RACTICEESSENTIALS
lifethreateningrespiratorydistress:
Pneumothorax is defined as the presence
ofairorgasinthepleuralcavity(ie,the
potential space between the visceral and
parietal pleura of the lung), which can
impairoxygenationand/orventilation.The
clinicalresultsaredependentonthedegree
ofcollapseofthelungontheaffectedside.
Ifthepneumothoraxissignificant,itcan
cause a shift of the mediastinum and
compromise hemodynamic stability. Air
canentertheintrapleuralspacethrougha
communication from the chest wall (ie,
trauma) or through the lung parenchyma
acrossthevisceralpleura.Seetheimage
below.
Radiograph of a patient with a complete
rightsided pneumothorax due to a stab
wound.
Signsandsymptoms
The presentation of patients with
pneumothorax varies depending on the
following types of pneumothorax and
ranges from completely asymptomatic to
Spontaneous pneumothorax: No
clinical signs or symptoms in
primary spontaneous
pneumothoraxuntilablebruptures
and causes pneumothorax;
typically, theresult is acute onset
of chest pain and shortness of
breath,particularlywithsecondary
spontaneouspneumothoraces
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
Catamenialpneumothorax:Women
aged 3040 years with onset of
symptoms within 48 hours of
menstruation, rightsided
pneumothorax,andrecurrence
Pneumomediastinum: Must be
differentiated from spontaneous
pneumothorax; patients may or
may not have symptoms of chest
pain,persistentcough,sorethroat,
dysphagia, shortness of breath, or
nausea/vomiting
SeeClinicalPresentationformoredetail.
Diagnosis
History and physical examination remain
the keys to making the diagnosis of
pneumothorax. Examination of patients
withthisconditionmayrevealdiaphoresis
and cyanosis (in the case of tension
pneumothorax).Affectedpatientsmayalso
reveal altered mental status changes,
including decreased alertness and/or
consciousness(ararefinding).
Findings on lung auscultation vary
depending on the extent of the
pneumothorax. Respiratory findings may
includethefollowing:
Respiratory distress (considered a
universal finding) or respiratory
arrest
Tachypnea (or bradypnea as a
preterminalevent)
Asymmetric lung expansion:
Mediastinal and tracheal shift to
contralateral side (large tension
pneumothorax)
Distant or absent breath sounds:
Unilaterally decreased/absent lung
soundscommon,butdecreasedair
entry may be absent even in
advancedstateofpneumothorax
Minimal lung sounds transmitted
from unaffected hemithorax with
auscultationatmidaxillaryline
Hyperresonance on percussion:
Rarefinding;maybeabsenteven
inanadvancedstate
Decreasedtactilefremitus
Adventitious lung sounds:
Ipsilateralcrackles,wheezes
Cardiovascular findings may include the
following:
Tachycardia: Most common
finding;ifheartrateisfasterthan
135 beats/min, tension
pneumothoraxlikely
Pulsusparadoxus
Hypotension: Inconsistently
presentfinding;althoughtypically
considered a key sign of tension
pneumothorax,hypotensioncanbe
delayed until its appearance
immediately precedes
cardiovascularcollapse
Jugular venous distention:
Generally seen in tension
pneumothorax; may be absent if
hypotensionissevere
Cardiac apical displacement: Rare
finding
Common findings among the types of
pneumothoracesincludethefollowing:
Spontaneous and iatrogenic
pneumothorax: Tachycardia most
common finding; tachypnea and
hypoxiamaybepresent
Tension pneumothorax: Variable
findings; respiratory distress and
chest pain; tachycardia; ipsilateral
air entry on auscultation; breath
sounds absent on affected
hemithorax; trachea may deviate
fromaffectedside;thoraxmaybe
hyperresonant; jugular venous
distention and/or abdominal
distentionmaybepresent
Pneumomediastinum: Variable or
absent findings; subcutaneous
emphysemaisthemostconsistent
sign; Hamman signa precordial
crunching noise synchronous with
theheartbeatandoftenaccentuated
during expirationhas a variable
 rateofoccurrence,withoneseries
reporting10%
Labandimagingstudies
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
immediatetreatmentanddoesnotrequire
potentiallyprolongeddiagnosticstudies.
Arterialbloodgas(ABG)studiesmeasure
thedegreesofacidemia,hypercarbia,and
hypoxemia, the occurrence of which
dependsontheextentofcardiopulmonary
compromiseatthetimeofcollection.ABG
analysis does not replace physical
diagnosis,norshouldtreatmentbedelayed
while awaiting results if symptomatic
pneumothorax is suspected. However,
ABGanalysismaybeusefulinevaluating
hypoxia and hypercarbia and respiratory
acidosis.
When pneumothorax is suspected,
confirmationbychestradiographyaffords
additional information beyond
confirmation, such as the extent of
pneumothorax,potentialcauses,abaseline
study from which to go forward, and
assistancewiththetherapeuticplan.
The following radiologic studies may be
usedtoevaluatesuspectedpneumothorax:
Chestradiography:Anteroposterior
and/orlateraldecubitusfilms
Contrastenhanced
esophagography:Ifemesis/retching
istheprecipitatingevent
Chest computed tomography
scanning: Most reliable imaging
study for diagnosis of
pneumothorax but not
recommended for routine use in
pneumothorax
Chestultrasonography
SeeWorkupformoredetail.
Management
Althoughthereisgeneralagreementonthe
management of pneumothorax, a full
consensusaboutmanagementofinitialor
recurrent pneumothorax does not exist.
