Spontaneous pneumothorax: Difference between revisions
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''"Spontaneous" essentially refers to all pneumothoraces of "non-traumatic" etiologies''
==Background==
==Background==
*Primary Pneumothorax
*Primary Pneumothorax
**[[marfan syndrome|Marfan's]], [[Ehlers-Danlos syndrome|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, [[COPD|emphysema]], [[cystic fibrosis]], [[PCP PNA|PJP pneumonia]], [[lung abscess]], [[tuberculosis]], neoplasm, catamenial
**Worse prognosis
**Worse prognosis


===Secondary Causes===
===Secondary Causes===
*Smoking
*Smoking (90%)
*[[COPD]]
*[[COPD]]
*[[Asthma]]
*[[Asthma]]
*Cystic fibrosis
*[[Cystic fibrosis]]
*Necrotizing pneumonia
*Necrotizing [[pneumonia]]
*Lung abscess
*[[Lung abscess]]
*[[PCP]] PNA
*[[PCP pneumonia]]
*[[TB]]
*[[TB]]
*Neoplasm
*Neoplasm
*Interstitial lung disease
*[[Interstitial lung disease]]
*Connective tissue disease
*[[Connective tissue disease]]
*Pulmonary infarct
*Pulmonary infarct
*[[Catamenial pneumothorax]]


==Clinical Features==
==Clinical Features==
*Sudden onset pleuritic [[chest pain]] evolving to dull constant ache over days
*Sudden onset pleuritic [[chest pain]] evolving to dull constant ache over days
*Most often occurs at rest, not during exertion
*Most often occurs at rest, not during exertion
*Tachypnea, hypoxemia, increased work of breathing
*[[Tachypnea]], [[hypoxemia]], increased work of breathing
*Reduced ipsilateral lung excursion
*Reduced ipsilateral lung excursion
*Hypotension -> tension pneumothorax
*[[Hypotension]]→ [[tension pneumothorax]]


==Differential Diagnosis==
==Differential Diagnosis==
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{{SOB DDX}}
{{SOB DDX}}


==Diagnosis==
==Evaluation==
[[File:Pneumothorax.jpeg|thumbnail]]
{{Pneumothorax diagnosis}}
*[[CXR]]
{{Lung ultrasound pneumothorax}}
**Displaced visceral pleural line w/o lung markings between pleural line and chest wall
{{Estimating pneumothorax size}}
**Air fluid level with [[Pleural Effusion]] = ptx
**Supine CXR view shows deep sulcus sign
*CT Chest
**Very sensitive and specific
*[[Ultrasound: Lungs]]
**NO comet tail artifact
**No sliding lung sign
**Bar Code (instead of waves on the beach) appearance on M-mode


===Size===
==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>==
*Small: ≤3cm apex to cupola (chest wall) on CXR
*Large: >3cm lung apex to cupola (chest wall) on CXR
 
==Management==
''[[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 decompression]] 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===
===Primary Spontaneous Pneumothorax (Stable)===
====Stable, First Episode====
====First Episode====
*Asymptomatic AND small
*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
*Symptomatic OR large
*Large OR symptomatic (e.g. dyspnea)
**Aspiration
**Aspiration (see below)
***If fail aspiration (see below), [[chest tube]] and thoracoscopy (VATS)^
***If fail, admit with [[chest tube]] to suction for thoracoscopy (VATS)^


====Stable, Recurrent OR Hemopneumothorax====
====Recurrent OR Hemopneumothorax====
*[[Chest tube]] + thoracoscopy (VATS)^
*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===
===Secondary Pneumothorax (Stable)===
*Small size, clinically stable
*Asymptomatic AND ''very'' small (<1 cm interpleural distance)
**Small-size catheter or [[chest tube]], Heimlich valve or water-seal drainage, and admit
**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
**Observation alone associated with some mortality
*Large size or bilateral
*Symptomatic OR large OR bilateral
**[[Chest tube]] and admission
**[[Chest tube]]
 
;Admit all secondary pneumothoraxes
 
{{Needle aspiration of pneumothorax}}


{{Chest tube size table}}
{{Chest tube size table}}
===Needle Aspiration===
*Use thoracentesis kit, if available
*Place in 2nd IC space in midclavicular line or 4th/5th IC space in anterior axillary line
*Air is manually withdrawn through catheter 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 chest radiograph four hours later
***If adequate lung expansion has occurred, the catheter can be removed
***Following another two hours of observation, another chest radiograph should be performed
***If the lung remains expanded on this chest radiograph, the patient can be discharged
**Option 2
***Leave catheter in place
***Attached to a Heimlich (one-way) valve
***Discharged with follow-up within two days


==Disposition==
==Disposition==
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===Secondary===
===Secondary===
*Almost all admitted
*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:Pulm]]
[[Category:Pulmonary]]

Revision as of 15:04, 12 October 2019

"Spontaneous" essentially refers to all pneumothoraces of "non-traumatic" etiologies

Background

Secondary Causes

Clinical Features

Differential Diagnosis

Pneumothorax Types

Acute dyspnea

Emergent

Non-Emergent

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

Pneumothorax.jpeg
  • 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]
  • Z-lines and lung sliding.png
  • No lung sliding.png
  • Lung sliding M mode.png
  • Lung point.gif

Estimating Pneumothorax Size

Measuring pneumothoraxes. Line A = lung apex to cupola. Line B = interpleural distance.
  • 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 decompression 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)
  • Large OR symptomatic (e.g. dyspnea)
    • Aspiration (see below)
      • If fail, admit with chest tube to suction for thoracoscopy (VATS)^

Recurrent OR Hemopneumothorax

^If thoracoscopy (VATS) is not readily available, chemical pleurodesis through the chest tube

Secondary Pneumothorax (Stable)

  • Asymptomatic AND very small (<1 cm interpleural distance)
  • 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
  • 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)
  • Alveolar-pleural fistulae (small air leak)
  • Iatrogenic air
Medium (20-28 Fr)
  • Trauma/bleeding (hemothorax/hemopneumothorax)
  • Bronchial-pleural fistulae (large air leak)
  • Malignant fluid
Large (36-40 Fr)
  • Thick pus

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

  1. ↑ Eur Respir J. 1996 Mar;9(3):406-9
  2. ↑ 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. ↑ 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
  4. ↑ Inaba Et. al J Trauma Acute Care Surg. 2012 Feb;72(2):422-7.
  5. ↑ Advanced Trauma Life Support® Update 2019: Management and Applications for Adults and Special Populations.
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