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Pneumothorax

Highlights
Summary Overview

Basics
Definition Epidemiology Aetiology Pathophysiology Classification

Prevention
Primary Screening Secondary

Diagnosis
History & examination Tests Differential Step-by-step Criteria Guidelines Case history

Treatment
Details Step-by-step Guidelines Evidence

Follow Up
Recommendations Complications Prognosis

Resources
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History & exam


Key factors
presence of risk factors chest pain dyspnoea

extreme breathlessness trachea shifted to contralateral side hyperexpanded ipsilateral hemithorax hyper-resonant ipsilateral hemithorax ipsilateral absent or diminished breath sounds History & exam details

Diagnostic tests
1st tests to order
x-ray chest

Tests to consider
CT chest bronchoscopy

Emerging tests
chest ultrasound

Diagnostic tests details

Treatment details
Presumptive
tension pneumothorax immediate decompression

Acute
primary spontaneous pneumothorax o o o o o o o small: visible rim of <2 cm between the lung margin and the chest wall observation and supplemental oxygen therapy large: visible rim 2 cm between the lung margin and the chest wall percutaneous aspiration supplemental oxygen therapy chest-tube thoracostomy supplemental oxygen therapy persistent air leak despite initial management video-assisted thoracoscopy with stapling of the air leak and pleurodesis supplemental oxygen therapy secondary spontaneous pneumothorax

o o o o o o

no contraindications to chest tube insertion or clinically unstable hospitalisation and supplemental oxygen chest-tube thoracostomy video-assisted thoracoscopy or pleurodesis contraindications to chest tube insertion or clinically stable hospitalisation and supplemental oxygen observation video-assisted thoracoscopy or pleurodesis catamenial pneumothorax

o o

supplemental oxygen percutaneous aspiration or chest-tube thoracostomy tube thoracotomy drainage ovulation suppression not contraindicated and acceptable to patient ovulation suppression ovulation suppression contraindicated or unsuccessful or unacceptable to patient video-assisted thoracoscopy or open thoracotomy + chemical or mechanical pleurodesis traumatic pneumothorax

percutaneous aspiration and oxygen therapy chest-tube thoracostomy and oxygen therapy thoracotomy pneumothorax ex vacuo

bronchoscopy hospitalisation and supplemental oxygen

Ongoing
recurrent pneumothorax o o o o primary spontaneous pneumothorax hospitalisation and supplemental oxygen video-assisted thoracoscopy with stapling of the air leak and pleurodesis secondary spontaneous pneumothorax hospitalisation and supplemental oxygen pleurodesis Treatment details

Summary
Accumulation of air in the pleural space.

Primary spontaneous pneumothoraces occur in young people without known respiratory illnesses. Patients with pre-existing pulmonary diseases may develop secondary spontaneous pneumothoraces.

A tension pneumothorax is a medical emergency that requires immediate intervention to decompress the involved hemithorax.

Patients with pneumothoraces typically complain of dyspnoea and chest pain. In tension pneumothorax, patients are distressed with rapid laboured respirations, cyanosis, profuse diaphoresis, and tachycardia.

First-line treatment of pneumothoraces includes observation with supplemental oxygen therapy, percutaneous aspiration of the air in the pleural space, chest-tube thoracostomy, and in some cases videoassisted thoracoscopy or thoracostomy.

Patients who suffer spontaneous pneumothoraces are at risk for recurrence. Pleurodesis (either by mechanical abrasion or by chemical irritation of pleural surfaces) is used to limit the likelihood of recurrence.

Other related conditions


COPD Asthma in adults Idiopathic pulmonary arterial hypertension Overview of COPD Cardiac arrest Assessment of chest pain Marfan's syndrome Pneumocystis jirovecii pneumonia Cystic fibrosis Pulmonary tuberculosis Smoking cessation

Definition
Pneumothorax occurs when air gains access to, and accumulates in, the pleural space. [1]

Epidemiology
In England and Wales, the overall rate of people consulting with pneumothorax (in both primary and secondary care combined) is 24/100,000 a year for men and 10/100,000 a year for women.[5] Death from spontaneous pneumothorax is rare, with a UK mortality of 1.26 per million a year for men and 0.62 per million a year for women. [5] Smoking increases the likelihood of spontaneous pneumothorax by 22 times for men and by 8 times for women. The incidence is directly related to the amount smoked. [6] The incidence of primary spontaneous pneumothorax in the US between 1950 and 1974 ranged from 7.4 to 18 per 100,000 population per year in males and from 1.2 to 6.0 per 100,000 population per year among females. [6] [7] The annual incidence of secondary spontaneous pneumothorax is 6.3 per 100,000 population in males and 2.0 per 100,000 population in females. [7] More than 50,000 trauma-related pneumothoraces occur

annually in the US. Pneumothorax ranks second only to rib fractures as the most common manifestation of significant chest injury. Pneumothoraces are seen in as many as 40% to 50% of chest trauma victims. [8] [9] [10]

Aetiology
Primary spontaneous pneumothorax occurs without preceding trauma or precipitating event, and develops in a person without clinically apparent pulmonary disease. Patients most at risk are those with history of cigarette smoking, Marfan's syndrome, homocystinuria, or family history of pneumothorax. Patients with primary spontaneous pneumothorax tend to be tall, slender, and young males. [11] [12] [13] [14] [15] [16] Secondary spontaneous pneumothorax occurs as a complication of an underlying pulmonary disease. COPD from cigarette smoking is the most common predisposing condition in the US and accounts for approximately 70% of these pneumothoraces. Other predisposing respiratory conditions include Pneumocystis jiroveci respiratory infection, cystic fibrosis, and tuberculosis. The severity of the patient's lung dysfunction correlates with the likelihood of developing a secondary spontaneous pneumothorax. [17] [18] [19] [20] Catamenial pneumothorax occurs secondary to thoracic endometriosis. Traumatic pneumothorax results from either penetrating or blunt injury to the chest. A tension pneumothorax can complicate primary and secondary spontaneous pneumothoraces as well as traumatic pneumothoraces.