Rather, many clinicians use a risk
stratification framework as well as other
approachesforchoosingamongoptionsto
restorelungvolumeandanairfreepleural
spaceandtopreventrecurrences.[1]
Therangeofmedicaltherapeuticoptions
forpneumothoraxincludesthefollowing:
Watchfulwaiting,withorwithout
supplementaloxygen
Simpleaspiration
Tube drainage, with or without
medicalpleurodesis
Surgery
Ifthepatienthashadrepeatedepisodesof
pneumothorax or if the lung remains
unexpandedafter5dayswithachesttube
in place, operative therapy such as the
followingmaybenecessary:
Thoracoscopy: Videoassisted
thoracoscopicsurgery(VATS)
Electrocautery: Pleurodesis or
sclerotherapy
Lasertreatment
 Resectionofblebsorpleura
Openthoracotomy
Pharmacotherapy
Thefollowingmedicationsmaybeusedto
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
presenceofairorgasinthepleural
cavity (ie, the potential space
between the visceral and parietal
pleura of the lung). The clinical
resultsaredependentonthedegree
of collapse of the lung on the
affected side. Pneumothorax can
impair oxygenation and/or
ventilation.Ifthepneumothoraxis
significant,itcancauseashiftof
the mediastinum and compromise
hemodynamic stability. Air can
entertheintrapleuralspacethrough
a communication from the chest
wall (ie, trauma) or through the
lung parenchyma across the
visceralpleura.
Amongthetopics thisarticlewill
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) longterm
followupofsurgicaltreatmentof
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)inabilityof
ultrasonography to distinguish
betweenintrapulmonarybullaeand
pneumothorax.
See also Restoring an AirFree
PleuralSpaceinPneumothorax.
Primary and secondary
spontaneouspneumothorax
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
underlyinglungdiseaseandinthe
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
underlyinghistoryofclinicallung
disease. However, many patients
whose condition is labeled as
primary spontaneous
pneumothorax have subclinical
lungdisease,suchaspleuralblebs,
that can be detected by CT
scanning. Patients are typically
aged 1840 years, tall, thin, and,
often,aresmokers.


Ra
diographofapatientwithasmall
spontaneous primary
pneumothorax

Expiratoryradiographofapatient
with a small spontaneous primary
pneumothorax (same patient as in
thepreviousimages).
Secondary spontaneous
Close
pneumothorax (SSP) occurs in
radiographicviewofpatientwitha
people with a wide variety of
small spontaneous primary
parenchymallungdiseases.[2]These
pneumothorax (same patient as
individuals have underlying
fromthepreviousimage).
pulmonary pathology that alters
normal lung structure (see the
image below). Air enters the
pleural space via distended,
damaged,orcompromisedalveoli.
The presentation of these patients
may include more serious clinical
symptoms and sequelae due to
comorbidconditions.

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,
withairintroducedintothepleural
space secondary to diagnostic or
therapeutic medical intervention
(see the following image). Half a
century ago, iatrogenic
pneumothorax was predominantly
theresultofdeliberateinjectionof
air into the pleural space for the
treatmentoftuberculosis(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
secondarypneumothorax.
Radiograph of an older man who
wasadmittedtotheintensivecare
unit (ICU) postoperatively. Note
the rightsided pneumothorax
induced by the incorrectly
positioned smallbowel feeding
tube in the rightsided bronchial
tree.Markeddepressionoftheright
hemidiaphragm is noted, and
mediastinalshiftistotheleftside,
suggestive of tension
pneumothorax. The endotracheal
tubeisinagoodposition.
Traumatic pneumothorax results
from blunt trauma or penetrating
trauma thatdisruptstheparietalor
visceral pleura (see the images
below). Management steps for
traumatic pneumothoraces are
similar to those for other,
nontraumatic causes. If
hemodynamicorrespiratorystatus
is compromised or an open
(communicatingtotheatmosphere)
and/orhemothoraxarealsopresent,
tubethoracostomyisperformedto
evacuate air and allow re
expansion of the lung. There is a
subset of traumatic
pneumothoraces classified as
occult;thatis,theycannotbeseen
on chest radiographs but can be
 seenonCTscans.Ingeneral,these
canbeobservedandtreatedifthey
becomesymptomatic.
Illustration depicting multiple
fractures of the left upper chest
wall.Thefirstribisoftenfractured
posteriorly (black arrows). If
multiple rib fractures occur along
the midlateral (red arrows) or
anteriorchestwall(bluearrows),a
flailchest(dottedblacklines)may
result, which may result in
pneumothorax.
Radiograph of a patient with a
completerightsidedpneumothorax
duetoastabwound.
Tensionpneumothorax
Atensionpneumothoraxisalife
threateningconditionthatdevelops
whenairis trappedinthepleural
cavity under positive pressure,
displacing mediastinal structures
and compromising
cardiopulmonary function. Prompt
recognitionofthisconditionislife
saving, both outside the hospital
and in a modern ICU. Because
tension pneumothorax occurs
infrequently and has a potentially
devastatingoutcome,ahighindex
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
theimagebelow.

This chest radiograph has 2

abnormalities: (1) tension Pneumomediastinum from
pneumothorax and (2) potentially barotrauma may result in tension
lifesaving intervention delayed pneumothorax and obstructive
while waiting for xray results. shock.
Tensionpneumothoraxisaclinical
diagnosis requiring emergent
needledecompression,andtherapy
shouldneverbedelayedforxray
confirmation.
Pneumomediastinum
Pneumomediastinum is the
presenceofgasinthemediastinal
tissuesoccurringspontaneouslyor
following procedures or trauma
(see the following images). A
pneumothorax may occur
secondarytopneumomediastinum.

