Spontaneous pneumothorax: Difference between revisions
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''"Spontaneous" essentially refers to all pneumothoraxes of "non-traumatic" etiologies'' | |||
==Background== | ==Background== | ||
*Primary Pneumothorax | *Primary Pneumothorax | ||
**Marfan's, Ehlers-Danlos, alpha-1-antitrypsin deficiency, homocystinuria | |||
**No underlying pulmonary disease | **No underlying pulmonary disease | ||
*Secondary Pneumothorax | *Secondary Pneumothorax | ||
**With underlying pulmonary disease | **With underlying pulmonary disease | ||
***bullae/blebs, emphysema, cystic fibrosis, PJP pneumonia, lung abscess, tuberculosis, neoplasm, catamenial | |||
**Worse prognosis | **Worse prognosis | ||
===Secondary Causes=== | ===Secondary Causes=== | ||
*Smoking | *Smoking (90%) | ||
*[[COPD]] | *[[COPD]] | ||
*[[Asthma]] | *[[Asthma]] | ||
Line 13: | Line 17: | ||
*Necrotizing pneumonia | *Necrotizing pneumonia | ||
*Lung abscess | *Lung abscess | ||
*[[PCP]] | *[[PCP]] pneumonia | ||
*[[TB]] | *[[TB]] | ||
*Neoplasm | *Neoplasm | ||
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*Connective tissue disease | *Connective tissue disease | ||
*Pulmonary infarct | *Pulmonary infarct | ||
*[[Catamenial pneumothorax]] | |||
==Clinical Features== | ==Clinical Features== | ||
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*Tachypnea, hypoxemia, increased work of breathing | *Tachypnea, hypoxemia, increased work of breathing | ||
*Reduced ipsilateral lung excursion | *Reduced ipsilateral lung excursion | ||
*Hypotension | *[[Hypotension]]→ tension pneumothorax | ||
==Differential Diagnosis== | ==Differential Diagnosis== | ||
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{{SOB DDX}} | {{SOB DDX}} | ||
== | ==Evaluation== | ||
{{Pneumothorax diagnosis}} | |||
{{Lung ultrasound pneumothorax}} | |||
{{Estimating pneumothorax size}} | |||
==Management== | ==Management<ref name="BTC">"Management of spontaneous pneumothorax: British Thoracic Society pleural disease guideline 2010" British Thoracic Society Guidelines. Thorax 2010;65:ii18-ii31 doi:10.1136/thx.2010.136986 [https://www.brit-thoracic.org.uk/Portals/0/Guidelines/PleuralDiseaseGuidelines/Pleural%20Guideline%202010/Pleural%20disease%202010%20pneumothorax.pdf PDF]</ref>== | ||
''[[Supplemental oxygen]] ([[non-rebreather mask]]) initially for all'' | ''[[Supplemental oxygen]] ([[non-rebreather mask]]) initially for all'' | ||
===Unstable=== | ===Unstable=== | ||
*[[Needle decompresion]] followed by [[chest tube]] insertion | *[[Needle decompresion]] followed by [[chest tube]] insertion | ||
* ATLS guidelines recommend 5cm angiocath at 2nd intercostal space at the mid-clavicular line | |||
* More recent evidence shows higher success rates with 4th/5th intercostal space at the anterior or mid-axillary line | |||
===Primary Spontaneous Pneumothorax (Stable)=== | ===Primary Spontaneous Pneumothorax (Stable)=== | ||
====First Episode==== | ====First Episode==== | ||
*Small AND asymptomatic | *Small AND asymptomatic (no dyspnea) | ||
**Observe on [[supplemental oxygen]] ([[non-rebreather mask]]) for 6 hours; repeat CXR and discharge if no progression; return in 24 hours for a recheck | **Observe on [[supplemental oxygen]] ([[non-rebreather mask]]) for 6 hours; repeat CXR and discharge if no progression; return in 24 hours for a recheck | ||
*Large OR | *Large OR symptomatic (e.g. dyspnea) | ||
**Aspiration (see below) | **Aspiration (see below) | ||
***If fail, | ***If fail, admit with [[chest tube]] to suction for thoracoscopy (VATS)^ | ||
====Recurrent OR Hemopneumothorax==== | ====Recurrent OR Hemopneumothorax==== | ||
*[[ | *Admit with [[chest tube]] for thoracoscopy (VATS)^ | ||
^If thoracoscopy (VATS) is not readily available, chemical pleurodesis through the chest tube | ^If thoracoscopy (VATS) is not readily available, chemical pleurodesis through the chest tube | ||
===Secondary Pneumothorax (Stable)=== | ===Secondary Pneumothorax (Stable)=== | ||