Pathophysiology
Pneumothorax refers to gas within the pleural space. Normally, the alveolar pressure is greater than the intrapleural pressure, while the intrapleural pressure is less than atmospheric pressure. Therefore, if a communication develops between an alveolus and the pleural space or between the atmosphere and the pleural space, gases will follow the pressure gradient and flow into the pleural space. This flow will continue until the pressure gradient no longer exists or the abnormal communication has been sealed. Since the thoracic cavity is normally below its resting volume, and the lung is above its resting volume, the thoracic cavity enlarges and the lung becomes smaller when a pneumothorax develops. [1] A tension pneumothorax is a medical emergency and occurs when the intrapleural pressure exceeds atmospheric pressure, especially during expiration, and results from a ball valve mechanism that promotes inspiratory accumulation of pleural gases. The build-up of pressure within the pleural

space eventually results in hypoxaemia and respiratory failure from compression of the lung. [1] The pathophysiology of catamenial pneumothoraces is not known. It has been suggested that air gains access to the peritoneal cavity during menstruation and then secondarily the pleural space through diaphragmatic defects. [21] Alternatively, it has been hypothesised that ectopic intrathoracic endometriosis results in visceral pleural erosions, thus causing a pneumothorax.[22]

Classification
Clinical classification [2] Tension pneumothorax: occurs when the intrapleural pressure exceeds atmospheric pressure throughout expiration and often during inspiration. It is a medical emergency that requires prompt intervention. Spontaneous pneumothorax: occurs without preceding trauma or precipitating event.
Primary: occurs without clinically apparent pulmonary disease. Secondary: occurs as a complication of an underlying pulmonary disease, including catamenial pneumothorax secondary to thoracic endometriosis.

Traumatic pneumothorax: results from either penetrating or blunt injury to the chest.
Iatrogenic: due to complications of invasive medical procedures such as transcutaneous needle aspiration of lung lesions, thoracentesis, endoscopic transbronchial biopsy, and central venous catheter placement. Accidental.

Primary prevention
Cigarette smoking cessation is the single most important preventative measure for both primary and secondary spontaneous pneumothoraces. [30]

Screening
There is no screening test for pneumothorax. If a pneumothorax is clinically suspected, then chest radiographs should be obtained.

Trauma victims with significant thoracic injuries should always be evaluated for pneumothoraces. Owing to the risk of injury to other intrathoracic structures, CT scanning is generally considered the test of choice in these patients. However, if a pneumothorax is suspected in an unstable thoracic trauma victim, a chest tube should be placed before radiographic confirmation. A delay in intervention for a traumatic pneumothorax may result in the death of the patient. [41] Thoracic ultrasound allows for the rapid detection of pneumothoraces in supine multiple trauma patients and could serve as an alternative in the hands of experienced clinicians. [42]

Secondary prevention
Early recognition and treatment of respiratory infections, such as tuberculosis andPneumocystis jiroveci respiratory infection in AIDS, are important measures in the prevention of pneumothoraces. Adherence to prescribed therapy is also an important issue that may curb the risk of a secondary spontaneous pneumothorax in those patients.

History & examination


Key diagnostic factorshide all
presence of risk factors (common)

Key risk factors include cigarette smoking, FHx, tall and slender body build, male sex, young age, presence of COPD, Marfan's syndrome, homocystinuria, recent invasive medical procedure, severe asthma, tuberculosis, Pneumocystis jiroveci infection, and cystic fibrosis.

chest pain (common) Chest pain occurs on the same side as the pneumothorax. [31][32] dyspnoea (common)

The degree of dyspnoea depends on the size of the pneumothorax and presence and severity of pre-existing lung disease. [1]

hyperexpanded ipsilateral hemithorax (common)

The degree of hyperexpansion depends on the size of the pneumothorax and whether a tension pneumothorax develops. [1]

hyper-resonant ipsilateral hemithorax (common) is a key diagnostic factor ipsilateral absent or diminished breath sounds (common) is a key diagnostic factor extreme breathlessness (uncommon) Associated with tension pneumothorax and significant pre-existing lung disease. [1] trachea shifted to contralateral side (uncommon)

Associated with tension pneumothorax. This is an important clinical finding in the evaluation of patients with pneumothorax. [1]

Risk factorshide all


Strong cigarette smoking

The estimated lifetime risk of developing a pneumothorax in healthy smoking men is approximately 12%, compared with 0.1% in non-smokers. Small-airway inflammation from tobacco smoke may contribute to the development of subpleural blebs. [6] [11]

FHx of pneumothorax

There seems to be a familial tendency for primary spontaneous pneumothoraces. There may be either autosomal-dominant with incomplete penetrance or X-linked recessive inheritance. [14] [15]

tall and slender body build

Patients with primary spontaneous pneumothoraces are usually taller and thinner than control patients. The alveoli at the lung apex are subjected to a greater mean distending pressure in taller patients, leading to the development of subpleural blebs and other abnormalities such as pleural porosis. [12] [23]

age <40 years

The peak age for primary spontaneous pneumothorax is 20 years at the first episode. Primary spontaneous pneumothoraces rarely occur after 40 years of age. [12]

recent invasive medical procedure

Invasive procedures such as transcutaneous needle aspiration of lung lesions, thoracentesis, endoscopic transbronchial biopsy, and central venous catheter placement are associated with iatrogenic pneumothoraces.

chest trauma Pneumothoraces are seen in as many as 40% to 50% of chest trauma victims. [8] [9] [10] acute severe asthma COPD

The air trapping associated with airway inflammation during an asthmatic attack can cause rupture of alveolar sacs leading to the development of a pneumothorax. [1] This is the leading cause of secondary spontaneous pneumothoraces and is due to rupture of subpleural emphysematous blebs. [17]

tuberculosis

Secondary spontaneous pneumothoraces occur in 1.5% of cases of active pulmonary tuberculosis. Ruptures of subpleural tuberculous cysts are thought to be responsible. [20]

AIDS-related Pneumocystis jiroveci infection

Pneumocystis jiroveci necrotic subpleural cyst may cause pneumothorax in patients with a history of HIV infection and AIDS. [23]

About 2% to 5% of patients with AIDS develop a secondary spontaneous pneumothorax. [23] cystic fibrosis

Secondary spontaneous pneumothorax is a frequent occurrence in cystic fibrosis and is associated with more severe disease. About 16% to 20% of patients with cystic fibrosis >18 years of age will

experience a pneumothorax at some time in their lives. Contralateral pneumothoraces occur in 40% of patients. [24] [25]
lymphangioleiomyomatosis

A multi-system disease of women, characterised by cystic lung destruction that can result in recurrent pneumothoraces. [26]

Birt-Hogg-Dube syndrome

An autosomal dominant inheritable disease characterised by pulmonary cysts, spontaneous pneumothoraces, benign skin lesions, and renal cancers. Mutations in the gene that encodes for folliculin have been identified in individuals with this familial spontaneous pneumothorax. [27]

pulmonary Langerhans cell histiocytosis

This is a smoking-related interstitial lung disease, characterised by the development of cystic changes in the lung that predisposes to pneumothorax. [28]

Erdheim-Chester disease

A rare disease characterised by disseminated non-Langerhans cell histiocytosis involving multiple organs. Pulmonary involvement is uncommon but the lung can become infiltrated by lipid-laden histiocytes, resulting in diffuse interstitial and cystic changes and pneumothorax. [29]