This chest radiograph shows

pneumomediastinum(radiolucency
notedaroundtheleftheartborder)
in this patient who had a
respiratoryandcirculatoryarrestin
the emergency department after
experiencing multiple episodes of
vomitingandarigidabdomen.The
patient was taken immediately to
 theoperatingroom,wherealarge
rupture of the esophagus was
repaired.
Anatomy
The inner surface of the thoracic cage
(parietal pleura) is contiguous with the
outersurfaceofthelung(visceralpleura);
this space contains a small amount of
lubricating fluid and is normally under
negativepressurecomparedtothealveoli.
Determinants of pleural pressure are the
opposing recoil forces of the lung and
chestwall.
Pathophysiology
The underlying pathophysiology of
pneumothoraxisreviewedinthissection.
Spontaneouspneumothorax
Spontaneous pneumothorax in most
patientsoccurs fromtheruptureofblebs
andbullae.Althoughprimaryspontaneous
pneumothorax (PSP) is defined as
occurring in patients without underlying
pulmonary disease, these patients have
asymptomaticblebsandbullaedetectedon
computed tomography scans or during
thoracotomy.PSPistypicallyobservedin
tall, young people without parenchymal
lungdiseaseandisthoughttoberelatedto Agrowingbodyofevidencesuggeststhat
increasedshearforcesintheapex.
Although PSP is associated with the
presenceofapicalpleuralblebs,theexact
anatomic site of air leakage is often
uncertain. Fluoresceinenhanced
autofluorescence thoracoscopy (FEAT) is
anovelmethodtoexaminethesiteofair
leakinPSP.FEATpositivelesionscanbe
detectedthatappearnormalwhenviewed
undernormalwhitelightthoracoscopy.[3]
Innormalrespiration,thepleuralspacehas
a negative pressure. As the chest wall
expands outward, the surface tension
between the parietal and visceral pleura
expandsthelungoutward.Thelungtissue
intrinsicallyhasanelasticrecoil,tending
tocollapseinwards.Ifthepleuralspaceis
invadedbygasfromarupturedbleb,the
lung collapses until equilibrium is
achievedortheruptureis sealed.Asthe
pneumothoraxenlarges,thelungbecomes
smaller. The main physiologic
consequenceofthisprocessisadecrease
in vital capacity and partial pressure of
oxygen.
Lung inflammation and oxidative stress
are hypothesized to be important to the
pathogenesisofPSP.[4]Currentsmokers,at
increased risk for PSP, have increased
numbersofinflammatorycellsinthesmall
airways. Bronchoalveolar lavage (BAL)
studiesinpatientswithPSPrevealthatthe
degreeofinflammationcorrelateswiththe
extent of emphysematouslike changes
(ELCs).OnehypothesisisthatELCsresult
from degradation of lung tissue due to
imbalances of enzymes and antioxidants
releasedbyinnateimmunecells.[5] Inone
study, erythrocyte superoxide dismutase
activity was significantly lower and
plasma malondialdehyde levels higher in
patientswithPSPthaninnormalcontrol
subjects.[4]
genetic factors may be important in the
pathogenesis of many cases of PSP.
Familial clustering of this condition has
beenreported.Geneticdisordersthathave
been linked to PSP include Marfan
syndrome,homocystinuria,andBirtHogg
Dube(BHD)syndrome.
BirtHoggDubesyndromeisanautosomal
dominantdisorderthatischaracterizedby
benign skin tumors (hair follicle
hamartomas),renalandcoloncancer,and
spontaneous pneumothorax. Spontaneous
pneumothorax occurs in about 22% of
patients with this syndrome. The gene
responsible for this syndrome is a tumor
suppressorgenelocatedonband17p11.2.
The gene encoding folliculin (FLCN) is
thought to be the etiology of BirtHogg
Dubesyndrome.Multiplemutationshave
been found, and phenotypic variation is
recognized. In one study, 8 patients
withoutskinorrenalinvolvementhadlung
cystsandspontaneouspneumothorax.[6] A
germlinemutationtothisgenehasbeen
foundin5patients,andgenetictestingis
nowavailable.
Tensionpneumothorax
Tension pneumothorax occurs anytime a
disruption involves the visceral pleura,
parietal pleura, or the tracheobronchial
tree.Thisconditiondevelopswheninjured
tissue forms a 1way valve, allowing air
inflow with inhalation into the pleural
space and prohibiting air outflow. The
volumeofthisnonabsorbableintrapleural
airincreaseswitheachinspirationbecause
of the 1way valve effect. As a result,
pressure rises within the affected
hemithorax.Inadditiontothismechanism,
thepositivepressureusedwithmechanical
ventilationtherapycancauseairtrapping.
As the pressure increases, the ipsilateral
lungcollapsesandcauseshypoxia.Further
pressureincreasescausethemediastinum
to shift toward the contralateral side and
impinge on and compress both the
contralateral lung and impair the venous
returntotherightatrium.Hypoxiaresults
asthecollapsedlungontheaffectedside
and the compressed lung on the
contralateral side compromise effective
gasexchange.Thishypoxiaanddecreased
venous return caused by compression of
therelativelythinwallsoftheatriaimpair
cardiac function. Kinking of the inferior
venacavaisthoughttobetheinitialevent
restricting blood to the heart. It is most
evident in trauma patients who are
hypovolemic with reduced venous blood
returntotheheart.
Arising from numerous causes, this
conditionrapidlyprogressestorespiratory
insufficiency,cardiovascularcollapse,and,
ultimately, death if unrecognized and
untreated.
