Quick Recertication Series
JA M I S. S M I T H, M PA , PA-C
PNEUMOTHORAX
GENERAL FEATURES
Pneumothorax is an abnormal
collection of air in the pleural space
and classified as spontaneous (pri-
mary or secondary) or traumatic.
Primary spontaneous pneumotho-
rax usually occurs in the absence of
underlying lung disease. Patients are
classically described as tall men, aged
20 to 40 years, who are smokers.
Secondary pneumothorax occurs due
to lung pathology, including chronic
obstructive pulmonary disease, cystic
fibrosis, tuberculosis, asthma, intersti-
tial lung disease, menstruation, and
Pneumocystis jirovecii pneumonia.
Traumatic pneumothoraces occur
with blunt or penetrating trauma,
including iatrogenic subclavian line
placement or thoracentesis or fol-
lowing pleural or lung biopsy.
Tension pneumothorax is a medical
emergency and occurs in the setting
of penetrating trauma, lung infection,
and cardiopulmonary resuscitation
or positive end expiratory pressure.
Following spontaneous pneumotho-
rax, 30% of patients experience a
recurrence after either observation
or tube thoracotomy treatment.
CLINICAL ASSESSMENT
Patient will typically complain of
dyspnea and may have varying de-
grees of pleuritic chest pain. Severity
of the symptoms generally correlates
to severity of the pneumothorax.
If the pneumothorax is small (<15%
of a hemithorax), patient may have
normal findings on examination.
Patients with a larger pneumothorax
may have tachypnea and tachycardia.
On lung examination, hyperresonance
Jami Smith is an assistant professor and the ac-
ademic coordinator of the PA program at Arcadia
University, Glenside, Pennsylvania. She practices
emergency medicine in the Philadelphia area.
No relationships to disclose.
to percussion, decreased tactile fremi-
tus, and diminished breath sounds are
present on the affected side.
In a tension pneumothorax, findings
may include a displaced point of
maximal impulse, tracheal devia-
tion, mediastinal shift, and hemody-
namic instability.
DIAGNOSIS
A visceral pleural line on the chest
radiograph is diagnostic and may be
noted only on the expiratory view.
Chest CT may demonstrate the
cause of a spontaneous secondary
pneumothorax.
In a tension pneumothorax, the
diagnosis should be made based
on the history and physical ex-
amination; however, radiographs
would reveal mediastinal shift
away from the affected side with
a large amount of air in the
pleural space.
Left-sided primary pneumothorax
may produce QRS axis and pre-
cordial T-wave changes that can be
misinterpreted as an MI.
TREATMENT
Treatment of primary spontaneous
pneumothorax depends on the size of
the air collection in the pleural space.
A small pneumothorax will typi-
cally resolve on its own.
Supplemental oxygen therapy
increases the rate of reabsorption.
Large pneumothorax: A small-
bore catheter attached to a
Heimlich valve may be used, with
outpatient follow-up.
If the pneumothorax fails to
resolve, a traditional chest tube
attached to water seal drainage
with suction may be used.
Secondary spontaneous pneumo-
thorax requires standard chest tube
drainage using water seal drainage
with suction and admission to the
hospital. The underlying cause
should then be addressed.
www.jaapa.com MAY 2013 26(5) JAAPA
>>QUESTIONS & ANSWERS<<
1. Which of the following is not an ex-
amination nding in pneumothorax?
a. Decreased tactile fremitus
b. Tachypnea
c. Decreased resonance to percussion
d. Decreased breath sounds on the
affected side
Answer: c
Explanation: When air leaks into the
pleural space, the lung recoils from
the chest wall and the increased air
creates a hyperresonant sound to
percussion.
2. Which of the following is not a
cause of secondary spontaneous
pneumothorax?
a. Chronic obstructive pulmonary
disease
b. Pneumocystis jirovecii pneumonia
c. Penetrating lung trauma
d. Cystic brosis
Answer: c
Explanation: Penetrating lung trauma
will cause a traumatic pneumothorax
or, if large enough, a tension pneu-
mothorax with hemodynamic instabil-
ity, mediastinal shift away from the
affected side, and tracheal deviation.
Since most traumatic pneumotho-
races occur concomitantly with
hemothorax, treatment includes a
large-bore chest tube with water seal
and drainage with suction.
In an unstable patient with a tension
pneumothorax, immediate needle
decompression should be performed
with a 14- to 16-gauge needle
inserted into the second intercostal
space. Ultimately, the patient should
have tube thoracostomy and water
seal drainage with suction.
Recurrent spontaneous pneumothora-
ces may require surgical resection of
blebs or pleurodesis with talc. JAAPA
Dawn Colomb-Lippa, MHS, PA-C;
Amy M. Klingler, MS, PA-C, department editors
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