Weak Marfan's syndrome

There are reports of families afflicted with Marfan's syndrome whose members suffered multiple bilateral episodes of primary spontaneous pneumothoraces. In this population, primary spontaneous pneumothoraces are attributed to pulmonary tissue fragility related to defective fibrillin. [13]

homocystinuria

There have been a few case reports of primary spontaneous pneumothoraces in patients with homocystinuria. The pathophysiology of this association is unknown. [16]

primary lung cancer and metastatic cancer to the lungs

Pneumothorax can occur in bronchogenic carcinomas and in a variety of cancers that have metastasised to the lungs. The pneumothoraces can develop following chemotherapy. It is postulated that necrosis of the peripherally located cancer causes the tumour to rupture into the pleural space, resulting in a pneumothorax. [18][19]

Diagnostic tests
1st tests to orderhide all
Test

x-ray chest necessary to visualise a pneumothorax in supine patients. [33] View image

As little as 50 mL of pleural gas can be visible in the upright position. Approximately 500 mL of intrapleural gas is

Presence of visceral pleural line, lung atelectasis, and loss of volume may suggest pneumothorax ex vacuo. [38]

Tests to considerhide all


Test

CT chest pneumothorax and bullous emphysema. [33] [38]

CT scanning may be necessary in patients with underlying respiratory diseases. CT is very useful in differentiatin

bronchoscopy Particularly useful in the setting of pneumothorax ex vacuo. [38]

Emerging testshide all


Test

chest ultrasound

In the hands of experienced practitioners, ultrasound has a reasonable sensitivity and specificity for the diagnosi

pneumothorax. [35] [36] This imaging modality may be particularly useful in blunt chest trauma victims. Since the

typically immobilised, upright PA chest radiographs cannot be obtained. Supine AP chest radiographs are not as

ultrasound in the detection of pneumothoraces. Ultrasound is an alternative screening test for these patients. [34

Last up

Differential diagnosis
Condition Differentiating signs/symptoms Differentiating tests

Asthma, acute exacerbation

Expiratory wheeze and chest tightness. [39]

Therapeutic trial of bronchodilators relieves symptoms.

COPD, acute exacerbation

Fever, increased cough, and change in sputum colour suggest an infective exacerbation. Bullous pulmonary disease may, however, be clinically indistinguishable from pneumothorax. [39]

CT of the chest may be necessary to differentiate a pneumothorax bulla. [33]

Pulmonary embolism

Presence of risk factors for thromboembolism, such as obesity, prolonged bed rest, pregnancy/postpart um period, inherited thrombophilias, active malignancy, recent trauma/fracture, and a history of previous thrombosis. Physical examination abnormalities suggestive of deep venous thrombosis are present in 50% of patients. [2]

The chest x-ray is most commonly normal, but pulmonary vascula not just wedge-shaped.

atelectasis may be present. Pulmonary infiltrates may develop and

CT pulmonary angiogram with direct visualisation of thrombus in a

Ventilation-perfusion scan (V/Q scan) with an area of ventilation th

Myocardial ischaemia

Typically the patient complains of chest tightness and shortness of breath that is brought on by exertion. The chest discomfort is usually substernal and is described as a pressure sensation. Pain may radiate into the neck and down the arms. Nausea, vomiting, and diaphoresis may accompany the chest discomfort.

An ECG may demonstrate ischaemia or injury patterns.

Serum levels of CK-MB and troponin increase when myocardial in

Pleural effusion

Patients will experience pain. However, as fluid accumulates in the pleural space, the visceral and parietal pleura will move apart and chest pain will ease. Physical examination demonstrates decreased fremitus, dullness to percussion, and decreased breath sounds. As pleural fluid accumulates, the patient may experience shortness of breath.

A chest x-ray is typically diagnostic of a pleural effusion. A menisc pleural fluid is necessary to visualise effusion by chest x-rays.

costophrenic angle in an upright chest x-ray is diagnostic. Betwee

CT scans are more sensitive and may give additional clues to the aetiology of the pleural fluid.

Bronchopleural fistula

A bronchopleural fistula is a communication between the pleural space and the bronchial tree that persists for 24 hours or more. The most common cause is postoperative complication of pulmonary resections. Other aetiologies include lung necrosis complicating infection, persistent spontaneous pneumothorax, chemotherapy or radiotherapy for bronchogenic carcinoma and metastatic cancer to the lung, and tuberculosis.

The diagnosis is established by placing a chest tube or small-bore pneumothorax and demonstrating a persistent air leak.

The presentation is characterised by sudden appearance of dyspnoea, hypotension, subcutaneous emphysema, cough, and purulent sputum, and shifting of the trachea and mediastinum. [40]

Fibrosing lung disease

Patients typically complain of slowly progressive dyspnoea. Crackles are present on auscultation of the chest. A prominent second heart sound may also be evident. The patient may have digital clubbing.

A chest x-ray is often the initial radiological examination when fibro suspected.

CT scanning, however, is more sensitive and helps in determining present.

active inflammatory disease of the lung. A ground-glass infiltrate in

Further diagnostic studies and therapeutic interventions may be n

Oesophageal perforation

Oesophageal perforations most commonly occur after medical instrumentation or para-oesophageal surgery, and following sudden increase in intraoesophageal pressure combined with negative intrathoracic pressure caused by straining or vomiting (Boerhaave's syndrome).

Plain chest radiography is almost always abnormal in oesophagea diagnosis is suggested by mediastinal or free peritoneal air. Later

mediastinum, subcutaneous emphysema, and pleural effusion wit

pneumothorax may develop. CT scan may demonstrate oesophag

thickening, extra-oesophageal air, peri-oesophageal fluid with or w

mediastinal widening, and air and fluid in the pleural spaces and th

The diagnosis can also be confirmed by water-soluble contrast oe

reveals the location and extent of extravasation of contrast materia

Patients complain of severe retrosternal chest and upper abdominal pain. Odynophagia, tachypnoea, dyspnoea, cyanosis, fever, and

shock develop rapidly thereafter. The physical examination is usually not helpful, particularly early in the course. Subcutaneous emphysema (crepitation) is an important diagnostic finding but is not very sensitive. A pleural effusion with or without a pneumothorax may be present.
Giant bullae

Patient's complaints and physical examination may mimic those of a pneumothorax. Patient may also present with acute dyspnoea due to another cause such as an exacerbation of COPD.

