Pneumothorax

Background

A pneumothorax refers to a collection of gas in the pleural space resulting in collapse

of the lung on the affected side. A tension pneumothorax is a life-threatening
condition caused by air within the pleural space that is under pressure; displacing
mediastinal structures and compromising cardiopulmonary function. A traumatic
pneumothorax results from blunt or penetrating injury that disrupts the parietal or
visceral pleura. Mechanisms include injuries secondary to medical or surgical
procedures.
Pneumothorax is shown in the image below.

Pneumothorax, Tension and Traumatic.

Pneumothorax, Tension and Traumatic.

Pathophysiology

A tension pneumothorax results from any lung parenchymal or bronchial injury that
acts as a one-way valve and allows free air to move into an intact pleural space but
prevents the free exit of that air. In addition to this mechanism, the positive pressure
used with mechanical ventilation therapy can cause air trapping. As pressure within
the intrapleural space increases, the heart and mediastinal structures are pushed to the
contralateral side. The mediastinum impinges on and compresses the contralateral
lung. Hypoxia results as the collapsed lung on the affected side and the compressed
lung on the contralateral side compromise effective gas exchange. This hypoxia and
decreased venous return caused by compression of the relatively thin walls of the atria
impair cardiac function. The decrease in cardiac output results in hypotension and,
ultimately, in hemodynamic collapse and death to the patient, if untreated.

Frequency

United States

A study conducted from 1959-1978 involving a US community with an average of

60,000 residents reported an incidence of primary spontaneous pneumothorax of 7.4
cases per 100,000 persons per year for men and 1.2 cases per 100,000 persons per
year for women. When these figures are extrapolated, about 8,600 individuals develop
primary spontaneous pneumothorax in the United States per year. Tension
pneumothorax is a complication in approximately 1-2% 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 patients with tuberculosis. Undoubtedly, the incidence of pneumothorax
and/or tension pneumothorax in US hospitals has increased as intensive care treatment
modalities have become increasingly dependent on positive-pressure ventilation,
central venous catheter placement, and other causes that potentially induce iatrogenic
pneumothorax.

International

Acupuncture is a traditional Chinese medicine technique used worldwide by

alternative medical practitioners. Although generally considered to be a safe form of
therapy, acupuncture's most frequently reported serious complication is
pneumothorax. In one Japanese report of 55,291 acupuncture treatments, an
approximate incidence of 1 pneumothorax in 5000 cases was documented.1

Mortality/Morbidity

The clinician should assume that a tension pneumothorax results in hemodynamic

instability and death, unless immediately treated.

Sex

The male-to-female ratio is about 6:1 for primary spontaneous pneumothorax

development.
 • In men, the risk of spontaneous pneumothorax is 102 times higher in heavy
smokers than in nonsmokers. Spontaneous pneumothorax most frequently
occurs in tall, thin men aged 20-40 years.
• Catamenial pneumothorax is a rare phenomenon that generally occurs in
women aged 30-50 years. It frequently begins 1-3 days after menses onset. Its
etiology may be primarily related to associated diaphragmatic defects.

Men undergoing treatment for tension pneumothorax are more likely to have a larger
body habitus with wider chest wall. Tension pneumothorax patients with wider chest
walls undergoing needle thoracostomy may need a catheter longer than 5 cm to
reliably penetrate into the pleural space.

Harcke et al using CT scan analysis of deployed male military personnel determined

that, at the second right intercostal space in the midclavicular line, the mean
horizontal thickness was 5.36 cm, and that an 8-cm angiocatheter would reach the
pleural space in 99% of the male soldiers in this series.2

Age

Pneumothorax occurs in 1-2% of all neonates. The incidence of pneumothorax in

infants with neonatal respiratory distress syndrome is higher. In one study, 19% of
such patients developed a pneumothorax.

Clinical

History

The signs and symptoms produced by tension pneumothorax are usually more
impressive than those seen with a simple pneumothorax. Unlike the obvious patient
presentations oftentimes used in medical training courses to describe a tension
pneumothorax, actual case reports include descriptions of the diagnosis of the
condition being missed or delayed because of subtle presentations that do not always
present with the classically described clinical findings of this condition.

