Difference between revisions of "Spontaneous pneumothorax"

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{{Estimating pneumothorax size}}

Revision as of 12:48, 20 July 2019

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


  • 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

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




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


  • 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

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


Supplemental oxygen (non-rebreather mask) initially for all


  • 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)
  • 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

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



  • See Management section


  • All admitted (even if small and clinically stable)

Special Instructions


  • Can consider flying 2 weeks after full resolution of traumatic pneumothroax[3]


See Also


  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.