A giant bulla is defined as a bulla that occupies one third or more for comparison, then differentiation from a pneumothorax may be chest x-ray is not a pneumothorax.

hemithorax and develops slowly over time. However, if there are n

radiopaque lines within the bulla may be the only clue that the abn

Since placement of a chest tube into a giant bulla can have delete

of the chest should be obtained to help make the differentiation be

Last upda

Step-by-step diagnostic approach


If the patient presents with tension pneumothorax, immediate intervention is required. Patients with pneumothoraces typically complain of dyspnoea and chest pain. The degree of shortness of breath depends on the size of the pneumothorax

and, if present, the extent of their pre-existing lung disease. Often patients can pinpoint the onset of their symptoms. Risk factors for the development of spontaneous pneumothorax, such as the presence of chronic respiratory diseases, should be assessed. [1] Since Pneumocystis jiroveci pulmonary infection can result in a pneumothorax, the patient should also be questioned about risk factors for HIV infection. [23]

Clinical presentation
Tension pneumothorax
Patients complain of severe and worsening dyspnoea and are distressed, with rapid laboured respirations, cyanosis, profuse diaphoresis, and tachycardia. It requires immediate intervention to decompress the involved hemithorax. [1] [31]

Primary spontaneous pneumothorax


Patients usually complain of a sudden onset of dyspnoea and ipsilateral chest pain. The severity of the dyspnoea is related to the volume of air in the pleural space. Most primary spontaneous pneumothoraces occur at rest. The patient can, therefore, often recall the exact time when the pneumothorax developed. [32]

Secondary spontaneous pneumothorax


Patients complain of dyspnoea and ipsilateral chest pain. Due to the underlying lung disease, their symptoms are typically more severe than those associated with primary spontaneous pneumothorax. [31] Catamenial pneumothoraces are secondary spontaneous pneumothoraces. They are usually right-sided. The diagnosis is not difficult if the possibility is considered.

Pneumothorax ex vacuo
Occurs when rapid collapse of the lung produces a decrease in the intrapleural pressure. In this instance, the pleural gas is called pneumothorax ex vacuo, and it is most commonly seen in atelectasis of the right upper lobe. The increased negative intrapleural pressure causes gaseous nitrogen molecules to migrate from the pulmonary capillaries into the pleural space. [3] Due to the airway obstruction, the patient may complain of cough. Dyspnoea may be related to the amount of collapsed lung and/or the volume of air in the pleural space.

Physical examination
Tension pneumothorax

Findings are similar to those seen with a large spontaneous pneumothorax; however, the involved hemithorax is larger, with intercostal interspace widening, than the contralateral hemithorax, and the trachea shifts towards the contralateral hemithorax.

The development of a tension pneumothorax is usually heralded by a sudden deterioration in the cardiopulmonary status of the patient. Loss of consciousness may follow quickly as blood flow to the brain is compromised. [1]

Primary spontaneous pneumothorax


Findings include decreased chest excursion, ipsilateral hyperinflation of the hemithorax with diminished breath sounds, and hyper-resonance on percussion. [1]

Secondary spontaneous pneumothorax


Findings are the same as in primary spontaneous pneumothorax; however, due to the patient's underlying respiratory disorder, the physical findings are less reliable than in patients without pre-existing lung disease. [1] Catamenial pneumothoraces are secondary spontaneous pneumothoraces. They are usually right-sided. The diagnosis is not difficult if the possibility is considered.

Pneumothorax ex vacuo
Findings include diminished breath sounds and hyper-resonance on percussion. The chest, however, is not hyperexpanded. [3]

Imaging
Tension pneumothorax is considered a medical emergency. If a tension pneumothorax is clinically suspected, the involved hemithorax should be decompressed immediately. Valuable time should not be wasted waiting for radiographic confirmation. A delay in intervention may result in the death of the patient. [1] A chest x-ray is generally recommended as first-line test, and shows a visceral pleural line. [33]View image Expiratory radiographs are not recommended for routine diagnosis. [33] In secondary spontaneous pneumothorax the pleural line may be difficult to visualise because the adjacent diseased lung may be hyperlucent. In addition, it may be difficult to distinguish a large, thin-walled bulla from a pneumothorax. In this situation it may be necessary to obtain a CT of the chest to confirm the diagnosis. [33] For pneumothorax ex vacuo, in addition to the presence of a visceral pleural line, ipsilateral loss of volume and lung atelectasis are present. CT may demonstrate an endobronchial obstruction.

Owing to the increasing availability of ultrasound in a variety of clinical settings, this imaging modality is gaining popularity as a means to diagnose pneumothoraces at the bedside. [34] In the hands of experienced practitioners, ultrasound has a reasonable sensitivity and specificity for the diagnosis of a pneumothorax. [35] [36] Thoracic ultrasound seems to be useful in the detection of pneumothoraces in adult blunt chest trauma victims who are immobilised. [37]

Other tests
If a pneumothorax ex vacuo is suspected, a bronchoscopy may be necessary to establish the diagnosis and to remove the endobronchial obstruction. [38]
Click to view diagnostic guideline references.

Diagnostic criteria

Size of pneumothorax [22]


Often, the PA chest radiograph is used to quantify the size of the pneumothorax. A pneumothorax with a visible rim of 2 cm between the lung margin and the chest wall, when measured at the level of the hilum, approximates a 50% pneumothorax. Thus the British Thoracic Society recommends the following as a gauge to the size of a pneumothorax:
Small pneumothorax - a visible rim of <2 cm between the lung margin and the chest wall at the level of the hilum on PA chest radiographs Large pneumothorax - a visible rim at least 2 cm between the lung margin and the chest wall at the level of the hilum on PA chest radiographs.

The choice of a 2 cm pneumothorax as the determinant of a small versus a large pneumothorax is a compromise between the theoretical risk of needle puncture of the lung with a smaller pneumothorax and the significant volume and length of time for spontaneous resolution of a larger pneumothorax. Unfortunately lung collapse is not always uniform, particularly in patients with diseased lungs. Thus, it is more difficult to estimate the size of these localised pneumothoraces. While CT scanning can be utilised as a means to estimate the size of a pneumothorax, not all facilities purchase the software necessary to make this assessment.

Case history #1
A 20-year-old man presents to the emergency department with complaints of left-sided chest pain and shortness of breath. He states that these symptoms

began suddenly 4 days ago while he was working at his computer. He initially thought that he might have strained a chest wall muscle, but since the pain and dyspnoea had not resolved, he decided to seek medical attention. He has no significant past medical history but has smoked cigarettes since the age of 16 years. His older brother suffered a pneumothorax at the age of 23 years. The patient's vital signs are normal. He appears in mild discomfort. Examination of his chest reveals that the left hemithorax is mildly hyperexpanded with decreased chest excursion. His left hemithorax is hyperresonant on percussion, and breath sounds are diminished when compared with the right hemithorax. His cardiovascular examination is normal.