Pneumomediastinum
With pneumomediastinum, excessive
intraalveolarpressuresleadtoruptureof
alveoli bordering the mediastinum. Air
escapes into the surrounding connective
tissue and dissects further into the
mediastinum. Esophageal trauma or
elevatedairwaypressuresmayalsoallow
air to dissect into the mediastinum. Air
may then travel superiorly into the
visceral, retropharyngeal, and
subcutaneousspacesoftheneck.Fromthe
neck, the subcutaneous compartment is
continuousthroughoutthebody;thus,air
can diffuse widely. Mediastinal air can
also pass inferiorly into the
retroperitoneum and other extraperitoneal
compartments.Ifthemediastinalpressure
rises abruptly or if decompression is not
sufficient, the mediastinal parietal pleura
mayruptureandcauseapneumothorax(in
1018%ofpatients).
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
 Marfansyndrome
Pregnancy
Familialpneumothorax
Blebs and bullae (sometimes called
emphysematouslikechangesorELCs)are
related to the occurrence of primary
spontaneous pneumothorax. Thoracic
computerized tomography (CT) scans of
patientswithPSPshowsipsilateralELCin
89% and contralateral changes in 80%
compared with a rate of 20% among
control subjects matched for age and
smoking.[2] NonsmokerswithPSPhadCT
scanELCabnormalitiesof80%compared
with a rate of 0% among nonsmoker
controlswithoutPSP.[2]
Although patients with PSP do not have
overtparenchymaldisease,thiscondition
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;thatis,theriskofPSPisrelated
totheintensityofsmoking,with102times
higherincidenceratesinmaleswhosmoke
heavily (ie, >22 cigarettes/d), compared
witha7foldincreaseinmaleswhosmoke
lightly (112 cigarettes/d). This
incrementalriskwithincreasingnumberof
cigarettes smoked per day is much more
pronouncedinfemalesmokers.
TypicalPSPpatientsalsotendtohavea
tallandthinbodyhabitus.Whetherheight
affectsdevelopmentofsubpleuralblebsor
whether more negative apical pleural
pressures cause preexisting blebs to
ruptureisunclear.
Pregnancyisanunrecognizedriskfactor,
as suggested by a 10year 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
vacuumassisted thoracostomy (VATS),
andnoharmoccurredtomotherorfetus.[7]
Other associations with pneumothorax
include increased intrathoracic pressure
withValsalva,althoughresultscontraryto
popular belief, most spontaneous
pneumothoracesoccurwhilethepatientis
atrest.Changesinatmosphericpressure,
proximity to loud music, and low
frequencynoisesareotherreportedfactors.
Familial associations have been noted in
morethan10%ofpatients.Somearedue
to rare connective tissue diseases, but
mutationsinthegeneencodingfolliculin
(FLCN) have been described. These
patients may represent an incomplete
penetrance of an autosomal dominant
genetic disorder. BirtHoggDube
syndromeischaracterizedbybenignskin
growths, pulmonary cysts, and renal
cancersandiscausedbymutationsinthe
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
positivefamilyhistory.[8]
Althoughrare,spontaneouspneumothorax
occurring bilaterally and progressing to
tension pneumothorax has been
documented.
Diseases and conditions associated with
secondary spontaneous pneumothorax
includethefollowing:
Chronic obstructive lung disease
(COPD)oremphysema:Increased
pulmonary pressure due to
 coughingwithabronchialplugof
mucus or phlegm bronchial plug
mayplayarole.
Asthma
Human immunodeficiency
virus/acquired immunodeficiency
syndrome (HIV/AIDS) with PCP
infection
Necrotizingpneumonia
Tuberculosis
Sarcoidosis
Cysticfibrosis
Bronchogenic carcinoma or
metastaticmalignancy
Idiopathicpulmonaryfibrosis
Inhalational and intravenous drug
use(eg,marijuana,cocaine)[9]
Interstitiallungdiseasesassociated
withconnectivetissuediseases
Lymphangioleiomyomatosis
Langerhanscellhistiocytosis
Severeacuterespiratorysyndrome
(SARS):Areported1.7%ofSARS
patients developed spontaneous
pneumothorax.[10]
Thoracic endometriosis and
catamenialpneumothorax
Collagen vascular disease,
includingMarfansyndrome
Secondary spontaneous pneumothoraces
(SSP) occur in the presence of lung
disease, primarily in the presence of
COPD.Otherdiseasesthatmaybepresent
when SSPs occur include tuberculosis,
sarcoidosis, cystic fibrosis, malignancy,
andidiopathicpulmonaryfibrosis.
Pneumocystis jiroveci pneumonia
(previously known as Pneumocystis
carinii pneumonia[PCP])wasacommon
causeofSSPinpatientswithAIDSduring
the last decade. In fact, 77% of AIDS
patients with spontaneous pneumothorax
had thinwalled cavities, cysts, and
pneumothoraxfromPCPinfection.[11]With
the advent of highly active antiretroviral
therapy(HAART)andwidespreaduseof
trimethoprimsulfamethoxazole (TMP
SMZ) prophylaxis, the incidence of PCP
and associated SSP has significantly
declined.
PCP in other immunocompromised
patients is seen only when TMPSMZ
prophylaxisiswithdrawnprematurely.For
practical purposes, if the
immunocompromised patient has been
taking TMPSMZ prophylaxis reliably,
PCP is reasonably excluded from the
differentialdiagnosisandshouldnotbea
causativefactorforSSP.
Incysticfibrosis,upto18.9%ofpatients
havebeenreportedtodevelopspontaneous
pneumothoraces, and they have a high
incidenceofrecurrenceonthesameside
after conservative management (50%) or
intercostal drainage (55.2%). The risk of
SSP in these patients increases with
Burkholderia cepacia or Pseudomonas
infectionsandallergicbronchopulmonary
aspergillosis (ABPA).[12] Pleurodesis
increases the risk of bleeding associated
with lung transplantation but is not an
absolutecontraindication.
