Pneumothorax Cause, Symptoms, Diagnosis, Treatment

Pneumothorax Definition

The presence of air within the pleural cavity is called as Pneumothorax.

Pneumothorax Classification

1) Spontaneous Pneumothorax

  • Primary Pneumothorax
  • Secondary Pneumothorax

2) Traumatic Pneumothorax

  • Non-iatrogenic Pneumothorax
  • Iatrogenic Pneumothorax

Spontaneous Pneumothorax

Pneumothorax occurring in the absence of trauma may be described as spontaneous. 

Presents in 3 ways: 

  • Open Pneumothorax- air moves freely in & out of pleural space during breathing. 
  • Closed pneumothorax- no movement of air from the pleural space due to the closure of the communication, air slowly gets absorbed & the lung re-expands.
  • Tension pneumothorax- a check – valve mechanism is produced; this allows air to enter the pleura & accumulate to raise the intrapleural pressure above the atmospheric pressure and leads to compression on the lung & shifting of mediastinum to the opposite side.

1) Primary spontaneous pneumothorax

  • Commonly occurs in healthy subjects with no h/o of pre-existing lung disease.
  • The disease of young adults.

2) Secondary spontaneous pneumothorax

  • Coexisting structural or functional abnormality in the lung.
  • Stature.

Causes of Pneumothorax

Primary spontaneous

  • Apical Blebs (90%)
  • Stature

Secondary spontaneous – less common

  • Chronic bronchitis & emphysema, (35%).
  • Asthma (0.8).
  • Suppurative pneumonia-like Staphylococci, Klebsiella, HIV (2-4%).
  • TB of lungs.

Traumatic Iatrogenic

  • Paracentesis thoracic (28%).
  • Central venous cannulation (22%).
  • Barotrauma (mechanical ventilation).
  • Tracheostomy.

Traumatic Non-Iatrogenic Pneumothorax

  • Open & closed chest injury, (road traffic accident).
  • Stab or gunshot wounds.
  • Rib fractures.

Pneumothorax Symptoms

  1. Small pneumothorax is asymptomatic.
  2. Chest pain – Sharp unilateral associated with shortness of breath is the commonest presentation.
  3. Sharp & stabbing Chest pain exacerbated by deep inspiration & postural change.
  4. Anxious, restless, tachypnoeic, struggling for breath, rapid low volume pulse & hypotension.
  5. May large pneumothorax produce respiratory distress, signs of shock.
  6. Closed pneumothorax –usually does not produce severe symptoms.
  7. Tension pneumothorax – a medical emergency.
Pneumothorax Definition, Pneumothorax Classification, Pneumothorax Cause, Pneumothorax Symptoms, Pneumothorax Diagnosis, Pneumothorax Treatment, Spontaneous Pneumothorax, Traumatic Pneumothorax, NHM CHO Notes, Community Health Officer,

Pneumothorax Physical signs 

  • Small pneumothorax – Difficult to detect on physical examination.
  • Absence or diminished breath sounds on the affected side.
  • Chest movement diminished on the affected side
  • Decreased vocal fremitus.
  • Hyper resonant percussion notes.
  • Ipsilateral enlargement of the chest due to decrease elastic recoil of the collapsed lung.
  • The shift of mediastinum on the opposite side.
  • Increased JVP.
  • Respiratory distress.
  • Diaphoresis
  • Cyanosis.
  • Hypotension.
  • Crepitus is seen if there is associated subcutaneous emphysema.

Pneumothorax Diagnosis

  1. ECG – Diminished anterior QRS amplitude.Radiographic appearances.
  2. X-ray chest – sharply defined lung edge convex outwards separated from chest wall by translucency with no lung markings & mediastinal displacement depending upon the extent of pneumothorax.

Pneumothorax Differential diagnosis

  • Transmural myocardial infarction-ECG changes & left-sided pneumothorax changes resolve once re-expansions.
  • Emphysema confused with pneumothorax but an x-ray is the main diagnostic tool.
  • Massive emphysematous bulla or congenital cyst, when ruptures may be confused with pneumothorax but the previous x-ray, lateral decubitus view is helpful in differentiating upper lobe bulla/cyst.

Pneumothorax Complications

  • Recurrence,
  • Haemopneumothorax,
  • Pyopneumothorax, 
  • Respiratory failure – when tension pneumothorax present.

Pneumothorax Treatment

Treatment depends on cause, size, degree of physiological derangement. A primary pneumothorax-smaller without pleural air leak may resolve spontaneously.

  • If pneumothorax small but the patient mild symptomatic, admit the patient & administer high–flow oxygen, resulting in nitrogen gradient will speed resorption.
  • If pneumothorax larger than 15% to 20% or more than mildly symptomatic, insert a thoracostomy tube.
  • Secondary pneumothorax – Patients are symptomatic & require lung re-expansion.
  • Often bronchopleural fistula persists & larger thoracostomy tube & suction are required.
  • Iatrogenic pneumothorax – Due to barotrauma from mechanical ventilation always persistent air leak & should be managed with a chest tube & suction.
  • Tension pneumothorax – decompress the affected hemithorax immediately with a 14-gauge needle attached to a fluid-filled syringe, release of air with clinical improvement confirms the diagnosis. Seal chest wound with an occlusive dressing & arrange the placement of a thoracostomy tube.

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