Case history #2
A 65-year-old patient with COPD presents to the emergency department with complaints of worsening shortness of breath and right-sided chest discomfort. He states that these symptoms occurred suddenly 1 hour prior to presentation. He denies fevers and chills. He also denies increased sputum production and a change in the colour or character of his sputum. He continues to smoke cigarettes against medical advice. The patient's blood pressure is 136/92 mmHg, heart rate is 110 beats per minute, and respiratory rate is 24 breaths per minute. Chest excursion is decreased on the right more than the left. His right hemithorax is more hyperinflated than the left. His right hemithorax is hyper-resonant on percussion. Breath sounds are distant bilaterally but more diminished on the right.

Other presentations
Atypical presentations include a patient with pleural gases accumulated at the site of atelectatic lung. In this instance, the pleural gas is called pneumothorax ex vacuo, and it is most commonly seen in atelectasis of the right upper lobe and occurs when rapid collapse of the lung produces a decrease in the intrapleural pressure. The increased negative intrapleural pressure causes gaseous nitrogen molecules to migrate from the pulmonary capillaries into the pleural space. [3] Catamenial pneumothoraces occur within 72 hours before or after menstruation in young women. They are thought to be relatively rare, with approximately 250 cases described in the medical literature, although they may be under-reported. These pneumothoraces are typically right-sided. [4]

Treatment Options

Treatment Patient group tension pneumothorax line 1st Treatmenthide all

immediate decompression

Achieved by immediate insertion of a standard 14gauge intravenous catheter into the pleural space at the intersection of the midclavicular line and the second or third intercostal space. Intervention should not be delayed by awaiting radiographic confirmation of the tension pneumothorax. [22]

Presumptive
Treatment Patient group primary spontaneous pneumothorax small: visible rim of <2 cm between the lung margin and the chest wall 1st line Treatmenthide all

observation and supplemental oxygen therapy

Clinically stable patients who are experiencing a small primary spontaneous pneumothorax can be observed and treated conservatively with supplemental high-flow (10 L/min) oxygen. The addition of high-flow oxygen therapy has been shown to result in a 4-fold increase in the rate of pneumothorax reabsorption during periods of oxygen supplementation. [46] Because these patients are typically young and otherwise healthy, they can often be managed as outpatients. If they remain stable in the emergency department for 4 to 6 hours, they can be released with follow-up in several days. Patients, however, should be instructed to immediately seek medical attention should they become short of breath.

large: visible rim 2 cm between the lung margin and the chest wall

1st

percutaneous aspiration

If the primary spontaneous pneumothorax is large, then percutaneous needle aspiration should be undertaken.[B Evidence] This can be accomplished by placement of an intravenous catheter into the pleural space at the intersection of the midclavicular

Treatment Patient group tension pneumothorax line 1st Treatmenthide all

immediate decompression

Achieved by immediate insertion of a standard 14gauge intravenous catheter into the pleural space at the intersection of the midclavicular line and the second or third intercostal space. Intervention should not be delayed by awaiting radiographic confirmation of the tension pneumothorax. [22]

Presumptive
Treatment Patient group line Treatmenthide all

line and the second or third intercostal space. A large syringe can then be used to withdraw air from the pleural space. Care must be taken not to allow air to gain access to the pleural space via the catheter. Coaching the patient to exhale while the syringe is detached from the catheter can prevent this. Alternatively, a stopcock attached to the catheter offers the advantage of sealing the pleural space from the atmosphere when the syringe is disconnected from the stopcock. adjunct [?] supplemental oxygen therapy

Supplemental high-flow (10 L/min) oxygen should be given. The addition of high-flow oxygen therapy has been shown to result in a 4-fold increase in the rate of pneumothorax reabsorption during periods of oxygen supplementation.[46]

2nd

chest-tube thoracostomy

If aspiration fails, a chest-tube or small-bore catheter should be inserted.

adjunct [?]

supplemental oxygen therapy

Supplemental high-flow (10 L/min) oxygen should be given where feasible. The addition of high-flow oxygen therapy has been shown to result in a 4-fold

Treatment Patient group tension pneumothorax line 1st Treatmenthide all

immediate decompression

Achieved by immediate insertion of a standard 14gauge intravenous catheter into the pleural space at the intersection of the midclavicular line and the second or third intercostal space. Intervention should not be delayed by awaiting radiographic confirmation of the tension pneumothorax. [22]

Presumptive
Treatment Patient group line Treatmenthide all

increase in the rate of pneumothorax reabsorption during periods of oxygen supplementation. [46]
persistent air leak despite initial management 1st

video-assisted thoracoscopy with stapling of the air leak and pleurodesis

If the air leak persists, further intervention is necessary. Video-assisted thoracoscopy with stapling of the air leak and pleurodesis is the procedure of choice in most circumstances.

adjunct [?]

supplemental oxygen therapy

Supplemental high-flow (10 L/min) oxygen should be given where feasible. The addition of high-flow oxygen therapy has been shown to result in a 4-fold increase in the rate of pneumothorax reabsorption during periods of oxygen supplementation. [46]

secondary spontaneous pneumothorax no contraindications to chest tube insertion or clinically unstable 1st

hospitalisation and supplemental oxygen

Because of diminished pulmonary reserve, patients with secondary spontaneous pneumothoraces should be hospitalised. Supplemental high-flow (10 L/min) oxygen should be given where feasible. The addition of high-flow oxygen therapy has been shown to result

Treatment Patient group tension pneumothorax line 1st Treatmenthide all

immediate decompression

Achieved by immediate insertion of a standard 14gauge intravenous catheter into the pleural space at the intersection of the midclavicular line and the second or third intercostal space. Intervention should not be delayed by awaiting radiographic confirmation of the tension pneumothorax. [22]

Presumptive
Treatment Patient group line Treatmenthide all

in a 4-fold increase in the rate of pneumothorax reabsorption during periods of oxygen supplementation. [46]Oxygen should be used with caution in patients with chronic lung disease and hypercarbic respiratory failure. plus [?] chest-tube thoracostomy

If the secondary spontaneous pneumothorax is large enough for safe placement of a chest tube [22] or the patient is clinically unstable, then a chest tube is indicated. Tube thoracostomy is preferred over simple aspiration of air from the pleural space.

Simple aspiration can be attempted in patients with large but asymptomatic secondary pneumothoraces. The success rate of this technique, however, is reduced in secondary spontaneous pneumothoraces.

In general, the chest tube should remain in place until a procedure is performed to prevent recurrent pneumothorax. [22] [43] [44] Chest-tube thoracostomy typically results in complete lung reexpansion in secondary spontaneous pneumothorax. In addition, air leak resolves within 7 days in approximately 80% of patients.

