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Pneumothorax, Spontaneous 973


Anorexia nervosa is thought to be a risk
BASIC INFORMATION factor due to pulmonary parenchymal conse- DIAGNOSIS P
quences of malnutrition.
DEFINITION Established by the chest x-ray (Fig. P1-50).
A spontaneous pneumothorax (SP) is defined PHYSICAL FINDINGS & CLINICAL
as the accumulation of air into the pleural PRESENTATION DIFFERENTIAL DIAGNOSIS
space, collapsing the lung without a precipitat- Sudden onset of pleuritic chest pain (90%), Pleurisy.
ing event. This can be primary SP (without any usually at rest, which often becomes dull Pulmonary embolism.
obvious underlying lung disease) or secondary after a few hours. Myocardial infarction.
SP (with underlying lung disease). Pain is usually unilateral and can be sharp Pericarditis.
and agonizing and associated with consider- Asthma.
SYNONYMS able apprehension. Pneumonia.
Primary spontaneous pneumothorax Dyspnea (80%), which often resolves within

and Disorders
Diseases
Secondary spontaneous pneumothorax 24 hr, despite persistence of pneumothorax.
Cough (10%).
ICD-9CM CODES Asymptomatic (5%); may take up to 7 days to
512.0SSpontaneous tension pneumothorax come to medical attention.
512.8Other spontaneous pneumothorax Tachycardia.
ICD-10CM CODES
J93.83 Other pneumothorax
Hypoxemia.
Hypercapnia is rare because the alveolar venti- I
J93.9Pneumothorax, unspecified lation is maintained by the contralateral lung.
Decreased chest excursion on the affected
side.
EPIDEMIOLOGY & Diminished breath sounds.
DEMOGRAPHICS Subcutaneous emphysema may be present.
Approximately 20,000 new cases of SP occur Hyperresonance on percussion.
each year in the United States.
SP is more common in men than women ETIOLOGY
(6:1). In primary SP, rupture of small blebs, usually
Incidence of primary SP is 7.4 per 100,000 in located near the apex of the upper lobes, is a
men and 1.2 per 100,000 in women. common cause. The check-valve mechanism
Incidence of secondary SP is 6.3 per 100,000 is uncommon in this case; therefore, tension FIGURE P1-50 Chest radiograph shows right
in men and 2.0 per 100,000 in women. pneumothorax rarely occurs. hydropneumothorax.Horizontal line in lower
SP is commonly seen in tall, thin young men In secondary SP, chronic obstructive pulmo- right hemithorax is interface between air and liquid
aged 20 to 40 yr. nary disease is the most common cause, but in pleural space. Arrows point to visceral pleura
Risk factors include smoking, family history, it can also be associated with pneumonia, above level of effusion. There is air in pleural space
Marfans syndrome, homocystinuria, and tho- bronchogenic carcinoma, mesothelioma, sar- between visceral pleura and chest wall. (From
racic endometriosis. coidosis, tuberculosis, cystic fibrosis, and Weinberg SE etal: Principles of pulmonary medicine,
many other lung diseases (Fig. P1-49). ed 5, Philadelphia, 2008, Saunders.)

Normal lung
markings Absence
extend to of lung
periphery markings
of thorax

Pleural
line

A B
FIGURE P1-49 Pneumothorax. A, Schematic of normal lung. B, Schematic of pneumothorax. Pneumothoraces can range in size from tiny to massive. Because of
the variability in their size and location, pneumothoraces can be difficult to detect on chest x-ray. For example, a pneumothorax that is anterior or posterior rather than
lateral may be hidden on frontal chest x-ray, particularly one taken in the supine position. An upright chest x-ray should be obtained if possible. An expiratory film is
thought to be more sensitive, because the lung and thorax decrease in size during expiration, but air trapped in the pleural space remains the same size and thus appears
relatively larger. Subtle pneumothoraces may not be visible on chest x-ray. In some cases, subcutaneous air may be the only visible clue to underlying lung injury. CT is
extremely sensitive for pneumothorax, although controversy remains over the proper management of pneumothoraces seen only on CT. Ultrasound is also thought to be
more sensitive than chest x-ray for detection of pneumothorax, although, again, the management of pneumothorax seen only on ultrasound is uncertain because this
is a relatively newly described method of detection. The chest x-ray findings of pneumothorax include a lack of the normal lung markings, which should be visible to
the periphery of the chest wall. Sometimes a line marking the boundary of the lung and visceral pleura is visible, although this can be confused with ribs and with the
medial margin of the scapula. Depending on the degree of pneumothorax and lung collapse, the lung parenchyma may appear denser than the opposite side. In extreme
cases of tension pneumothorax, the pressure exerted by the air in the pleural space may begin to displace other structures, including the diaphragm and mediastinum.
In tension pneumothorax, the hyperinflated hemithorax may also have abnormally positioned ribs, with a position more horizontal than usual. (From Broder JS: Diagnostic
imaging for the emergency physician, Philadelphia, 2011, Saunders.)

