Pneumothorax (main)

Spontaneous Pneumothorax

Background

• Primary Pneumothorax
  • Spontaneous ptx in pt w/o underlying pulm disease
• Secondary Pneumothorax
  • Spontaneous ptx in pt w/ underlying pulm disease
  • Worse prognosis

Causes

1. Smoking
2. COPD
3. Asthma
4. Cystic fibrosis
5. Necrotizing pneumonia
6. Lung abscess
7. PCP PNA
8. TB
9. Neoplasm
10. Interstitial lung disease
11. Connective tissue disease
12. Pulmonary infarct

Diagnosis

Presentation

• Sudden onset pleuritic chest pain evolving to dull constant ache over days
• Most often occurs at rest, not during exertion

Physical Exam

• Tachypnea
• Hypoxemia
• Increased work of breathing
• Reduced ipsilateral lung excursion
• Hyperresonance
• Hypotension -> tension pneumothorax

Imaging

• Ultrasound
  • NO comet tail artifact
  • No sliding lung sign
  • Bar Code (instead of waves on the beach) appearance on M-mode
• 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
• Size
  • Large >3cm lung apex to cupola (chest wall)
  • Small <3cm apex to cupola (chest wall)

Management

• Important considerations are:

1. Stability
   1. RR<24, O2 Sat >90%, HR between 60-120, nl BP
   2. Can speak in full sentences
   3. Absence of hemothorax
2. Size of ptx
3. Primary or secondary pneumothorax

Treatment Options

1. Observation alone
2. Observation + oxygen,
   1. Oxygen (3L/min nasal cannula to 10L/min mask) increases pleural air resorption by 3-4x
3. Needle or catheter aspiration
   1. Needle/catheter aspiration is as effective as chest tube for small ptxs
      1. Place in 2nd IC space in midclavicular line or 4th/5th IC space in ant axillary line
      2. If lung fails to expand can try 2nd aspiration attempt, Heimlich valve, or chest tube
4. Tube thoracostomy
   1. Use for large, recurrent, or b/l ptxs, abnormal vitals, large air leak anticipated
   2. Underwater seal drainage is adequate (suction only necessary if persistent air leak)

Primary Spontaneous Pneumothorax

1. Small size, clinically stable
   1. Option 1: Observe for 6hr; d/c if no sx and have pt return in 24hr for recheck
   2. Option 2: Small-size catheter (<14F) aspiration with immediate catheter removal
      1. Then observe for 6h; d/c if no sx and have pt return in 24hr for recheck
   3. Option 3: Small-size catheter or chest tube (10-14F), Heimlich valve or water-seal, admit
2. Large size or bilateral
   1. Mod-size chest tube (16-22) and admit; large-size chest tube (24-36) if hemothorax

Secondary Spontaneous Pneumothorax

1. Small size, clinically stable
   1. Small-size catheter or chest tube, Heimlich valve or water-seal drainage, and admit
   2. Observation alone associated with some mortality
2. Large size or bilateral
   1. Mod-size chest tube (16-22) and admission; large-size chest tube (24-36) if hemothorax

Tension Pneumothorax

• Death occurs from hypoxic respiratory arrest (V-Q mismatch), not circulatory arrest

Diagnosis

• Diminished or absent breath sounds
• Hypotension or e/o hypoperfusion
• Distended neck veins
  • May not occur if pt is hypovolemic
• Tracheal deviation
  • Late sign

Treatment

• Immediate needle decompression if unstable
  • Wait for CXR confirmation if stable
  • 14ga IV in midclavicular line just above the rib at the second intercostal space
• Always followed by Chest Tube placement

Traumatic Pneumothorax

Background

• Present in 25% of pts w/ chest trauma
• Rib fx and penetrating trauma most common causes
• Isolated ptx does not cause severe symptoms until >40% of hemithorax is occupied

Types

• Can be open, closed, or occult
  • Open
    • Communication between pleural space and atmospheric pressure (sucking chest wound)
  • Occult
    • PPV can convert an occult ptx to a tension ptx

Diagnosis

• Ptx after a stab wound may be delayed for up to 6 hr
  • If pt decompensates obtain repeat imaging
• CXR
  • Upright is best (esp expiratory film)
    • Thin white line (pleura) between 2 areas of lucency (lung parenchyma and air)
    • No lung markings distal to white line
  • Supine
    • Look for deep sulcus sign
• US
  • Absence of lung sliding; absence of seashore (M-mode)

Treatment

• Tension ptx
  • Immediate needle thoracostomy
• Open ptx
  • Cover wound with three-sided dressing
    • Make sure to avoid complete occlusion (may convert injury to a tension ptx)
• Tube thoracostomy indicated if:
  • Pt cannot be observed closely
  • Pt requires intubation
  • Pt will be transported by air or over a long distance
• Observation alone ok if:
  • Small ptx (<1cm wide, confined to upper 1/3 of chest) is unchanged on two CXR 6hr apart
  • Occult ptx (seen only on CT) unless pt requires mechanical ventilation

See Also

• Chest Tube
• Thoracentesis
• Thoracic Trauma
• Hemothorax

Source

• Tintinalli
• Roberts and Hedges Clinical Procedures in Emergency Medicine
• Rosen's
• American College of Chest Physicians Consensus Statement