2nd

video-assisted thoracoscopy or pleurodesis

Subsequent interventions are aimed at preventing

Treatment Patient group tension pneumothorax line 1st Treatmenthide all

immediate decompression

Achieved by immediate insertion of a standard 14gauge intravenous catheter into the pleural space at the intersection of the midclavicular line and the second or third intercostal space. Intervention should not be delayed by awaiting radiographic confirmation of the tension pneumothorax. [22]

Presumptive
Treatment Patient group line Treatmenthide all

recurrences. Video-assisted thoracoscopy with stapling of the subpleural bleb and mechanical pleural abrasion is the procedure of choice, since it is more effective than chemical pleurodesis. However, the perioperative morbidity and mortality of videoassisted thoracosocopy in patients with secondary spontaneous pneumothorax may be prohibitively high. [22] [43] [44]

The high recurrence rates and the small respiratory reserve of patients with pulmonary diseases dictate that pleurodesis should be attempted in all of these patients. Diffuse pleurodesis with either videoassisted thoracoscopy or intrapleural chemical instillation should, however, be avoided in patients with cystic fibrosis or alpha-1 antitrypsin deficiency, and in younger patients with smoking-related COPD who are being considered for lung transplant. Previous diffuse pleurodesis results in a more difficult and bloody dissection during the lung transplantation procedure. Conservative measures and observation or video-assisted thoracoscopy and stapling of the air leak with or without directed mechanical abrasion are preferred in this subset of patients.

Treatment Patient group tension pneumothorax line 1st Treatmenthide all

immediate decompression

Achieved by immediate insertion of a standard 14gauge intravenous catheter into the pleural space at the intersection of the midclavicular line and the second or third intercostal space. Intervention should not be delayed by awaiting radiographic confirmation of the tension pneumothorax. [22]

Presumptive
Treatment Patient group line Treatmenthide all

Primary Options video-assisted thoracoscopy and stapling of the air leak with or without directed mechanical abrasion : Secondary Options chemical or talc pleurodesis :
contraindications to chest tube insertion or clinically stable 1st

hospitalisation and supplemental oxygen

Because of diminished pulmonary reserve, patients with secondary spontaneous pneumothoraces should be hospitalized. Supplemental high-flow (10 L/min) oxygen should be given where feasible. The addition of high-flow oxygen therapy has been shown to result in a 4-fold increase in the rate of pneumothorax reabsorption during periods of oxygen supplementation. [46]Oxygen should be used with caution in patients with chronic lung disease and hypercarbic respiratory failure.

plus [?]

observation

Clinically stable patients, or those who are experiencing a small secondary spontaneous pneumothorax that is too small to be drained safely by percutaneous chest-tube placement, [22] are

Treatment Patient group tension pneumothorax line 1st Treatmenthide all

immediate decompression

Achieved by immediate insertion of a standard 14gauge intravenous catheter into the pleural space at the intersection of the midclavicular line and the second or third intercostal space. Intervention should not be delayed by awaiting radiographic confirmation of the tension pneumothorax. [22]

Presumptive
Treatment Patient group line Treatmenthide all

treated with oxygen and observation.


2nd

video-assisted thoracoscopy or pleurodesis

Subsequent interventions are aimed at preventing recurrences. Video-assisted thoracoscopy with stapling of the subpleural bleb and mechanical pleural abrasion is the procedure of choice, since it is more effective than chemical pleurodesis. However, the perioperative morbidity and mortality of videoassisted thoracosocopy in patients with secondary spontaneous pneumothorax may be prohibitively high. [22] [43] [44]

The high recurrence rates and the small respiratory reserve of patients with pulmonary diseases dictate that pleurodesis should be attempted in all of these patients. Diffuse pleurodesis with either videoassisted thoracoscopy or intrapleural chemical instillation should, however, be avoided in patients with cystic fibrosis or alpha-1 antitrypsin deficiency, and in younger patients with smoking-related COPD who are being considered for lung transplant. Previous diffuse pleurodesis results in a more difficult and bloody dissection during the lung transplantation procedure. Conservative measures and observation

Treatment Patient group tension pneumothorax line 1st Treatmenthide all

immediate decompression

Achieved by immediate insertion of a standard 14gauge intravenous catheter into the pleural space at the intersection of the midclavicular line and the second or third intercostal space. Intervention should not be delayed by awaiting radiographic confirmation of the tension pneumothorax. [22]

Presumptive
Treatment Patient group line Treatmenthide all

or video-assisted thoracoscopy and stapling of the air leak with or without directed mechanical abrasion are preferred in this subset of patients. Primary Options video-assisted thoracoscopy and stapling of the air leak with or without directed mechanical abrasion Secondary Options chemical or talc pleurodesis

catamenial pneumothorax

1st

supplemental oxygen percutaneous aspiration or chest-tube thoracostomy

The acute treatment of catamenial pneumothorax is similar to that of other secondary spontaneous pneumothoraces. If the pneumothorax is small, supplemental oxygen should be administered.

Patients with large pneumothoraces should also undergo percutaneous aspiration or chest-tube thoracostomy.

adjunct [?]

tube thoracotomy drainage

Some patients with catamenial pneumothorax also

Treatment Patient group tension pneumothorax line 1st Treatmenthide all

immediate decompression

Achieved by immediate insertion of a standard 14gauge intravenous catheter into the pleural space at the intersection of the midclavicular line and the second or third intercostal space. Intervention should not be delayed by awaiting radiographic confirmation of the tension pneumothorax. [22]

Presumptive
Treatment Patient group line Treatmenthide all

develop a haemothorax, resulting in a hydropneumothorax as a complication of their thoracic endometriosis. The blood in the pleural space requires tube thoracostomy drainage.
ovulation suppression not contraindicated and acceptable to patient

plus [?]

ovulation suppression

The mainstay of treatment for catamenial pneumothorax is generally suppression of the ectopic endometrium by interfering with ovarian oestrogen secretion. This can be accomplished with oral contraceptives, gonadotrophin-releasing hormone analogues, progestogens, and danazol.

Many patients who experience catamenial pneumothoraces will not suffer recurrences as long as ovulation and menstruation are suppressed. [53]

ovulation suppression contraindicated or unsuccessful or unacceptable to patient

1st

video-assisted thoracoscopy or open thoracotomy + chemical or mechanical pleurodesis

If the patient cannot take ovulation-suppressing medications, wishes to discontinue this therapy to become pregnant, or fails hormonal manipulation, then an invasive procedure to prevent a recurrence of the catamenial pneumothorax should be considered. Video-assisted thoracoscopy or open thoracotomy can be performed. The pleura should be inspected

Treatment Patient group tension pneumothorax line 1st Treatmenthide all

immediate decompression

Achieved by immediate insertion of a standard 14gauge intravenous catheter into the pleural space at the intersection of the midclavicular line and the second or third intercostal space. Intervention should not be delayed by awaiting radiographic confirmation of the tension pneumothorax. [22]

Presumptive
Treatment Patient group line Treatmenthide all

for endometrial implants and the diaphragm examined for perforations. The implants should be excised and diaphragmatic defects repaired.

