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pneumothorax

The presence of air or gas in the pleural cavity. Etiology: 1) primary spontaneous pneumothorax* a) rupture of apical bullae b) smoking increases risk (30 fold) c) thoracic endometriosis d) tall stature 2) secondary spontaneous pneumothorax a) COPD (most common), emphysema b) asthma, status asthmaticus c) interstitial lung disease 1] lymphangioleiomyomatosis (premenopausal women) 2] Langerhans cell granuloma 3] sarcoidosis 4] idiopathic pulmonary fibrosis d) bullous lung disease e) cystic fibrosis f) lung tumors, lung cancer g) end-stage fibrosis h) honeycombing of the lungs j) Marfan's syndrome j) catamenial hemopneumothorax (during menses) k) AIDS, Pneuomocystis pneumonia l) tuberculosis m) connective tissue disease with pulmonary involment 1] rheumatoid pleurisy 2] lupus pleuritis 3) tension pneumothorax 4) iatrogenic a) thoracentesis b) trauma c) esophageal rupture d) tracheal fracture e) subclavian needle sticks f) high positive end-expiratory pressure with mechanical ventilation g) transtracheal aspiration h) severe Valsalva maneuver i) pneumoperitoneum * primary spontaneous pneumothorax: no underlying lung disease Epidemiology: 1) primary spontaneous pneumothorax* a) annual incidence 9/100,000 b) male:female ratio 6:1 c) up to 40% patients have a recurrence 2) secondary spontaneous pneumothorax b) annual incidence 4/100,000 c) male:female ratio 3:1 Pathology: - secondary pneumothorax 1) occur in patients with compromised pulmonary function 2) frequent airleaks or bronchopleural fistulas complicate resolution Genetics: - spontaneous pneumothorax may be associated with defects in FLCN Clinical manifestations: 1) sudden onset pleuritic chest pain [3] 2) dyspnea 3) inspiratory chest expansion lag on affected side 4) absent fremitus 5) hyperresonant or tympanitic to percussion 6) cough may be present 7) absent breath sounds Radiology: 1) chest X-ray (upright) a) pneumothorax appears at the apex of the lung b) end-expiratory chest X-ray is more sensitive for identifying a small pneumothorax c) tracheal deviation d) sensitivity: 52%; specificity 100% 2) CT of lung - look for interstitial lung disease, alveolar infiltrates, & subpleural blebs & bullae especially in the lung contralateral to the pneumothorax 3) ultrasound: sensitivity: 88%; specificity 99% [5] - lung sliding indicated no pneumothorax at that speicific location - presence of a lung point confirms edge of pneumothorax Complications: - tension pneumothorax Management: 1) initial management for large, hemodynamically significant pneumothorax (primary or secondary) is a) supplemental oxygen b) bedside ultrasound for acute respiratory failure in critically ill patients prior to emergent needle aspiration for decompression followed by thoracostomy/chest tube placement [3] c) hospitalize [3] 2) primary pneumothorax a) observation for spontaneous primary pneumothorax - occupying < 15% of hemithorax - < 2 cm air rim on chest X-ray [3]; < 3.5 cm [11] - without dyspnea or hypoxemia (asymptomatic) - avoid sudden changes in barometric pressure - airline travel - SCUBA diving - easy access to medical care should be available if condition deteriorates [3] - pneumothorax detected only with CT, but not chest X-ray observed vs thoracostomy (65% vs 30%) [10] - conservative management safe & effective [12] - do not treat chest pain with NSAID [15] b) needle aspiration & high-flow supplemental oxygen - symptomatic primary spontaneous pneumothorax of any size - larger primary spontaneous pneumothorax (> 2 cm air rim on chest X-ray [3]; > 3.5 cm [11]) - fewer complications with needle aspiration than chest tube with similar likelihood of immediate success [13] - failure at 24 hours more common with aspiration than chest tube (29 vs 18%) but similar 7 day & 1 year outcomes [14] c) ipsilateral thoracostomy +/- pleurodesis for 2nd spontaneous primary pneumothorax & for patients in high-risk occupations (scuba diving) [3] 3) secondary pneumothorax a) hospitalize - small pneumothorax (< 2 cm) with minimal symptoms may be observed in an inpatient setting [3] (< 3.5 cm [11]) b) chest tube drainage - aspiration through a plastic intercostal catheter - thoracostomy vs thoracoscopy with pleurodesis [3] - chest tube drainage if > 3 cm air rim on chest X-ray [3] c) chemical pleurodesis d) surgical decortication 4) also see tension pneumothorax