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974 Pneumothorax, Spontaneous
WORKUP to evaluate for underlying lung pathology, The catheter is left in place and attached to
Includes CXR and, in some inconclusive cases, especially in patients with secondary pneu- a three-way stopcock and a large syringe.
CT scan of the chest. mothorax. Air is aspirated until resistance is met or
the patient experiences significant coughing.
LABORATORY TESTS Repeat CXR is done immediately after aspi-
TREATMENT ration and again in 4 to 24 hr to document
Arterial blood gases may show hypoxemia
and hypocapnia as a result of hyperventila- INITIAL MANAGEMENT reexpansion of the lung. If the pneumothorax
tion. fails to resolve with aspiration, a chest tube
100% oxygen administration reduces the
should be placed.
partial pressure of nitrogen in pleural cap-
IMAGING STUDIES If there is improvement but not complete
illaries, consequently quadrupling the rate
SP is usually confirmed by upright CXR: resolution of pneumothorax after the aspi-
of pneumothorax absorption, and should be
1. A white visceral pleural line. The absence ration, the catheter can be attached to a
administered to all patients with pneumo-
of vessel markings peripheral to this line Heimlich (one-way) valve to allow further
thorax.
helps differentiate from mimicking condi- lung expansion. Some stable patients can
Further treatment is based on the size of the
tions such as an overlying skin fold. A be discharged home with this device in
pneumothorax.
lateral width of 1 cm corresponds to 10% place if close follow-up monitoring can
1.  If the pneumothorax is small (<3 cm
pneumothorax. be obtained. An alternative approach is to
between lung and chest wall on CXR), the
2. The left lateral decubitus position is the perform an autologous blood patch. This
patient can be treated with observation
most sensitive and the supine position the involves withdrawal of peripheral blood
alone. Repeat imaging should be per-
least sensitive. Inspiratory and expiratory and infusion into the pleural space through
formed to ensure stability/resorption of
films have equal sensitivities. a chest tube.
the pneumothorax.
3. As little as 50 ml of air can be detected on Chest tube insertion has been recommended
2. If the pneumothorax is >3 cm, or if the
upright film. for patients with primary SP who do not
patient is symptomatic with chest pain
Tension pneumothorax (Fig. P1-51) is a medi- respond to simple aspiration and for all
and dyspnea, initial management should
cal emergency and should be suspected patients with secondary SP, recurrent pneu-
focus on removing air from the pleural
when the patient is hemodynamically unsta- mothorax, or tension pneumothorax. Most
space. Needle aspiration is the treatment
ble or with contralateral tracheal and medi- patients can be managed with small chest
of choice in the clinically stable patient.
astinal deviation and ipsilateral flattening or tubes (<22 Fr). The chest tube can be con-
Needle aspiration can be done at the bedside
inversion of the diaphragm on the CXR (Fig. nected to a water seal device, with or without
using a large-bore angiocatheter needle or
EP1-52). suction, and left in position until the pneumo-
commercially available needle thoracotomy
CT scan can be done in suspected but thorax has resolved.
kit. The needle is introduced in the sec-
difficult-to-visualize pneumothoraces, to dif- An algorithmic approach to the treatment
ond intercostal space midclavicular line.
ferentiate from large subpleural bullae or of primary spontaneous pneumothorax is
outlined in Fig. P1-53.

PREVENTION
Approximately 25% to 50% of patients with
primary SP with have a recurrence within 1 yr.
Multiple techniques have been used to pre-
vent recurrence, including intrapleural instil-
lation of sclerosing agents, pleurectomy,
laser abrasion of parietal pleura, and pleural
abrasion with dry gauze.
The current recommended approach is the use
of video-assisted thoracoscopy (VATS) with an
aim to excise the associated bullae or perform
guided pleurodesis or treatment. Most pulmo-
nologists recommend definitive management
after the first recurrence. However, high-risk
occupations such as divers or pilots should
be considered for surgery after their first
pneumothorax. Similarly, complex conditions
such as patients with persistent bronchopleu-
ral fistula suggested by a persistent air leak
from the chest tube should also be considered
for VATS and early surgical intervention. The
overall recurrence rate is estimated at <5%
after VATS.
The recurrence rates for the instillation of
sclerosing agents (minocycline 5 mg/kg in
50 ml of normal saline or doxycycline 500 mg
in 50 ml of normal saline) are higher than
for VATS-guided therapy (<25%). Therefore
this mode of therapy should be reserved for
FIGURE P1-51 Tension pneumothorax.On this PA chest radiograph, the left hemithorax is very dark patients who are poor surgical candidates.
or lucent because the left lung has collapsed completely (white arrows). The tension pneumothorax can be Talc has also been used as a sclerosing agent
identified by the fact that the mediastinal contents, including the heart, are shifted toward the right (black with favorable results; however, concerns
arrows), and the left hemidiaphragm is flattened and depressed. (From Mettler FA etal: Primary care radiology, persist due to case reports describing acute
Philadelphia, 2000, Elsevier.)

