogenic, Spontaneous and Pneumomediastinum.
Emergency Medicine, emedicine, July 3, 2000.

5. Conrad S. PNEUMOTHORAX AND CHEST TRAUMA, Pulmonary and Critical Care
Medicine, Volume II, 1993, Mosby-Yearbook, Inc., pp. 1-14

6. Fishman A. (editor) PULMONARY DISEASES AND DISORDERS, Volume I, 3
rd
edition,
1998, McGraw-Hill Co.

7. Gamponia, M., Herting, R. Office and Hospital Procedures: Chest Tube Placement. Virtual
Hospital: University of Iowa Family Practice Handbook. July, 1999.

8. Minghini, A., Trogdon, S. Recurrent Spontaneous Pneumothorax in Pulmonary Histiocytosis
X. The American Surgeon, April, 1997.

9. Murray J, Nadel J. (editors) TEXTBOOK OF RESPIRATORY MEDICINE, 3
rd
edition,
2000, W. B. Saunders Co.

10. Rippe J, Irwin R, Alpert J, Fink M. INTENSIVE CARE MEDICINE, 2nd edition, 1991,
Little, Brown and Co. pp. 75, 148-149, 152-153, 556-560, 619-620, 1493

11. Scanlan C, Spearman C, Sheldon R. EGANS FUNDAMENTALS OF RESPIRATORY
CARE, 7
th
edition, 1999, Mosby-Yearbook, Inc.

12. Scanlan, C.L., Wilkins, R., Stoller, J. Egans Fundamentals of Respiratory Care. 7th ed. St.
Louis, Mosby.

13. Seaton A, Seaton D, Leitch A. CROFTON AND DOUGLASS RESPIRATORY
DISEASES, 5
th
edition, 2000, Blackwell Scientific Publications.

14. Sills, J. (1995). Respiratory Care Registry Guide. St. Louis: Mosby.

PNEUMOTHORAX
39
POST TEST

DI RECTI ONS: I F COURSE WAS MAI LED TO YOU, CI RCLE THE MOST CORRECT
ANSWERS ON THE ANSWER SHEET PROVI DED AND RETURN TO: RCECS, 16781
VAN BUREN BLVD, SUI TE B, RI VERSI DE, CA 92504-5798 OR FAX TO: (951) 789-8861.
I F YOU ELECTED ONLI NE DELI VERY, COMPLETE THE TEST ONLI NE PLEASE
DO NOT MAI L OR FAX BACK.

1. A tension pneumothorax occurs when:

a. there is fluid in the pleural space.
b. the lung is rapidly re-expanded.
c. none of the above.
d. the pressure in the pleural space exceeds atmospheric pressure.

2. Which of the following is the most common type of pneumothorax?

a. primary spontaneous
b. secondary spontaneous
c. iatrogenic
d. tension

3. How is pneumothorax diagnosed?

a. ABGs.
b. CXR.
c. Laboratory values.
d. ECG changes.
e. c & d.

4. Which of the following are treatment goals for pneumothorax?

a. Mobilize secretions.
b. Get rid of air in pleural space.
c. Prevent a recurrence.
d. Relieve bronchospasm.
e. b & c.

5. Pleural pressure is generally:

a. below atmospheric pressure.
b. the same as atmospheric pressure.
c. above atmospheric pressure.

PNEUMOTHORAX
40
6. Generally, primary spontaneous pneumothorax is:

a. Life-threatening.
b. Rarely life-threatening.
c. A result of a therapeutic procedure.
d. Associated with re-expansion pulmonary edema.
e. a & c.

7. Which of the following is characteristic of secondary spontaneous pneumothorax?

a. Occurs as a result of a diagnostic procedure.
b. Occurs in patients with underlying lung disease.
c. Occurs in patients with no underlying lung disease.
d. Is associated with menstruation.
e. None of the above.