Manydifferenttypesofmalignanciesare
known to present with a pneumothorax,
especiallysarcomas,butalsogenitourinary
cancers and primary lung cancer; thus, commoncause,accountingfor32
pneumothorax in a patient with 37%ofcases)
malignancy should prompt a look for
metastatic disease. Chemotherapeutic Transbronchialorpleuralbiopsy
agents,attimes,canalsoinduceSSP.[13]
Thoracentesis
Interstitial lung diseases are associated
with connectivetissue diseases. Central venous catheter insertion,
Ankylosing spondylitis may be noted usually subclavian or internal
whenapicalfibrosisispresent;infact,the jugular[16]
typically low incidence of spontaneous
pneumothoraxinpatientswithankylosing Intercostalnerveblock
spondylitis (0.29%) increases 45fold (to
13%)whenapicalfibroticdiseaseexists.[14] Tracheostomy

Lymphangioleiomyomatosis (LAM) may Cardiopulmonary resuscitation

present with spontaneous pneumothorax. (CPR):Considerthepossibilityof
This disease is characterized by thin a pneumothorax if ventilation
walled cysts in women of childbearing becomes progressively more
age.Respiratoryfailuremayleadtoaneed difficult.
for lung transplantation, and previous
pleurodesis is no longer an absolute Acute respiratory distress
contraindicationforlungtransplantation.
syndrome ( ARDS) and positive
pressure ventilation in the ICU:
Thoracicendometriosisisararecauseof
High peak airway pressures can
recurrent pneumothorax (catamenial
translate into barotrauma in upto
pneumothorax) in women that is thought
3%ofpatientsonaventilatorand
to arise from endometriosis reaching the
upto5%ofpatientswithARDS.
chest wall across the diaphragm (ie, its [17]
etiology may be primarily related to
associated diaphragmatic defects). In a
Nasogastricfeedingtubeplacement
case series of 229 patients, catamenial
pneumothorax caused by thoracic
Iatrogenicpneumothoraxisacomplication
endometriosiswaslocalizedtothevisceral
ofmedicalorsurgicalprocedures.Itmost
pleura in 52% of patients and to the
commonly results from transthoracic
diaphragm in 39% of patients.[15] Before
needle aspiration. Other procedures
recurrence,thisconditionmaybeinitially
commonly causing iatrogenic
diagnosed as primary spontaneous
pneumothorax are therapeutic
pneumothorax.
thoracentesis, pleural biopsy, central
venous catheter insertion, transbronchial
Iatrogenicandtraumaticpneumothorax
biopsy, positive pressure mechanical
ventilation, and inadvertent intubation of
Causes of iatrogenic pneumothorax
therightmainstembronchus.Therapeutic
includethefollowing:
thoracentesis is complicated by
pneumothorax 30% of the time when
Transthoracic needle aspiration performed by inexperienced operators in
biopsyofpulmonarynodules(most
contrast to only 4% of the time when
performedbyexperiencedclinicians.
Theroutineuseofultrasonographyduring
diagnosticthoracentesisisassociatedwith
lower rates of pneumothorax (4.9% vs
10.3%) and need for tube thoracostomy
(0.7%vs4.1%).Similarly,inpatientswho
are mechanically ventilated, thoracentesis
guided by bedside ultrasonography
without radiology support results in a
relativelylowerrateofpneumothorax.
Causesoftraumaticpneumothoraxinclude
thefollowing:
Trauma: Penetrating
nonpenetratinginjury
Ribfracture
Highrisk occupation (eg, diving,
flying)
Traumaticpneumothoracescanresultfrom
both penetrating and nonpenetrating lung
injuries. Complications include
hemopneumothorax and bronchopleural
fistula. Traumatic pneumothoraces often
can create a 1way valve in the pleural
space(onlylettinginairwithoutescape)
andcanleadtoatensionpneumothorax.
Tensionpneumothorax
The most common etiologies of tension
pneumothorax are either iatrogenic or
relatedtotrauma,suchasthefollowing:
Blunt or penetrating trauma:
Disruptionofeitherthevisceralor
parietalpleuraoccursandisoften
associated with rib fractures,
although rib fractures are not
necessary for tension
pneumothoraxtooccur.
Barotraumasecondarytopositive
pressure ventilation, especially
when using high amounts of
positive endexpiratory pressure
(PEEP)
Pneumoperitoneum[18,19]
Fiberoptic bronchoscopy with
closedlungbiopsy[20]
Markedlydisplacedthoracicspine
fractures
Acupuncture[21,22,23]
and PreexistingBochdalekherniawith
trauma[24]
Colonoscopy [25] and gastroscopy
have been implicated in case
reports.
Percutaneoustracheostomy[26]
Conversion of idiopathic,
spontaneous,simplepneumothorax
totensionpneumothorax
Unsuccessful attempts to convert
anopenpneumothoraxtoasimple
pneumothorax in which the
occlusivedressingfunctionsasa1
wayvalve
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
requiringventilatoryassistanceandthose
with meconium aspiration have a
particularly high risk for tension
pneumothorax. Aspirated meconium may
serve as a 1way valve and produce a
tensionpneumothorax.
