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-1-antitrypsin deficiency and "typical" emphysema.
Folliculin gene disorders have been described in familial spontaneous pneumothorax .
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 H 2 O, or a positive
end-expiratory pressure greater than 15 cm H 2 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 1way 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 Coronary Syndrome

Acute Respiratory Distress Syndrome
Aortic Dissection
Congestive Heart Failure and Pulmonary Edema
Esophageal Rupture and Tears
Myocardial Infarction
Pericarditis and Cardiac Tamponade
Pulmonary Embolism
Rib Fracture

Prognosis
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 28-32% 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.