Chemical or mechanical pleurodesis should also be undertaken to prevent recurrence.

traumatic pneumothorax

1st

percutaneous aspiration and oxygen therapy

First-line treatment involves percutaneous needle aspiration. This can be accomplished by placement of an intravenous catheter into the pleural space at the intersection of the midclavicular line and the second or third intercostal space. A large syringe can then be used to withdraw air from the pleural space. Care must be taken not to allow air to gain access to the pleural space via the catheter. Coaching the patient to exhale while the syringe is detached from the catheter can prevent this. Alternatively, a stopcock attached to the catheter offers the advantage of sealing the pleural space from the atmosphere when the syringe is disconnected from the stopcock.

Supplemental high-flow (10 L/min) oxygen should be given where feasible. The addition of high-flow

Treatment Patient group tension pneumothorax line 1st Treatmenthide all

immediate decompression

Achieved by immediate insertion of a standard 14gauge intravenous catheter into the pleural space at the intersection of the midclavicular line and the second or third intercostal space. Intervention should not be delayed by awaiting radiographic confirmation of the tension pneumothorax. [22]

Presumptive
Treatment Patient group line Treatmenthide all

oxygen therapy has been shown to result in a 4-fold increase in the rate of pneumothorax reabsorption during periods of oxygen supplementation. [46] Oxygen should be used with caution in patients with chronic lung disease and hypercarbic respiratory failure
2nd

chest-tube thoracostomy and oxygen therapy

If aspiration fails or the pneumothorax is large, a chest-tube placement is usually required. Hospitalisation is required to perform chest-tube thoracostomy.

adjunct [?]

thoracotomy

May be needed in some patients to repair tears in the lungs or air passages. Thoracotomy is an operative procedure where the surgeon gains access to the pleural space by making an incision into the chest wall and spreading the ribs apart. There are several different methods to perform a thoracotomy, but posterolateral thoracotomy is the approach most commonly used. Upon completion, the chest incision is closed and 1 or more chest tubes are placed into the pleural space.

Treatment Patient group tension pneumothorax line 1st Treatmenthide all

immediate decompression

Achieved by immediate insertion of a standard 14gauge intravenous catheter into the pleural space at the intersection of the midclavicular line and the second or third intercostal space. Intervention should not be delayed by awaiting radiographic confirmation of the tension pneumothorax. [22]

Presumptive
Treatment Patient group line 1st Treatmenthide all

pneumothorax ex vacuo

bronchoscopy

Bronchoscopy may be necessary to relieve the endobronchial obstruction. Tube thoracostomy is not indicated. [3] The pneumothorax spontaneously resolves when the bronchial obstruction is relieved and the lobe re-expands.

adjunct [?]

hospitalisation and supplemental oxygen

Supplemental high-flow (10 L/min) oxygen should be given where feasible. The addition of high-flow oxygen therapy has been shown to result in a 4-fold increase in the rate of pneumothorax reabsorption during periods of oxygen supplementation. [46] Oxygen should be used with caution in patients with chronic lung disease and hypercarbic respiratory failure.

Acute
Treatment Patient group recurrent pneumothorax primary spontaneous pneumothorax 1st line Treatmenthide all

hospitalisation and supplemental oxygen

Supplemental high-flow (10 L/min) oxygen should be

Treatment Patient group recurrent pneumothorax line Treatmenthide all

given where feasible. The addition of high-flow oxygen therapy has been shown to result in a 4-fold increase in the rate of pneumothorax reabsorption during periods of oxygen supplementation. [46] plus [?] video-assisted thoracoscopy with stapling of the air leak and pleurodesis

A chest tube should be placed if the patient develops a recurrent ipsilateral primary spontaneous pneumothorax. Most recurrences occur in the first year. Video-assisted thoracoscopy with stapling of the air leak and pleurodesis is typically recommended for a recurrent ipsilateral primary spontaneous pneumothorax.

secondary spontaneous pneumothorax

1st

hospitalisation and supplemental oxygen

Due to diminished pulmonary reserve, patients with secondary spontaneous pneumothoraces should be hospitalised. Supplemental high-flow (10 L/min) oxygen should be given where feasible. The addition of high-flow oxygen therapy has been shown to result in a 4-fold increase in the rate of pneumothorax reabsorption during periods of oxygen supplementation. [46]Oxygen should be used with caution in patients with chronic lung disease and hypercarbic respiratory failure.

plus [?]

pleurodesis

Video-assisted thoracoscopy with stapling of the subpleural bleb and mechanical pleural abrasion is the procedure of choice to prevent recurrences, as it is more effective than chemical pleurodesis. However, the perioperative morbidity and mortality of video-assisted thoracoscopy in patients with secondary spontaneous pneumothorax may be prohibitively high.[22] [43] [44]

In non-operative patients, chemical or talc pleurodesis should be undertaken.[B Evidence]

Treatment Patient group recurrent pneumothorax line Treatmenthide all

Diffuse pleurodesis with either video-assisted thoracoscopy or intrapleural chemical instillation should be avoided in patients with cystic fibrosis or alpha-1 antitrypsin deficiency, and in younger patients with smoking-related COPD who are being considered for lung transplant. Video-assisted thoracoscopy and stapling of the air leak with or without directed mechanical abrasion are preferred in this subset of patients.

Ongoing

Treatment approach
The main goals of treatment of spontaneous pneumothoraces are to remove the air from the pleural space and to decrease the likelihood of recurrence. If a tension pneumothorax is suspected, prompt intervention is required to decompress the involved hemithorax. [1] The initial treatment includes observation with supplemental oxygen therapy, percutaneous aspiration of the air in the pleural space,[C Evidence] and chest-tube thoracostomy, depending on type and size of pneumothorax.[B Evidence] Video-assisted thoracoscopy or thoracostomy may be necessary to eliminate the site of the air leak. [22] [30] [43] [44] Pleurodesis is used to limit the likelihood of recurrence.[B Evidence] It can be accomplished either by mechanical abrasion of the pleura or by introduction of a substance into the pleural space that irritates the pleural surfaces with subsequent adhesion of the parietal and visceral pleurae. The procedure of choice depends on patient characteristics and clinical circumstances. [22] [43] [44] Several methods have been proposed for estimating the size of pneumothoraces on plain posterior-anterior chest radiographs. Unfortunately, each of these methods suffers from inaccuracies and/or lack of validation. [45] The British Thoracic Society recommends a simplified method to determine the size of a pneumothorax: pneumothoraces can be small (visible rim of <2 cm between the lung margin and the chest wall) or large (visible rim at least 2 cm between the lung margin and the chest wall). [22]

