Spontaneous pneumothorax: Difference between revisions
| Line 55: | Line 55: | ||
====Stable, First Episode==== | ====Stable, First Episode==== | ||
*Asymptomatic AND small (≤3 cm between the lung and chest wall on a chest radiograph) | *Asymptomatic AND small (≤3 cm between the lung and chest wall on a chest radiograph) | ||
**Supplemental oxygen and observe for 6 hours; repeat CXR and discharge if no progression; return in 24 hours for a recheck | **Supplemental oxygen (10L/min mask) and observe for 6 hours; repeat CXR and discharge if no progression; return in 24 hours for a recheck | ||
*Symptomatic OR large (>3 cm rim of air on chest radiograph) | *Symptomatic OR large (>3 cm rim of air on chest radiograph) | ||
**Aspiration | **Aspiration | ||
Revision as of 13:48, 13 May 2015
Background
- Primary Pneumothorax
- No underlying pulmonary disease
- Secondary Pneumothorax
- With underlying pulmonary disease
- Worse prognosis
Causes
- Smoking
- COPD
- Asthma
- Cystic fibrosis
- Necrotizing pneumonia
- Lung abscess
- PCP PNA
- TB
- Neoplasm
- Interstitial lung disease
- Connective tissue disease
- Pulmonary infarct
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
Diagnosis
- CXR
- Displaced visceral pleural line w/o lung markings between pleural line and chest wall
- 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
- Small: <3cm apex to cupola (chest wall)
- Large: >3cm lung apex to cupola (chest wall)
Management
Unstable
- Needle decompresion followed by chest tube insertion
Primary Spontaneous Pneumothorax
Stable, First Episode
- Asymptomatic AND small (≤3 cm between the lung and chest wall on a chest radiograph)
- Supplemental oxygen (10L/min mask) and observe for 6 hours; repeat CXR and discharge if no progression; return in 24 hours for a recheck
- Symptomatic OR large (>3 cm rim of air on chest radiograph)
- Aspiration
- If fail aspiration, chest tube and thoracoscopy (VATS)^
- Aspiration
Stable, Recurrent OR Hemopneumothorax
- Chest tube + thoracoscopy (VATS)^
^if thoracoscopy (VATS) is not readily available, chemical pleurodesis through the chest tube
Secondary Pneumothorax
- Small size, clinically stable
- Small-size catheter or chest tube, Heimlich valve or water-seal drainage, and admit
- Observation alone associated with some mortality
- Large size or bilateral
- Mod-size chest tube (16-22) and admission; large-size chest tube (24-36) if hemothorax
Adult Chest Tube Sizes
| Chest Tube Size | Type of Patient | Underlying Causes |
| Small (8-14 Fr) |
|
|
| Medium (20-28 Fr) |
|
|
| Large (36-40 Fr) |
|
Management Options
- Suplementary oxygen:
- Oxygen (10L/min mask) increases pleural air resorption by 3-4x
- Tube thoracostomy
- Use for large, recurrent, or b/l ptxs, abnormal vitals, or large air leak anticipated
- Underwater seal drainage is adequate (suction only necessary if persistent air leak)
Needle or catheter 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
- Option 1
Disposition
Special Instructions
Flying
- Patients can consider flying 1 week after resolution of pneumothorax [3]
See Also
References
- ↑ 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.
- ↑ British Thoracic Society Guidelines PDF