Symptoms and signs of tension pneumothorax may include the following:

• Chest pain (90%)

• Dyspnea (80%)
• Anxiety
• Acute epigastric pain (a rare finding)
• Fatigue

Physical

Findings at physical examination may include the following:

• Respiratory distress (considered a universal finding) or respiratory arrest

• Unilaterally decreased or absent lung sounds (a common finding; but
decreased air entry may be absent even in an advanced state of the disease)
• Adventitious lung sounds (crackles, wheeze; an ipsilateral finding)
 • Lung sounds transmitted from the nonaffected hemithorax are minimal with
auscultation at the midaxillary line
• Tachypnea; bradypnea (as a preterminal event)
• Hyperresonance of the chest wall on percussion (a rare finding; may be absent
even in an advanced state of the disease)
• Hyperexpansion of the chest wall
• Increasing resistance to providing adequate ventilation assistance
• Cyanosis (a rare finding)
• Tachycardia (a common finding)
• Hypotension (should be considered as an inconsistently present finding; while
hypotension is typically considered as a key sign of a tension pneumothorax,
studies suggest that hypotension can be delayed until its appearance
immediately precedes cardiovascular collapse)
• Pulsus paradoxus
• Jugular venous distension
• Cardiac apical displacement (a rare finding)
• Tracheal deviation (an inconsistent finding; while historic emphasis has been
placed on tracheal deviation in the setting of tension pneumothorax, tracheal
deviation is a relatively late finding caused by midline shift)
• Mental status changes, including decreased alertness and/or consciousness (a
rare finding)
• Abdominal distension (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)
• When examining a patient for suspected tension pneumothorax, helpful
indications of subtle thoracic size and thoracic mobility differences may be
elicited by performing careful visual inspection along the line of the thorax. In
a supine patient, by lowering oneself to be in level with the patient.
• Tension pneumothorax may be a difficult diagnosis to make and may present
with considerable variability in signs presented. Respiratory distress and chest
pain are generally accepted as being universally present in tension
pneumothorax. Tachycardia and ipsilateral air entry are also common findings.
• The development of tension pneumothorax in patients who are ventilated will
generally be of faster onset with immediate, progressive arterial and mixed
venous oxyhemoglobin saturation decline and immediate decline in cardiac
output.
• Cardiac arrest associated with asystole or pulseless electrical activity (PEA)
may ultimately result.

Causes

A wide variety of disease states and circumstances increase the patient's risk of a
pneumothorax. If a pneumothorax is complicated by a one-way valve effect, tension
pneumothorax may result.

• Infants requiring ventilatory assistance and those with meconium aspiration

have a particularly high risk for tension pneumothorax. Aspirated meconium
may serve as a one-way valve and produce a tension pneumothorax.
• Trauma may cause a pneumothorax.
 o Tension pneumothorax may be the result of blunt trauma with or
without associated rib fractures.
o Incidents that may cause tension pneumothoraces include unrestrained
head-on motor vehicle accidents, falls, and altercations involving
laterally directed blows.
o Any penetrating wound that produces an abnormal passageway for gas
exchange into the pleural spaces and that results in air trapping may
produce a tension pneumothorax.
o Significant chest injuries carry an estimated 10-50% risk of associated
pneumothorax. In about half of these cases, the pneumothorax may be
occult; therefore, chest CT should always be performed.
o In one study, 12% of patients with asymptomatic chest stab wounds
had a delayed pneumothorax or hemothorax.
o McPherson et al, analyzing data from the Vietnam Wound Data and
Munitions Effectiveness Team study, determined that tension
pneumothorax was the cause of death in 3-4% of fatally wounded
combat casualties.3
• Many procedures performed in an intensive care or emergency setting can
result in an iatrogenic pneumothorax and tension pneumothorax. Examples of
these procedures include incorrect chest tube insertion, mechanical ventilation
therapy, central venous cannulation; cardiopulmonary resuscitation;
hyperbaric oxygen therapy; needle, transbronchial, or transthoracic lung
biopsy; liver biopsy or surgery; and neck surgery.
• Secondary or spontaneous tension pneumothorax is possible in many medical
conditions.
o Pneumothorax is associated with asthma, chronic obstructive
pulmonary disease, pneumonia (especially with Staphylococcus,
Klebsiella, Pseudomonas, and Pneumocystis species), pertussis,
tuberculosis, lung abscess, and cystic fibrosis.
o In pulmonary disorders such as asthma and emphysema,
hyperexpansion disrupts the alveoli.
o Increased pulmonary pressure due to coughing with a bronchial plug of
mucus or phlegm bronchial plug may play a role.
o Marfan syndrome is associated with an increased risk of
pneumothorax.
o Individuals may inherit a predisposition for primary spontaneous
pneumothorax.
o Although rare, spontaneous pneumothorax occurring bilaterally and
progressing to tension pneumothorax has been documented.