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Pneumothorax, Spontaneous 975

Spontaneous pneumothorax
P
Yes
Signs of tension PTX Immediate
decompression

Evidence of lung disease?

No Yes

and Disorders
Diseases
Primary pneumothorax Secondary pneumothorax

Intrapleural space <3 cm apex-cupula or Intrapleural space <3 cm apex-cupula or


<2 cm at level of hilum and asymptomatic <2 cm at level of hilum and asymptomatic

Yes No Yes No
I
Observation for 3 hours Simple small (14-16 g) Intrapleural space Small (14 Fr)
Repeat CXR catheter aspiration at level of hilum? percutaneous chest
Follow-up in tube to water seal
24-48 hours Admit

Less than
Successful Unsuccessful 1 cm 1-2 cm

Unsuccessful
If discharged with Small (14 Fr) Consider observation Simple small (14-16 g)
Heimlich valve, percutaneous chest versus catheter aspiration
follow-up in tube to water seal simple small
48-72 hours Admit (14-16 g)
Or admit catheter aspiration
Successful

Admit

FIGURE P1-53 Algorithmic approach to the treatment of primary spontaneous pneumothorax.


CXR, Chest radiograph. (From Adams JG etal: Emergency medicine: clinical essentials, ed 2, Philadelphia, 2013,
Elsevier.)

respiratory distress syndrome and pleural COMMENTS


calcification occurring after use. PEARLS & Patients with AIDS and Pneumocystis cari-
Open thoracotomy is performed in patients CONSIDERATIONS nii infection have a high incidence of SP.
who do not respond to VATS or when VATS is Treatment typically requires chest tube
not available. The rate of pleural air absorption is approxi-
placement and either thoracoscopy or open
mately 1.25% of the volume of the hemi-
thoracotomy.
DISPOSITION thorax per day. Therefore the interval for
Smoking cessation should be advised. complete resolution of pneumothorax with
Death from primary SP is uncommon. In observation can be estimated. SUGGESTED READINGS
patients with secondary SP and chronic Catamenial pneumothorax is a rare condition
Available at www.expertconsult.com
obstructive pulmonary disease, mortality characterized by recurrent SP coinciding
rates range from 1% to 16%. with the onset of menses. It usually affects RELATED CONTENT
the right lung and is believed to be caused
Pneumothorax (Patient Information)
REFERRAL by endometriosis with involvement of the
diaphragm and/or pleura. It is believed to be AUTHORS: JOHANNES STEINER, M.D., and
A pulmonary specialist and surgical consultation RICHARD REGNANTE, M.D.
are recommended. hormonally related, and treatment is aimed at
endometrial suppression.

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Pneumothorax, Spontaneous 975.e1

SUGGESTED READINGS
Baumann MH etal.: Management of spontaneous pneumothorax: an American
College of Chest Physicians Delphi consensus statement, Chest 119(2):590,
2001.
Baumann MH etal.: Pneumothorax, Respirology 9(2):137, 2004.
Biffl WL, Narayanan V, Gaudiani JL, Mehler PS: The management of pneumothorax
in patients with anorexia nervosa: A case report and review of the literature,
Patient Saf Surg 4:1, 2010.
Chen F etal.: Position of a chest tube at video-assisted thoracoscopic surgery for
spontaneous pneumothorax, Respiration 73(3):329, 2006.
Deavanand A etal.: Simple aspiration versus chest tube insertion in the manage-
ment of primary spontaneous pneumothorax: a systematic review, Respir Med
98(7):579, 2004.
Morimoto T etal.: Effects of timing of thoracoscopic surgery for primary spon-
taneous pneumothorax on prognosis and cost, Am J Surg 187(6):767, 2004.
Morse JL, Sadafer B: Acute tension pneumothorax and tension penumoperito-
neum in a patient with anorexia nervosa, J Emerg Med 38:e13, 2010.
Noppen M etal.: Music: a new cause of primary spontaneous pneumothorax,
Thorax 59(8):722, 2004.
Sahn SA, Heffner JE: Spontaneous pneumothorax, N Engl J Med 342:868, 2000.
Wakai A: Spontaneous pneumothorax, Clin Evid 13:2005, 1884.

FIGURE EP1-52 Chest radiograph showing left pneumothorax with shift of the mediastinum and trachea to the right side (white arrows). The left lung is not completely
collapsed, suggesting the presence of a loculated tension pneumothorax. (From Siu Wa Chan, S: Tension pneumothorax managed without immediate needle decompres-
sion, Am J Emerg Med 36(3):242-245, 2009.

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