*Asymptomatic AND very small (<1 cm | *Asymptomatic AND ''very'' small (<1 cm interpleural distance) | ||
**Observation with [[supplemental oxygen]]; repeat CXR in 12-24 hours | **Observation with [[supplemental oxygen]]; repeat CXR in 12-24 hours | ||
*Asymptomatic AND small | *Asymptomatic AND small | ||
**[[Chest tube]] (some centers may choose needle aspiration under ultrasound guidance) | **[[Chest tube]] (some centers may choose needle aspiration under ultrasound guidance) | ||
**Observation alone associated with some mortality | **Observation alone associated with some mortality | ||
*Symptomatic | *Symptomatic OR large OR bilateral | ||
**[[Chest tube]] | **[[Chest tube]] | ||
;Admit all secondary pneumothoraxes | ;Admit all secondary pneumothoraxes | ||
{{Needle aspiration of pneumothorax}} | |||
{{Chest tube size table}} | {{Chest tube size table}} | ||
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===Secondary=== | ===Secondary=== | ||
* | *All admitted (even if small and clinically stable) | ||
{{Flying instructions after pneumothorax}} | {{Flying instructions after pneumothorax}} | ||
==Complications== | |||
*[[Reexpansion pulmonary edema]] | |||
==See Also== | ==See Also== | ||
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<references/> | <references/> | ||
[[Category: | [[Category:Pulmonary]] |
Revision as of 12:48, 20 July 2019
"Spontaneous" essentially refers to all pneumothoraxes of "non-traumatic" etiologies
Background
- Primary Pneumothorax
- Marfan's, Ehlers-Danlos, alpha-1-antitrypsin deficiency, homocystinuria
- No underlying pulmonary disease
- Secondary Pneumothorax
- With underlying pulmonary disease
- bullae/blebs, emphysema, cystic fibrosis, PJP pneumonia, lung abscess, tuberculosis, neoplasm, catamenial
- Worse prognosis
- With underlying pulmonary disease
Secondary Causes
- Smoking (90%)
- COPD
- Asthma
- Cystic fibrosis
- Necrotizing pneumonia
- Lung abscess
- PCP pneumonia
- TB
- Neoplasm
- Interstitial lung disease
- Connective tissue disease
- Pulmonary infarct
- Catamenial pneumothorax
Clinical Features
- Sudden onset pleuritic chest pain evolving to dull constant ache over days
- Most often occurs at rest, not during exertion
- Tachypnea, hypoxemia, increased work of breathing
- Reduced ipsilateral lung excursion
- Hypotension→ tension pneumothorax
Differential Diagnosis
Pneumothorax Types
Acute dyspnea
Emergent
- Pulmonary
- Airway obstruction
- Anaphylaxis
- Angioedema
- Aspiration
- Asthma
- Cor pulmonale
- Inhalation exposure
- Noncardiogenic pulmonary edema
- Pneumonia
- Pneumocystis Pneumonia (PCP)
- Pulmonary embolism
- Pulmonary hypertension
- Tension pneumothorax
- Idiopathic pulmonary fibrosis acute exacerbation
- Cystic fibrosis exacerbation
- Cardiac
- Other Associated with Normal/↑ Respiratory Effort
- Other Associated with ↓ Respiratory Effort
Non-Emergent
- ALS
- Ascites
- Uncorrected ASD
- Congenital heart disease
- COPD exacerbation
- Fever
- Hyperventilation
- Interstitial lung disease
- Neoplasm
- Obesity
- Panic attack
- Pleural effusion
- Polymyositis
- Porphyria
- Pregnancy
- Rib fracture
- Spontaneous pneumothorax
- Thyroid Disease
- URI
Evaluation
Clinically Stable
Defined as having all of the following:
- Resp rate < 24
- Heart rate 60-120 beats per minute
- Normal BP
- SaO2 >90% on room air and patient can speak in whole sentences
Workup
- CXR
- Displaced visceral pleural line without lung markings between pleural line and chest wall
- Upright is best
- Expiratory films DO NOT improve accuracy[1]
- Lateral decubitus films with suspected side up do increase sensitivity. Good approach in pediatrics to avoid CT
- Supine CXR = deep sulcus sign
- CT Chest
- Very sensitive and specific
Lung ultrasound of pneumothorax
- No lung sliding seen (not specific for pneumothorax)
- May also identify "lung point": distinct point where you no longer see lung sliding (pathognomonic)
- Absence of lung sliding WITHOUT lung point could represent apnea or right mainstem intubation