Any penetrating wound that produces an Asthma
abnormal passageway for gas exchange
intothepleuralspacesandthatresultsin Respiratorytractinfection
air trapping may produce a tension
pneumothorax. Blunt trauma, with or Parturition
without associated rib fractures, and
incidents such as unrestrained headon Emesis
motor vehicle accidents, falls, and
altercations involving laterally directed Severecough
blows may also cause tension
pneumothoraces. Mechanicalventilation
Significant chest injuries carry an Trauma or surgical disruption of
estimated 1050% risk of associated
the oropharyngeal, esophageal, or
pneumothorax; in about 50% of these
respiratorymucosa
cases,thepneumothoraxmaynotbeseen
onstandardradiographsandaretherefore
Athleticcompetition
deemed occult. In one study, 12% of
patients with asymptomatic chest stab
pidemiology
wounds had a delayed pneumothorax or
hemothorax. McPherson et al analyzed The epidemiologic data vary among the
data from the Vietnam Wound Data and
pneumothoraxclassifications.
Munitions Effectiveness Team study and
determinedthattensionpneumothoraxwas
Primary, secondary, and recurring
the cause of death in 34% of fatally
woundedcombatcasualties.[27] spontaneouspneumothorax

It is likely that the incidence for

Acupuncture is a traditional Chinese
medicine technique used worldwide by
alternative medical practitioners.
Acupuncture's most frequently reported
serious complicationispneumothorax;in
oneJapanesereportof55,291acupuncture
treatments,anapproximateincidenceof1
pneumothorax in 5000 cases was
documented.[28]
Pneumomediastinum
The following factors may result in
pneumomediastinum:
Acute generation of high
intrathoracic pressures (often as a
resultofinhalationaldruguse,such
smokingmarijuanaorinhalationof
cocaine)
spontaneous pneumothorax is
underestimated. Up to 10% of patients
may be asymptomatic, and others with
mild symptoms may not present to a
medicalprovider.
Primary spontaneous pneumothoraces
(PSPs)occurinpeopleaged2030years,
with a peak incidence is in the early
twenties.PSPisrarelyobservedinpeople
older than 40 years. The ageadjusted
incidence of PSP is 7.418 cases per
100,000personsperyearformenand1.2
6casesper100,000personsperyearfor
women.[29] The maletofemale ratio of
ageadjustedratesis6.2:1.
Secondary spontaneous pneumothoraces
(SSPs) occur more frequently in patients
aged 6065 years. The ageadjusted
incidenceofSSPis6.3casesper100,000
personsperyearformenand2.0casesper followingthesesurgeries.
100,000personsperyearforwomen.The
maletofemaleratioofageadjustedrates
is 3.2:1. Chronic obstructive pulmonary
disease (COPD) is a common cause of
secondaryspontaneouspneumothoraxthat
carries an incidence of 26 cases per
100,000persons.[30]
Smoking increases the risk of a first
spontaneous pneumothorax by more than
20fold in men and by nearly 10fold in
women compared with risks in
nonsmokers.[31] Increased risk of
pneumothorax and recurrence appears to
rise proportionally with number of
cigarettessmoked.
In men, the risk of spontaneous
pneumothoraxis102timeshigherinheavy
smokersthaninnonsmokers.Spontaneous
pneumothorax most frequently occurs in
tall,thinmenaged2040years.
Iatrogenicandtraumaticpneumothorax
Traumatic and tension pneumothoraces
occur more frequently than spontaneous
pneumothoraces, and the rate is
undoubtedlyincreasinginUShospitalsas
intensive care treatment modalities have
become increasingly dependent on
positivepressure ventilation, central
venous catheter placement, and other
causes that potentially induce iatrogenic
pneumothorax.
Iatrogenic pneumothorax may cause
substantial morbidity and, rarely, death.
Theincidenceofiatrogenicpneumothorax
is57per10,000hospitaladmissions,with
thoracicsurgerypatientsexcludedbecause
pneumothorax may bea typical outcome
Pneumothorax occurs in 12% of all
neonates, with a higher incidence in
infants with neonatal respiratory distress
syndrome. In one study, 19% of such
patientsdevelopedapneumothorax.
Tensionpneumothorax
Tension pneumothorax is a complication
in approximately 12% 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
patientswithtuberculosis.
The actual incidence of tension
pneumothoraxoutsideofahospitalsetting
isimpossibletodetermine.Approximately
1030%ofpatientstransportedtolevel1
traumacentersintheUnitedStatesreceive
prehospital decompressive needle
thoracostomies;however,notallofthese
patients actually have a true tension
pneumothorax. Although this occurrence
rate may seem high, disregarding the
diagnosis would probably result in
unnecessarydeaths.Areviewofmilitary
deathsfromthoracictraumasuggeststhat
up to 5% of combat casualties with
thoracic trauma have tension
pneumothoraxatthetimeofdeath.[27]
The overall incidence of tension
pneumothorax in the intensive care unit
(ICU)isunknown.Themedicalliterature
provides onlyglimpses ofthefrequency.
Inonereport,of2000incidentsreportedto
theAustralianIncidentMonitoringStudy
(AIMS), 17 involved actual or suspected
pneumothoraces, and 4 of those were
diagnosedastensionpneumothorax.
Catamenialpneumothorax
Catamenial pneumothorax is a rare
phenomenon that generally occurs in
women aged 3050 years. It frequently
begins 13 days after menses onset. The
risk of thoracic endometriosis cannot be
predicted from the site of peritoneal
lesions.[15]
Pneumomediastinum
Spontaneous pneumomediastinum
generallyoccursinyoung,healthypatients
without serious underlying pulmonary
disease, mostly in the second to fourth
decadesoflife.Aslightpredominanceof
pneumomediastinumexistsformales.This
conditionoccursinapproximately1case
per10,000hospitaladmissions
Prognosis
The prognosis varies among the
pneumothoraxclassifications.
Primary, secondary, and recurring
spontaneouspneumothorax
Completeresolutionofanuncomplicated
pneumothorax takes approximately 10
days. PSP is typically benign and often
resolveswithoutmedicalattention.Many
affected individuals do not seek medical
attentionfordaysaftersymptomsdevelop.
