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| ==Spontaneous Pneumothorax== | | ==Types== |
| ===Background===
| | {{Pneumothorax types}} |
| *Primary Pneumothorax
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| **Spontaneous ptx in pt w/o underlying pulm disease
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| *Secondary Pneumothorax
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| **Spontaneous ptx in pt w/ underlying pulm disease
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| **Worse prognosis
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| ===Causes===
| | [[File:Pneumothorax.png|thumbnail|Right sided pneumothorax]] |
| #Smoking
| | [[File:PMC2892654 CRM2010-213818.004.png|thumb|Left sided [[tension pneumothorax]] with mediastinal shift]] |
| #COPD
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| #Asthma
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| #Cystic fibrosis
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| #Necrotizing pneumonia
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| #Lung abscess
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| #PCP PNA
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| #TB
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| #Neoplasm
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| #Interstitial lung disease
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| #Connective tissue disease
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| #Pulmonary infarct
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| ===Diagnosis===
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| ====Presentation====
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| *Sudden onset pleuritic chest pain evolving to dull constant ache over days
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| *Most often occurs at rest, not during exertion
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| ====Physical Exam====
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| *Tachypnea
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| *Hypoxemia
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| *Increased work of breathing
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| *Reduced ipsilateral lung excursion
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| *Hyperresonance
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| *Hypotension -> tension pneumothorax
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| ====Imaging====
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| *Ultrasound
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| **NO comet tail artifact
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| **No sliding lung sign
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| **Bar Code (instead of waves on the beach) appearance on M-mode
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| *CXR
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| **Displaced visceral pleural line w/o lung markings between pleural line and chest wall
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| **Air fluid level with [[Pleural Effusion]] = ptx
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| **Supine CXR view shows deep sulcus sign
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| *CT Chest
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| **Very sensitive and specific
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| *Size
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| **Large >3cm lung apex to cupola (chest wall)
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| **Small <3cm apex to cupola (chest wall)
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| ===Management===
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| *Important considerations are:
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| #Stability
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| ##RR<24, O2 Sat >90%, HR between 60-120, nl BP
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| ##Can speak in full sentences
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| ##Absence of hemothorax
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| #Size of ptx
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| #Primary or secondary pneumothorax
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| ====Treatment Options====
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| #Observation alone
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| #Observation + oxygen,
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| ##Oxygen (3L/min nasal cannula to 10L/min mask) increases pleural air resorption by 3-4x
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| #Needle or catheter aspiration
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| ##Needle/catheter aspiration is as effective as chest tube for small ptxs
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| ###Place in 2nd IC space in midclavicular line or 4th/5th IC space in ant axillary line
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| ###If lung fails to expand can try 2nd aspiration attempt, Heimlich valve, or chest tube
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| #Tube thoracostomy
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| ##Use for large, recurrent, or b/l ptxs, abnormal vitals, large air leak anticipated
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| ##Underwater seal drainage is adequate (suction only necessary if persistent air leak)
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| =====Primary Spontaneous Pneumothorax=====
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| #Small size, clinically stable
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| ##Option 1: Observe for 6hr; d/c if no sx and have pt return in 24hr for recheck
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| ##Option 2: Small-size catheter (<14F) aspiration with immediate catheter removal
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| ###Then observe for 6h; d/c if no sx and have pt return in 24hr for recheck
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| ##Option 3: Small-size catheter or chest tube (10-14F), Heimlich valve or water-seal, admit
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| #Large size or bilateral
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| ##Mod-size chest tube (16-22) and admit; large-size chest tube (24-36) if hemothorax
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| =====Secondary Spontaneous Pneumothorax=====
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| #Small size, clinically stable
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| ##Small-size catheter or chest tube, Heimlich valve or water-seal drainage, and admit
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| ##Observation alone associated with some mortality
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| #Large size or bilateral
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| ##Mod-size chest tube (16-22) and admission; large-size chest tube (24-36) if hemothorax
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| ==Tension Pneumothorax==
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| *Death occurs from hypoxic respiratory arrest (V-Q mismatch), not circulatory arrest
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| ===Diagnosis===
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| *Diminished or absent breath sounds
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| *Hypotension or e/o hypoperfusion
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| *Distended neck veins
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| **May not occur if pt is hypovolemic
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| *Tracheal deviation
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| **Late sign
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| ===Treatment===
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| *Immediate needle decompression if unstable
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| **Wait for CXR confirmation if stable
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| **14ga IV in midclavicular line just above the rib at the second intercostal space
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| *Always followed by [[Chest Tube]] placement
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| ==Traumatic Pneumothorax==
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| ===Background===
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| *Present in 25% of pts w/ chest trauma
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| *Rib fx and penetrating trauma most common causes
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| *Isolated ptx does not cause severe symptoms until >40% of hemithorax is occupied
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| ===Types===
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| *Can be open, closed, or occult
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| **Open
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| ***Communication between pleural space and atmospheric pressure (sucking chest wound)
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| **Occult
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| ***PPV can convert an occult ptx to a tension ptx
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| ===Diagnosis===
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| *Ptx after a stab wound may be delayed for up to 6 hr
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| **If pt decompensates obtain repeat imaging
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| *CXR
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| **Upright is best (esp expiratory film)
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| ***Thin white line (pleura) between 2 areas of lucency (lung parenchyma and air)
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| ***No lung markings distal to white line
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| **Supine
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| ***Look for deep sulcus sign
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| *US
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| **Absence of lung sliding; absence of seashore (M-mode)
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| ===Treatment===
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| *Tension ptx
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| **Immediate needle thoracostomy
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| *Open ptx
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| **Cover wound with three-sided dressing
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| ***Make sure to avoid complete occlusion (may convert injury to a tension ptx)
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| *Tube thoracostomy indicated if:
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| **Pt cannot be observed closely
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| **Pt requires intubation
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| **Pt will be transported by air or over a long distance
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| *Observation alone ok if:
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| **Small ptx (<1cm wide, confined to upper 1/3 of chest) is unchanged on two CXR 6hr apart
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| **Occult ptx (seen only on CT) unless pt requires mechanical ventilation
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| ==See Also== | | ==See Also== |
| *[[Chest Tube]] | | *[[Pneumomediastinum]] |
| | *[[Chest tube]] |
| *[[Thoracentesis]] | | *[[Thoracentesis]] |
| *[[Thoracic Trauma]] | | *[[Thoracic trauma]] |
| *[[Hemothorax]] | | *[[Hemothorax]] |
| | *[[Deterioration After Intubation (DOPE)]] |
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| ==Source== | | ==References== |
| *Tintinalli
| | <references/> |
| *Roberts and Hedges Clinical Procedures in Emergency Medicine
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| *Rosen's
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| *American College of Chest Physicians Consensus Statement
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| [[Category:Pulm]] | | [[Category:Pulmonary]] |
| [[Category:Trauma]] | | [[Category:Trauma]] |