Interactions

disease interactions

Related

collapsed lung

Specific

hemopneumothorax pneumomediastinum; mediastinal emphysema pneumopericardium tension pneumothorax

General

pleural disorder

Database Correlations

OMIM 173600

References

  1. Stedman's Medical Dictionary 26th ed, Williams & Wilkins, Baltimore, 1995
  2. Mayo Internal Medicine Board Review, 1998-99, Prakash UBS (ed) Lippincott-Raven, Philadelphia, 1998, pg 773
  3. Medical Knowledge Self Assessment Program (MKSAP) 11, 14, 15, 16, 17, 18, 19. American College of Physicians, Philadelphia 1998, 2006, 2009, 2012, 2015, 2018, 2022. - Medical Knowledge Self Assessment Program (MKSAP) 19 Board Basics. An Enhancement to MKSAP19. American College of Physicians, Philadelphia 2022
  4. Harrison's Principles of Internal Medicine, 13th ed. Isselbacher et al (eds), McGraw-Hill Inc. NY, 1994, pg 1146
  5. Ding W et al. Diagnosis of pneumothorax by radiography and ultrasonography: A meta-analysis. Chest 2011 Oct; 140:859. PMID: 21546439 - Baumann MH. Chest ultrasonography: Where's the beef? Chest 2011 Oct; 140:837. PMID: 21972375
  6. OMIM :accession 173600
  7. Noppen M Spontaneous pneumothorax: epidemiology, pathophysiology and cause. Eur Respir Rev. 2010 Sep;19(117):217-9. PMID: 20956196
  8. Baumann MH, Strange C, Heffner JE et al Management of spontaneous pneumothorax: an American College of Chest Physicians Delphi consensus statement. Chest. 2001 Feb;119(2):590-602 PMID: 11171742
  9. MacDuff A, Arnold A, Harvey J et al Management of spontaneous pneumothorax: British Thoracic Society Pleural Disease Guideline 2010. Thorax. 2010 Aug;65 Suppl 2:ii18-31. PMID: 20696690
  10. Rodriguez RM, Canseco K, Baumann BM et al. Pneumothorax and hemothorax in the era of frequent chest computed tomography for the evaluation of adult patients with blunt trauma. Ann Emerg Med 2018 Oct 1; S0196-0644(18)31159-4; PMID: 30287121
  11. Eddine SBZ, Boyle KA, Dodgion CM et al. Observing pneumothoraces: The 35 millimeter rule is safe for both blunt and penetrating chest trauma. J Trauma Acute Care Surg 2019 Jan 8; https://journals.lww.com/jtrauma/Abstract/publishahead/Observing_Pneumothoraces__The_35_Millimeter_Rule.98431.aspx
  12. Brown SGA, Ball EL, Perrin K et al. Conservative versus interventional treatment for spontaneous pneumothorax. N Engl J Med 2020 Jan 30; 382:405. PMID: 31995686 - Broaddus VC. Clearing the air - A conservative option for spontaneous pneumothorax. N Engl J Med 2020 Jan 30; 382:469 PMID: 31995695
  13. Mummadi SR, de Longpre' J, Hahn PY. Comparative effectiveness of interventions in initial management of spontaneous pneumothorax: A systematic review and a Bayesian network meta-analysis Ann Emerg Med 2020 Feb 27; PMID: 32115203 https://www.annemergmed.com/article/S0196-0644(20)30009-3/fulltext
  14. Marx T et al. Simple aspiration versus drainage for complete pneumothorax: A randomized noninferiority trial. Am J Respir Crit Care Med 2023 Jun 1; 207:1475. PMID: 36693146 https://www.atsjournals.org/doi/10.1164/rccm.202110-2409OC
  15. NEJM Knowledge+
  16. https://radiopaedia.org/articles/pneumothorax