Pneumothorax

Definition
• Pneumothorax is defined as the presence of
air or gas in the pleural cavity (ie, the potential
space between the visceral and parietal pleura
of the lung), which can impair oxygenation
and/or ventilation.
 Spontaneous Pneimothorax
• Primary spontaneous pneumothorax (PSP)
occurs in people without underlying lung
disease and in the absence of an inciting event
• Secondary spontaneous pneumothorax (SSP)
occurs in people with a wide variety of
parenchymal lung diseases. [2] These
individuals have underlying pulmonary
pathology that alters normal lung structure
 Iatrogenic pneumothorax
• Iatrogenic pneumothorax is a traumatic
pneumothorax that results from injury to the
pleura, with air introduced into the pleural
space secondary to diagnostic or therapeutic
medical intervention
 Traumatic pneumothorax
• Traumatic pneumothorax results from blunt
trauma or penetrating trauma that disrupts
the parietal or visceral pleura
 Tension pneumothorax

• A tension pneumothorax is a life-threatening

condition that develops when air is trapped in
the pleural cavity under positive pressure,
displacing mediastinal structures and
compromising cardiopulmonary function.
 Pneumomediastinum

• Pneumomediastinum is the presence of gas in

the mediastinal tissues occurring
spontaneously or following procedures or
trauma (see the following images). A
pneumothorax may occur secondary to
pneumomediastinum.
 Pathophysiology
• Spontaneous Pneumothorax
– Bleb—gas—invade pleural space—equal pressure
• Lung inflammation and oxidative stress are
hypothesized to be important to the
pathogenesis of PSP. Current smokers, at
increased risk for PSP, have increased numbers
of inflammatory cells in the small airways.
• Genetic disorders that have been linked to PSP
include Marfan syndrome, homocystinuria,
and Birt-Hogg-Dube (BHD) syndrome.
• Tension pneumothorax
Tension pneumothorax occurs anytime a
disruption involves the visceral pleura, parietal
pleura, or the tracheobronchial tree. This
condition develops when injured tissue forms
a one-way valve, allowing air inflow with
inhalation into the pleural space and
prohibiting air outflow.
• Arising from numerous causes, this condition
rapidly progresses to respiratory insufficiency,
cardiovascular collapse, and, ultimately, death
if unrecognized and untreated.
• Pneumomediastinum
With pneumomediastinum, excessive intra-
alveolar pressures lead to rupture of alveoli
bordering the mediastinum. Air escapes into
the surrounding connective tissue and dissects
further into the mediastinum.
 Risks factors for primary spontaneous
pneumothorax (PSP) include the
• Smoking
following:
• Tall, thin stature in a healthy person
• Marfan syndrome
• Pregnancy
• Familial pneumothorax
• Blebs and bullae (sometimes called referred to
as ELCs) are related to the occurrence of
primary spontaneous pneumothorax
 Diseases and conditions associated with
secondary spontaneous pneumothorax include
the following:
• Chronic obstructive lung disease (COPD) or emphysema -
Increased pulmonary pressure due to coughing with a
bronchial plug of mucus or phlegm bronchial plug may play
a role.
• Asthma
• Human immunodeficiency virus/acquired
immunodeficiency syndrome (HIV/AIDS) with PCP infection
• Necrotizing pneumonia
• Tuberculosis
• Sarcoidosis
• Cystic fibrosis
 Iatrogenic and traumatic pneumothorax

• Causes of iatrogenic pneumothorax include the

following:
• Transthoracic needle aspiration biopsy of pulmonary
nodules (most common cause, accounting for 32-37%
of cases)
• Transbronchial or pleural biopsy
• Thoracentesis
• Central venous catheter insertion, usually subclavian or
internal jugular
• Intercostal nerve block
• Tracheostomy
• Trauma - Penetrating and nonpenetrating
injury
• Rib fracture
• High-risk occupation (eg, diving, flying)