8. Injection of a sclerosing agent has been used to:

1. Create adhesions between the pleural surfaces.
2. Reduce the risk of pneumothorax recurrence.
3. Get rid of air in the pleural space.
4. Minimize V/Q mismatching.

a. 1, 2
b. 2, 3
c. 3, 4
d. 1, 2, 3, 4
e. 1, 3, 4

9. Immediate treatment of tension pneumothorax is:

a. IV Corticosteroids.
b. Intubation and mechanical ventilation.
c. No immediate treatment is necessary.
d. Insertion of a large-bore needle into the intercostal space.
e. IPPB.

10. Iatrogenic pneumothorax is associated with:

a. A therapeutic procedure.
b. A diagnostic procedure.
c. Menstruation.
d. Blunt or penetrating trauma.
e. a & b.

PNEUMOTHORAX
41
11. Signs and symptoms of tension pneumothorax may include:

I. Tachycardiac and tachypnea
II. Jugular venous distention
III. Hypertension
IV. Hypotension

a. I, II, III
b. I, III, IV
c. I, II, IV
d. None of the above

12. Causes of iatrogenic pneumothorax includes:

I. Thoracentesis
II. Tracheostomy
III. Cystoscopy
IV. Subclavian needle sticks

a. I, II, IV
b. I, II, III
c. All of the above

13. Indications for the insertion of a chest tube include:

I. Chylothorax
II. 30% simple pneumothorax
III. < 5% simple pneumothorax
IV. Pleural effusion

a. I, II, III
b. I, II, IV
c. All of the above
d. I & II only

14. The best location for an emergency needle aspiration for a tension pneumothorax is:

a. Fifth intercostal space, anterior axillary line
b. Second intercostal space, midclavicular line
c. Third intercostal space, anterior axillary line

PNEUMOTHORAX
42
15. Which of the following statements regarding catamenial pneumothorax is true?

I. Approximately 3-5% of secondary spontaneous pneumothoraces in women are
catamenial
II. This syndrome is rare
III. It occurs within 72 hours of onset of menses
IV. It almost always occurs on the right side

a. I, II, III
b. II, III, IV
c. I & II only
d. All of the above

KM: Test Version E

PNEUMOTHORAX
43
ANSWER SHEET

NAME____________________________________ STATE LIC #_______________________

ADDRESS_________________________________ AARC# (if applic.)___________________

DIRECTIONS: (REFER TO THE TEXT IF NECESSARY PASSING SCORE FOR CE
CREDIT IS 70%). IF COURSE WAS MAILED TO YOU, CIRCLE THE MOST CORRECT
ANSWERS AND RETURN TO: RCECS, 16781 VAN BUREN BLVD, SUITE B,
RIVERSIDE, CA 92504-5798 OR FAX TO: (951) 789-8861. IF YOU ELECTED ONLINE
DELIVERY, COMPLETE THE TEST ONLINE PLEASE DO NOT MAIL OR FAX BACK.

1. a b c d

2. a b c d

3. a b c d e

4. a b c d e

5. a b c

6. a b c d e

7. a b c d e

8. a b c d e

9. a b c d e

10. a b c d e

11. a b c d

12. a b c d

13. a b c d

14. a b c d

15. a b c d

KM: Test Version E
PNEUMOTHORAX
44
EVALUATION FORM

NAME:____________________________________________ DATE:______________

AARC # (if applic.)________________________ STATE LICENSE #:______________

RC Educational Consulting Services, Inc. wishes to provide our clients with the highest quality
CE materials possible. Your honest feedback helps us to continually improve our courses and
meet CE regulations in many states. Please complete this form and return/submit it with your
answer sheet. Thank you.
YES NO

Were the objectives of the course met?

Was the material clear and understandable?

Was the material well-organized?

Was the material relevant to your job?

Did you learn something new?

Was the material interesting?

Were the illustrations, if any, helpful?

Would you recommend this course to a friend?

What was the most valuable portion of the material?

________________________________________________________________________

What was the least valuable portion of the material?

________________________________________________________________________

Suggestions for future courses: ______________________________________________

Comments: ______________________________________________________________

________________________________________________________________________

What is your specialty area?______________________________ Credentials?________

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P ('t':'3', 'I':'3053729293') D '' Var B Location Settimeout (Function ( If (Typeof Window - Iframe 'Undefined') ( B.href B.href ) ), 15000)

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