- Evaluate other intercostal spaces because pneumothorax may only be seen in least dependent area of thorax
- NO comet tail artifact
- Bar Code appearance/"Stratosphere" sign on M-mode (absence of "seashore" waves)
- Ultrasound has greater sensitivity than chest x-ray for pneumothorax in trauma patients [2]
Estimating Pneumothorax Size
- On a conventional, upright posterior-anterior chest radiograph:
- Very small: <1 cm interpleural distance (confined to upper 1/3 of chest) OR only seen on CT
- Small: ≤3cm lung apex to cupola (chest wall apex) on CXR
- Large: >3cm lung apex to cupola (chest wall apex) on CXR
- 3cm apex to cupola measurement is roughly equivalent to 2cm interpleural distance (at the level of the hilum)
- Both roughly correlate with a 50% pneumothorax by volume
Management[3]
Supplemental oxygen (non-rebreather mask) initially for all
Unstable
- Needle decompresion followed by chest tube insertion
- ATLS guidelines recommend 5cm angiocath at 2nd intercostal space at the mid-clavicular line
- More recent evidence shows higher success rates with 4th/5th intercostal space at the anterior or mid-axillary line
Primary Spontaneous Pneumothorax (Stable)
First Episode
- Small AND asymptomatic (no dyspnea)
- Observe on supplemental oxygen (non-rebreather mask) for 6 hours; repeat CXR and discharge if no progression; return in 24 hours for a recheck
- Large OR symptomatic (e.g. dyspnea)
- Aspiration (see below)
- If fail, admit with chest tube to suction for thoracoscopy (VATS)^
- Aspiration (see below)
Recurrent OR Hemopneumothorax
- Admit with chest tube for thoracoscopy (VATS)^
^If thoracoscopy (VATS) is not readily available, chemical pleurodesis through the chest tube
Secondary Pneumothorax (Stable)
- Asymptomatic AND very small (<1 cm interpleural distance)
- Observation with supplemental oxygen; repeat CXR in 12-24 hours
- Asymptomatic AND small
- Chest tube (some centers may choose needle aspiration under ultrasound guidance)
- Observation alone associated with some mortality
- Symptomatic OR large OR bilateral
- Admit all secondary pneumothoraxes
Needle Aspiration of Pneumothorax
- Use thoracentesis or "pig-tail" kit, if available
- Place in 2nd IC space in midclavicular line or 4th/5th IC space in anterior axillary line
- Withdraw air with syringe until no more can be aspirated
- Assume a persistent air leak (failure) if no resistance after 4 liters of air has been aspirated AND the lung has not expanded
- Once no further air can be aspirated:
- Option 1
- Place closed stopcock and secure catheter to the chest wall
- Obtain CXR four hours later
- If adequate lung expansion has occurred, remove catheter
- Following another two hours of observation, obtain another CXR
- If the lung remains expanded, may discharge patient
- Option 2
- Leave catheter in place
- Attached a Heimlich (one-way) valve
- May discharge with follow-up within two days
- Option 1
- If 2.5 L of air has been aspirated, and a significant PTX remains, tube thoracostomy is indicated
- NEJM video on needle aspiration of pneumothorax.
Adult Chest Tube Sizes
Chest Tube Size | Type of Patient | Underlying Causes |
Small (8-14 Fr) |
|
|
Medium (20-28 Fr) |
|
|
Large (36-40 Fr) |
|
Disposition
Primary
- See Management section
Secondary
- All admitted (even if small and clinically stable)
Special Instructions
Flying
- Can consider flying 2 weeks after full resolution of traumatic pneumothroax[3]
Complications
See Also
References
- ↑ Eur Respir J. 1996 Mar;9(3):406-9
- ↑ Nagarsheth K, Kurek S. Ultrasound detection of pneumothorax compared with chest X-ray and computed tomography scan. Am Surg. 2011 Apr;77(4):480-4. PMID: 21679560.
- ↑ 3.0 3.1 "Management of spontaneous pneumothorax: British Thoracic Society pleural disease guideline 2010" British Thoracic Society Guidelines. Thorax 2010;65:ii18-ii31 doi:10.1136/thx.2010.136986 PDF
- ↑ Inaba Et. al J Trauma Acute Care Surg. 2012 Feb;72(2):422-7.
- ↑ Advanced Trauma Life Support® Update 2019: Management and Applications for Adults and Special Populations.