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

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

Diagnosis

• Ultrasound: Lungs
  • 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)

Differential Diagnosis

Thoracic Trauma

• Airway/Pulmonary
  • Bronchial injury
  • Diaphragmatic trauma
  • Hemothorax
  • Pneumomediastinum
  • Pulmonary contusion
  • Tracheal injury
  • Trachobronchial injury
  • Traumatic pneumothorax
    • Tension pneumothorax
• Cardiac/Vascular
  • Cardiac injury
    • Blunt cardiac injury
      • Cardiac contusion
      • Commotio cordis
    • Penetrating cardiac injury
    • Cardiac tamponade
  • Traumatic aortic transection
• Musculoskeletal
  • Clavicle fracture
    • Clavicle fracture (peds)
  • Rib fracture
    • Flail chest
  • Scapular fracture
  • Scapulothoracic dissociation
  • Sternoclavicular dislocation
  • Sternum fracture
  • Thoracic and lumbar fractures and dislocations
• Other
  • Esophageal injury or Perforation
  • Pneumomediastinum
  • Pneumopericardium
  • Traumatic asphyxia

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

Special Instructions

Flying

• Patients can consider flying 1 week after resolution of pneumothorax

General 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, or 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) or needle 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 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

See Also

• Pneumothorax
• Chest Tube
• Thoracentesis

Source

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