Spontaneous pneumothorax

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

The pleural cavity is normally a potential space, in which air collects in a pneumothorax.

Acute dyspnea

Emergent

Non-Emergent

Diagnosis

Pneumothorax.jpeg
  • 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) on CXR
  • Large: >3cm lung apex to cupola (chest wall) on CXR

Management

Unstable

Primary Spontaneous Pneumothorax

Stable, First Episode

  • Asymptomatic AND small
    • 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
    • Aspiration
      • If fail aspiration (see below), chest tube and thoracoscopy (VATS)^

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)
  • 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

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

Disposition

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Special Instructions

Flying

  • Patients can consider flying 1 week after resolution of pneumothorax [3]

See Also

References

  1. ↑ Inaba Et. al J Trauma Acute Care Surg. 2012 Feb;72(2):422-7.
  2. ↑ Advanced Trauma Life Support® Update 2019: Management and Applications for Adults and Special Populations.
  3. ↑ British Thoracic Society Guidelines PDF
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