ESSENTIAL FEATURES
• Air in pleural space
• Breach in parietal or visceral pleura
• Described as percentage of chest cavity involved
• Open pneumothorax is associated with open sucking chest wound
• Tension pneumothorax causes shift in mediastinum toward contralateral lung
• 5–10% small pleural effusion present, may be hemorrhagic
EPIDEMIOLOGY
• Etiologies of spontaneous pneumothorax include:
–Secondary to some pathologic process
–Rupture of bleb is most common
–Male:female ratio 6:1
–Age 16 to 24 years, tall, thin, smoking are risk factors
–Apical bullae (patients with chronic obstructive pulmonary disease [COPD])
–Pneumocystic pneumonia
–Metastatic cancer
–Rupture of esophagus
–Lung abscess
–Cystic fibrosis
CLINICAL FINDINGS
SYMPTOMS AND SIGNS
• Pleuritic chest pain
• Dyspnea, hypoxia, hypocapnia
• Diaphoresis, cyanosis, weakness, hypotension, cardiovascular collapse
• Tachypnea, tachycardia, deviation of trachea away (tension)
• Decreased breath sounds, hyperresonance, diminished local fremitus
LABORATORY FINDINGS
• ECG: May show nonspecific axis deviation, ST changes, T wave inversion
IMAGING FINDINGS
• Chest x-ray: Diagnostic
• CT scan: May help differentiate pneumothorax from apical pleural bleb
DIAGNOSTIC CONSIDERATIONS
• 1 cm pneumothorax correlates with 25% loss of lung volume
WORK-UP
• Chest x-ray
WHEN TO refer
• Patients with cystic fibrosis
• Patients with AIDS and pneumocystis pneumonia
TREATMENT AND MANAGEMENT
• Small (< 25%), minimal symptoms: Can be monitored conservatively
• Larger asymptomatic, symptomatic, increasing pneumothorax, or associated with effusion:
–Insert chest tube
–Underwater suction drainage or Heimlich (can treat as outpatient)
• Select patients can get aspiration without chest tube, but 20–50% have recurrence
• Patients with AIDS and pneumocystis pneumonia has high failure rate and mortality
Surgery urgery
• Pleurodesis with doxycycline or talc
• Axillary thoracotomy with apical bullectomy, parietal pleurectomy, and pleurodesis (preferred technique)
• Complete parietal pleurectomy
• Transplantation: Patients with cystic fibrosis or severe COPD; pleurodesis may be contraindicated in these patients
Indications
• Pleurodesis:
–Air leaks > 7 days
–Lung does not fully expand
–High-risk occupation (scuba divers, pilots)
Contraindications
• Pleurodesis:
–Cystic fibrosis, severe COPD (relative)
TREATMENT MONITORING
• Repeat chest film mandatory within 24 hours of chest tube removal due to recurrence
Complications omplications
• Recurrence
–Spontaneous, 50%
–After 2 episodes, 75%
–After 3 episodes, > 80%
RESOURCES
REFERENCES
• Brasel KJ et al: Treatment of occult pneumothoraces from blunt trauma. J Trauma 1999;46:987.
• Cothren C et al: Lung-sparing techniques are associated with improved outcome compared with anatomic resection for severe lung injuries. J Trauma 2002;53:483.
• Dulchavsky SA et al: Prospective evaluation of thoracic ultrasound in the detection of pneumothorax. J Trauma 2001;50:201.
• Karmy-Jones R et al: Urgent and emergent thoracotomy for penetrating chest trauma. J Trauma 2004;56:664.
• Lowdermilk GA, Naunheim KS: Thoracoscopic evaluation and treatment of thoracic trauma. Surg Clin North Am 2000;80:1535.
• Mayberry JC et al: Absorbable plates for rib fracture repair: preliminary experience. J Trauma 2003;55:835.
• Meredith JW, Hoth JJ: Thoracic trauma: when and how to intervene. Surg Clin N Am 2007;87:95.
• Richardson JD et al: Operative fixation of chest wall fractures and underused procedure? Am Surg 2007;73:591.