This trend is important, because the
incidence of reexpansion pulmonary
edema increases in patients whose chest
tubes have been placed 3 or more days
afterthepneumothoraxoccurred.
Recurrencesusuallystrikewithinthefirst
6monthsto3years.The5yearrecurrence
rate is 2832% for primary spontaneous
pneumothorax (PSP) and 43% for
secondary spontaneous pneumothorax
(SSP).
Recurrences are more common among
patientswhosmoke,patientswithchronic
obstructive pulmonary disease (COPD),
and patients with acquired
immunodeficiency syndrome (AIDS).
Predictors of recurrence include
pulmonary fibrosis, younger age, and
increased heighttoweight ratio. In a
retrospective study of 182 consecutive
patients with a newly diagnosed first
episodeofpneumothorax,ahigherrateof
recurrencewasnotedintallerpatients,thin
patients,andpatientswithSSP.
Patientswhounderwentbedsidechesttube
pleurodesis had cumulative rates of
recurrenceof13%at6months,16%at1
year,and27%at3yearscomparedwith
26%, 33%, and 50%, respectively. The
agentused(tetracyclineorgentamicin)did
not have any significant impact on the
recurrencerate.
Bullous lesions found on computed
tomography(CT)scanoratthoracoscopy
and the presence of emphysematouslike
changesinPSParealsonotpredictiveof
recurrence. However, contralateral blebs
were seen by CT scanning in higher
frequencyinthepatientswithcontralateral
recurrence (33 patients; 14%) than those
without a contralateral recurrence in a treated before it results in hemodynamic
retrospective study of 231 patients with instabilityanddeath.
PSP. Primary bilateral spontaneous
pneumothorax (PBSP) was significantly Pneumomediastinum
morecommoninpatientswithlowerbody
Pneumomediastinumisgenerallyabenign,
massindex(BMI)andamongsmokers.[32]
selflimited condition. Malignant
Inthisseries,allpatientswithcontralateral
pneumomediastinum, or tension
recurrenceweretreatedsurgically.
pneumomediastinum (unvented
mediastinal or pulmonary adventitial air
AlthoughsomeauthorsviewPSPasmore
causingpressuresohighthatcirculatoryor
ofanuisancethanamajorhealththreat,
ventilatory failure occurs), was first
deathshavebeenreported.SSPsaremore
described in 1944; however, all patients
often life threatening, depending on the
described in this report had serious
severityoftheunderlyingdiseaseandthe
comorbid conditions, often related to
sizeofthepneumothorax(117%mortality
trauma or in association with Boerhaave
rate).Inparticular,comparedwithsimilar
syndrome.
patients without pneumothorax, age
matchedpatientswithCOPDhavea3.5
No reports of fatal outcomes in patients
foldincreaseinrelativemortalitywhena
with spontaneous pneumomediastinum in
spontaneous pneumothorax occurs, and
theabsenceofunderlyingdiseaseexistin
their risk of recurrence rises with each
the more recent literature. The mortality
occurrence.Onestudyindicatedthat5%of
rate is as high as 70% in patients with
patients with COPD died before a chest
pneumomediastinum secondary to
tubewasplaced.
Boerhaave syndrome, even with surgical
intervention. Traumatic mediastinum,
Patients with AIDS also have a high
althoughpresentinupto6%ofpatients
inpatient mortality rate of 25% and a
doesnotportendseriousinjury.[33
median survival of 3 months after the
pneumothorax. These data were derived
PatientEducation
from an era before highly active
antiretroviral therapy (HAART) was Two important concerns that clinicians
available. should educate patients with
pneumothorax/resolving pneumothorax
Tensionpneumothorax aboutareavoidanceofairtravel/travelto
remote regions and prohibition of
Tension pneumothorax arises from
smoking.Patients shouldalsobeadvised
numerouscausesandrapidlyprogressesto
towearsafetybeltsandpassiverestraint
respiratory insufficiency, cardiovascular
deviceswhiledriving.
collapse, and, ultimately, death if not
recognized and treated. Therefore, if the
Avoidtravelingbyairortoremoteareas
clinical picture fits a tension
pneumothorax, it must be emergently
Patientsshouldnottravelbyairortravelto
remote sites until radiography shows
completeresolution.Althoughcommercial
airtravelachievesminimalchangeingas
volumesduetopressurizationofthecabin,
spontaneous pneumothorax has been
describedduringcommercialtravel.
Patients with previous spontaneous
pneumothoracesareatriskforrecurrence
and are advised not to dive unless
thoracotomy or pleurodesis has been
performed.[34] Ascentfromdeepseadiving
causes gases to expand and can lead to
pneumothoraxinpatientswithbullaeand
blebs.
Stopsmoking
Smokingcessationisstronglyadvisedfor
allpatients.Theyshouldbeassessedasto
readiness to quit, to be educated about
smoking cessation,and beprovidedwith
pharmacotherapy if ready to quit. Direct
patients indicating a readiness to quit
smokingtotheirprimarycarephysicianor
offer referral for cessation management.
Thismayincludenicotinereplacementand
nonnicotine pharmacotherapy such as
bupropionorvarenicline.
Whether primary or secondary
pneumothorax, smoking increases the
likelihoodofblebruptureandrecurrence,
anditdoessoinapredictable,doserelated
manner.Relativeriskofblebruptureand
recurrencerisesbyuptoafactorof20.
Forpatienteducationinformation,seethe
Lung and Airway Center and Breathing
Difficulties Center, as well as Collapsed
Lung(Pneumothorax)andChestPain.
