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| ==Spontaneous Pneumothorax== | | ==Types== |
| ===Background===
| | {{Pneumothorax types}} |
| *Primary Pneumothorax
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| **Spontaneous ptx in pt w/o underlying pulm disease
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| *Secondary Pneumothorax
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| **Spontaneous ptx in pt w/ underlying pulm disease
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| **Worse prognosis
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| ===Causes===
| | [[File:Pneumothorax.jpeg|thumbnail|Right sided pneumothorax]] |
| #COPD/Asthma
| | [[File:PMC2892654 CRM2010-213818.004.png|thumb|Left sided [[tension pneumothorax]] with mediastinal shift]] |
| #Cystic fibrosis
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| #Necrotizing pneumonia
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| #Lung abscess
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| #PCP
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| #TB
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| #Neoplasm
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| #Interstitial lung disease
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| #Connective tissue disease
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| #Pulmonary infarct
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| ===Diagnosis===
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| ====Presentation====
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| *Sudden onset of pleuritic chest pain evolving to dull constant ache over days
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| *Most often occurs at rest, not during exertion
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| ====Physical Exam====
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| *Reduced ipsilateral lung excursion
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| *Hyperresonance
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| *Tachypnea
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| *Hypoxia
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| *Increased work of breathing
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| *Hypotension -> tension pneumothorax
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| ====Imaging====
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| *Ultrasound
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| **NO comet tail artifact
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| **No sliding lung sign
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| **Bar Code (instead of waves on the beach) appearance on M-mode
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| *CXR*
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| *Displaced visceral pleural line
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| *Size
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| **Large >3cm apex to cupola
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| **Small <3cm apex to cupola
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| *Air fluid level with [[Pleural Effusion]] = ptx
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| *Deep sulcus sign
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| *CT Chest
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| **Very sensitive and specific
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| ===Treatment===
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| Important features are:
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| #Stability of the patient
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| ##2001 ACP Guidelines for stability:
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| ###RR<24, O2 Sat >90%, HR between 60-120, nl BP
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| ###Can speak in full sentences
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| ###Age <50yo
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| #Size of pneumothorax
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| #Primary or secondary pneumothorax
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| #Time course unimportant
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| ====Primary Spontaneous Pneumothorax====
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| #Clinically stable and small pneumothorax
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| ##Observe in ED at least 6hr
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| ##Repeat CXR shows stable or smaller pneumothorax then no chest tube required
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| ##May DC home with f/u in 12-24 hr
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| ##If no f/u or unreliable admit, high-flow O2
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| ##If ptx enlarges then place chest tube
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| #Clincally stable & large pneumothorax
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| ##Place [[Chest Tube]] and admit
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| #If pt refuses admission:
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| ##14Fr catheter to Heimlich valve
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| ##12 hour f/u
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| ====Secondary Spontaneous Pneumothorax====
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| #Clincally stable and small pneumothorax
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| ##[[Chest Tube]]
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| ##Observation alone associated with some mortality
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| ##Admit
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| ##Do not simply aspirate or ED observe
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| #Clincically stable and large pneumothorax
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| ##[[Chest Tube]]
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| ##Admit
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| ==Tension Pneumothorax==
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| ===Diagnosis===
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| *Diminished or absent breath sounds
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| *Hypotension or e/o hypoperfusion
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| *Distended neck veins
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| **May not occur if pt is hypovolemic
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| *Tracheal deviation
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| **Late sign
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| ===Treatment===
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| *Immediate needle decompression if unstable (clinical = decreased BS or US findings)
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| **Wait for CXR confirmation if stable
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| **14ga IV in midclavicular line just above the rib at the second intercostal space
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| *Always followed by [[Chest Tube]] placement
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| ==Traumatic Pneumothorax==
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| ===Background===
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| *Present in 25% of pts w/ chest trauma
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| *Rib fx and penetrating trauma most common causes
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| *Isolated ptx does not cause severe symptoms until >40% of hemithorax is occupied
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| ===Types===
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| *Can be open, closed, or occult
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| **Open
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| ***Communication between pleural space and atmospheric pressure (sucking chest wound)
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| **Occult
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| ***PPV can convert an occult ptx to a tension ptx
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| ===Diagnosis===
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| *Ptx after a stab wound may be delayed for up to 6 hr
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| **If pt decompensates obtain repeat imaging
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| *CXR
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| **Upright is best (esp expiratory film)
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| ***Thin white line (pleura) between 2 areas of lucency (lung parenchyma and air)
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| ***No lung markings distal to white line
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| **Supine
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| ***Look for deep sulcus sign
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| *US
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| **Absence of lung sliding; absence of seashore (M-mode)
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| ===Treatment===
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| *Tension ptx
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| **Immediate needle thoracostomy
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| *Open ptx
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| **Cover wound with three-sided dressing
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| ***Make sure to avoid complete occlusion (may convert injury to a tension ptx)
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| *Tube thoracostomy indicated if:
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| **Pt cannot be observed closely
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| **Pt requires intubation
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| **Pt will be transported by air or over a long distance
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| *Observation alone ok if:
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| **Small ptx (<1cm wide, confined to upper 1/3 of chest) is unchanged on two CXR 6hr apart
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| **Occult ptx (seen only on CT) unless pt requires mechanical ventilation
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| ==See Also== | | ==See Also== |
| [[Chest Tube]] | | *[[Pneumomediastinum]] |
| | | *[[Chest tube]] |
| [[Thoracic Trauma]] | | *[[Thoracentesis]] |
| | *[[Thoracic trauma]] |
| | *[[Hemothorax]] |
| | *[[Deterioration After Intubation (DOPE)]] |
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| [[Hemothorax]]
| | ==References== |
| ==Source== | | <references/> |
| *Tintinalli
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| *Roberts and Hedges Clinical Procedures in Emergency Medicine
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| *Rosen's
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| *American College of Chest Physicians Consensus Statement
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| [[Category:Pulm]] | | [[Category:Pulmonary]] |
| [[Category:Trauma]] | | [[Category:Trauma]] |