Traumatic pneumothoraces often can create a

one-way valve in the pleural space (only
letting in air without escape) and can lead to a
tension pneumothorax.
The most common etiologies of tension pneumothorax
are either iatrogenic or related to trauma, such as the
following:
• Blunt or penetrating trauma - Disruption of either the
visceral or parietal pleura occurs and is often
associated with rib fractures, though rib fractures are
not necessary for tension pneumothorax to occur.
• Barotrauma secondary to positive-pressure ventilation
(PPV), especially when high amounts of positive end-
expiratory pressure (PEEP) are used
• Pneumoperitoneum [18, 19]
• Fiberoptic bronchoscopy with closed lung biopsy [20]
• Markedly displaced thoracic spine fractures
• Acupuncture [21, 22, 23]
• Colonoscopy [25] and gastroscopy have been
implicated in case reports.
• Percutaneous tracheostomy [26]
• Conversion of idiopathic, spontaneous, simple
pneumothorax to tension pneumothorax
• Unsuccessful attempts to convert an open
pneumothorax to a simple pneumothorax in
which the occlusive dressing functions as a
one-way valve
 Symptoms and sign
• Shortness of breath/dyspnea in PSP is
generally of sudden onset and tends to be
more severe with SSPs because of decreased
lung reserve. Anxiety, cough, and vague
presenting symptoms (eg, general malaise,
fatigue) are less commonly observed.
• Symptoms of tension pneumothorax may
include chest pain (90%), dyspnea (80%),
anxiety, fatigue, or acute epigastric pain (a
rare finding), hypotension, hypoxia.
• In pleuromesiastinum, one retrospective
review of cases presenting to an academic
medical center, 67% of identified patients had
chest pain; 42% had persistent cough; 25%
had sore throat; and 8% had dysphagia,
shortness of breath, or nausea/vomiting.
• Other symptoms may include substernal chest
pain, usually radiating to the neck, back, or
shoulders and exacerbated by deep
inspiration, coughing, or supine positioning;
dyspnea; neck or jaw pain; dysphagia,
dysphonia, and/or abdominal pain (unusual
symptoms).
 Physical Examination
Respiratory findings may include the following:
• Respiratory distress (considered a universal
finding) or respiratory arrest
• Tachypnea (or bradypnea as a preterminal
event)
• Asymmetric lung expansion - A mediastinal
and tracheal shift to the contralateral side can
occur with a large tension pneumothorax
• Distant or absent breath sounds - Unilaterally
decreased or absent lung sounds is a common
finding, but decreased air entry may be absent
even in an advanced state of the disease
• Lung sounds transmitted from the unaffected
hemithorax are minimal with auscultation at the
midaxillary line
• Hyperresonance on percussion - This is a rare
finding and may be absent even in an advanced
state of the disease
• Decreased tactile fremitus
• Adventitious lung sounds (crackles, wheeze;
an ipsilateral finding)
Cardiovascular findings may include the
following:
• Tachycardia - This is the most common finding.
If the heart rate is faster than 135 beats/min,
tension pneumothorax is likely
• Pulsus paradoxus
• Hypotension - This should be considered as an
inconsistently present finding; although
hypotension is typically considered a key sign
of a tension pneumothorax, studies suggest
that hypotension can be delayed until its
appearance immediately precedes
cardiovascular collapse
• Jugular venous distention - This is generally
seen in tension pneumothorax, although it
may be absent if hypotension is severe
• Cardiac apical displacement - This is a rare
finding
 Work up
• Pneumothorax relies heavily on physical
diagnosis
• Chest Radiograph
• CT Scan
• ABG
– ABG analysis may be useful in evaluating hypoxia
and hypercarbia and respiratory acidosis.
 Management
• Pharmacotherapy
– Antibiotics
– Analgesics
• Risk Stratification
– Asymptomatic: estimate long term risk
– Clinically stable : Simple aspiration by small bore
catheter or chest tube placement
– Life threatening: tube torachostomy
• Interval Observation
– At 0-6 hours - The ACCP Delphi consensus
statement recommends observation in an ED for 6
hours, and discharge to home if a follow-up chest
radiograph shows no enlargement of the lesion, in
reliable patients
• At 24-96 hours - Additional follow up in 2 days
is recommended, with preference given to a
24-48 hour follow-up radiograph in the
outpatient setting; outpatient follow-up
during the 96-hour window is essential to
distinguish between a resolved pneumothorax
and one that needs evacuation
• At 1 month - Full lung reexpansion can occur,
on average, 3 weeks after the initial event
• Options for Restoring Air-Free Pleural Space
– Observation without oxygen
• Simple observation is appropriate for asymptomatic
patients with a minimal pneumothorax (< 15-20% by
Light criteria; 2-3 cm from apex to cupola by alternate
criteria) with close follow-up, ensuring no enlargement
– Supplemental oxygen
• Oxygen administration at 3 L/min nasal canula or higher
flow treats possible hypoxemia and is associated with a
fourfold increase in the rate of pleural air absorption
compared with room air alone
• Simple aspiration
– in 131 cases of small spontaneous pneumothorax
yielded successful results up to 87%.
• Chest tube placement
– A tube inserted into the pleural space is
connected to a device with one-way flow for air
removal.
TERIMA KASIH