PhysicalExamination
The presentation of a patient with
pneumothoraxmayrangefromcompletely
asymptomatic to lifethreatening
respiratory distress. Symptoms may
includediaphoresis,splintingchestwallto
relievepleuriticpain,andcyanosis(inthe
case of tension pneumothorax). Findings
onlungauscultationalsovarydepending
on the extent of the pneumothorax.
Affectedpatients mayalsorevealaltered
mentalstatuschanges,includingdecreased
alertness and/or consciousness (a rare
finding).
Respiratory findings may include the
following:
Respiratory distress (considered a
universal finding) or respiratory
arrest
Tachypnea (or bradypnea as a
preterminalevent)
Asymmetric lung expansion: A
mediastinalandtrachealshifttothe
contralateralsidecanoccurwitha
largetensionpneumothorax.
Distant or absent breath sounds:
Unilaterally decreased or absent
lungsoundsisacommonfinding,
but decreased air entry may be
absenteveninanadvancedstateof
thedisease.
Lungsounds transmittedfromthe
unaffectedhemithoraxareminimal
withauscultationatthemidaxillary
line
Hyperresonance on percussion:
Thisisararefindingandmaybe
absenteveninanadvancedstateof
thedisease.
 Decreasedtactilefremitus
Adventitious lung sounds
(crackles, wheeze; an ipsilateral
finding)
Cardiovascular findings may include the
following:
Tachycardia: This is the most
commonfinding.Iftheheartrateis
faster than 135 beats per minute
(bpm), tension pneumothorax is
likely.
Pulsusparadoxus
Hypotension: This should be
considered as an inconsistently
present finding; although
hypotensionistypicallyconsidered
a key sign of a tension
pneumothorax,studiessuggestthat
hypotension can be delayed until
its appearance immediately
precedescardiovascularcollapse.
Jugular venous distention: This is
generally seen in tension
pneumothorax,althoughitmaybe
absentifhypotensionissevere.
Cardiac apical displacement: This
isararefinding.
Spontaneous and iatrogenic
pneumothorax
Signs of spontaneous and iatrogenic
pneumothoraxaresimilaranddependon
theunderlyinglungdiseaseandextentof
thepneumothorax.Tachycardiaisthemost
common finding, and tachypnea and
hypoxiamaybepresent.
Tensionpneumothorax
Althoughtensionpneumothoraxmaybea
difficult diagnosis to make and may
present with considerable variability in
signs, respiratory distress and chest pain
aregenerallyacceptedasbeinguniversally
present,andtachycardiaandipsilateralair
entry on auscultation are also common
findings. Sometimes, reliance on history
alonemaybewarranted.
Findings may be affected by the volume
status of the patient. In hypovolemic
traumapatientswithongoinghemorrhage,
thephysicalfindings maylagbehindthe
presentationofshockandcardiopulmonary
collapse. Increased pulmonary artery
pressuresanddecreasedcardiacoutputor
cardiac index are evidence of tension
pneumothoraxinpatientswithSwanGanz
catheters.
When examining a patient for suspected
tension pneumothorax, any clue may be
helpful,assubtlethoracicsizeandthoracic
mobility differences may be elicited by
performingcarefulvisualinspectionalong
thelineofthethorax.Inasupinepatient,
theexaminershouldlowerthemselves to
beonalevelwiththepatient.
Tracheal deviation is an inconsistent
finding. Although historic emphasis has
been placed on tracheal deviation in the
settingoftensionpneumothorax,tracheal
deviationisarelativelylatefindingcaused
bymidlineshift.
Abdominal distention may occur from
increased pressure in the thoracic cavity
producing caudal deviation of the
diaphragm and from secondary
pneumoperitoneum produced as air
dissectsacrossthediaphragmthroughthe
poresofKohn.
Ifpatientswhoaremechanicallyventilated
are difficult to ventilate during
resuscitation, high peak airway pressures
are clues to pneumothorax. A tension
pneumothorax causes progressive
difficulty with ventilation as the normal
lung is compressed. On volumecontrol
ventilation, this is indicated by marked
increase in both peak and plateau
pressures, with relatively preserved peak
and plateau pressure difference. On
pressure control ventilation, tension
pneumothoraxcausessuddendropintidal
volume. However, these observations are
neither sensitive nor specific for making
the diagnosis of pneumothorax or ruling
outthepossibilityofpneumothorax.
Thedevelopmentoftensionpneumothorax
in patients who are ventilated will
generally be of faster onset with
immediate,progressivearterialandmixed
venous oxyhemoglobin saturation decline
and immediate decline in cardiac output.
Cardiacarrestassociatedwithasystoleor
pulseless electrical activity (PEA) may
ultimatelyresult.Occasionally,thetension
pneumothorax may be tolerated and its
diagnosis delayedforhourstodaysafter
the initial insult. The diagnosis may
become evident only if the patient is
receiving positivepressure ventilation.
Tensionpneumothoraxhasbeenreported
during surgery with both single and
doublelumentubes.
Pneumomediastinum
As withpneumothorax,physical findings
of pneumomediastinum may be variable,
including absent signs in some patients.
However,subcutaneousemphysemaisthe
most consistent sign. Another sign, the
Hamman signa precordial crunching
noisesynchronouswiththeheartbeatand
oftenaccentuatedduringexpirationhasa
variablerateofoccurrence,withoneseries
reporting10%
Diagnostic
ConsiderationsSpontaneou
s pneumothoraxTraumatic
pneumothoraxTension
pneumothoraxAdditional
considerations
This section reviews some important
points to consider in the diagnosis of
pneumothoraces.
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.[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.
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.
The diagnosis of a tension pneumothorax
should largely be 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 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