Tension pneumothorax
A tension pneumothorax is a medical emergency. Decompression is accomplished by immediate insertion of a standard 14-gauge intravenous catheter into the pleural space at the intersection of the midclavicular line and the second or third intercostal space. This decompression acts as a bridge to tube thoracostomy. Intervention should not be delayed by awaiting radiographic confirmation of the tension pneumothorax. [22]

Primary spontaneous pneumothorax


Clinically stable patients who are experiencing a small primary spontaneous pneumothorax can be observed and treated conservatively with supplemental high-flow (10 L/min) oxygen and expectant observation. It is generally accepted that a small asymptomatic pneumothorax can be observed without invasive intervention. [22] [43] [44] The addition of high-flow oxygen therapy has been shown to result in a 4-fold increase in the rate of pneumothorax reabsorption during periods of oxygen supplementation. [46] If the pneumothorax is large, then percutaneous needle aspiration should be undertaken. This can be accomplished by placement of an intravenous catheter into the pleural space at the intersection of the midclavicular line and the second or third intercostal space. A large syringe can be used to withdraw air from the pleural space. Care must be taken not to allow air to gain access to the pleural space by the catheter. Coaching the patient to exhale while the syringe is detached from the catheter can prevent this from occurring. A stopcock attached to the catheter offers the advantage of sealing the pleural space from the atmosphere when the syringe is disconnected from the stopcock. Often these procedures can be accomplished in the emergency department without admission to hospital. Chest x-rays should be obtained afterwards. Needle aspiration of primary spontaneous pneumothoraces is generally as safe and effective as tube thoracostomy. Needle aspiration also has the benefit to the patients of needing fewer admissions to the hospital ward and shorter hospital stays. [22] [47] [48] If aspiration fails, a chest tube or small-bore catheter should be inserted into the pleural space. Small-bore catheters can be attached to a one-way flutter valve rather than negative pressure suction. Since patients with primary spontaneous pneumothoraces have no underlying lung disease, and, therefore, a large respiratory reserve, they can be discharged from the emergency department as long as the flutter valve is functioning properly.

If the patient requires negative pressure suction to resolve the pneumothorax, hospitalisation is required. Further intervention is only necessary should the air leak persist. Most suction devices have a water-filled chamber through which air removed from the pleural space bubbles. The bubbles and, therefore, a persistent air leak are easy to identify. Video-assisted thoracoscopy with stapling of the air leak and pleurodesis is the procedure of choice in most circumstances. Compared with open pleurectomy for primary spontaneous pneumothoraces, video-assisted thoracoscopy results in reductions in length of hospitalisation and analgesic requirements for pain control. Recurrence rates, however, are higher following video-assisted thoracoscopy pleurectomy than following open pleurectomy. [49] [50] A chest tube should also be placed if the patient develops a recurrent ipsilateral primary spontaneous pneumothorax. Interestingly, most recurrences occur in the first year. Video-assisted thoracoscopy with stapling of the air leak and pleurodesis is typically recommended for a recurrent ipsilateral primary spontaneous pneumothorax.[B Evidence]

Secondary spontaneous pneumothorax


The size of a secondary spontaneous pneumothorax may not correlate well with the clinical manifestations. In general, the clinical symptoms associated with secondary spontaneous pneumothoraces are more severe than those associated with primary spontaneous pneumothoraces. In addition, studies have determined that patients over 50 years of age who develop a pneumothorax should be treated similarly to those with known lung disease. It is likely that these older patients had an unrecognised underlying pulmonary disease. [22] Because of diminished pulmonary reserve, patients with secondary spontaneous pneumothoraces are typically hospitalised. Moreover, the recurrence rate in patients with pulmonary diseases is somewhat higher than that of primary spontaneous pneumothorax. Thus, chest tube thoracostomy is preferred over simple aspiration of air from the pleural space. Simple aspiration can be performed in patients with large asymptomatic secondary pneumothoraces. There is, however, a reduced success rate for simple aspiration in these patients. [22] In clinically stable patients who are experiencing a secondary spontaneous pneumothorax that is too small for a chest tube to be placed safely, treatment should include supplemental high-flow (10 L/min) oxygen and expectant observation. The addition of high-flow oxygen therapy has been shown to result in a 4-fold increase in the rate of pneumothorax reabsorption during periods of oxygen supplementation. [46] Oxygen should be used with caution

in patients with chronic lung disease and hypercarbic respiratory failure. In all other patients, the initial management is directed at removing the gas from the pleural space. Subsequent interventions are aimed at preventing recurrences. In general, the chest tube should remain in place until a procedure is performed to prevent recurrent pneumothorax. [22][43] [44] Chest-tube thoracostomy typically results in complete lung re-expansion in secondary spontaneous pneumothorax. In addition, air leaks resolve within 7 days in approximately 80% of patients. However, the high recurrence rates and the small respiratory reserve of patients with pulmonary diseases dictate that pleurodesis should be attempted in all of these patients.[B Evidence] Video-assisted thoracoscopy with stapling of the subpleural bleb and mechanical pleural abrasion is the procedure of choice, since it is more effective than chemical pleurodesis. However, the perioperative morbidity and mortality of videoassisted thoracoscopy in patients with secondary spontaneous pneumothorax may be prohibitively high. [22] [43] [44]In view of the significant risk of morbidity and mortality after video-assisted thoracoscopy or open thoracotomy, less invasive measures may be tried, especially in patients with severe pulmonary disease, whether due to COPD, cystic fibrosis, or another lung disorder. In non-operative patients, chemical or talc pleurodesis should be undertaken. While all patients with a secondary spontaneous pneumothorax should be considered for a preventive intervention, patients who are possible lung transplantation candidates require special consideration. Diffuse pleurodesis with either video-assisted thoracoscopy or intrapleural chemical instillation should be avoided in patients with cystic fibrosis or alpha-1 antitrypsin deficiency, and in younger patients with smoking-related COPD who are being considered for lung transplant. Previous diffuse pleurodesis results in a more difficult and bloody dissection during the lung transplantation procedure. Conservative measures and observation or video-assisted thoracoscopy with or without directed mechanical abrasion are preferred in this subset of patients. Unfortunately there are no randomised controlled trials comparing medical and surgical intervention for persistent or recurrent pneumothoraces in patients with cystic fibrosis. Therefore, the potential efficacy of each intervention must be weighed against the possible risk of complications for each cystic fibrosis patient on a case-by-case basis. [51] [52]

Catamenial pneumothorax

The acute treatment of catamenial pneumothorax is similar to that of other secondary spontaneous pneumothoraces. If the pneumothorax is small, supplemental oxygen should be administered. In addition to oxygen therapy, patients with large pneumothoraces undergo percutaneous aspiration or chest-tube thoracostomy. Some patients with catamenial pneumothorax also develop a haemothorax, resulting in a hydropneumothorax as a complication of their thoracic endometriosis. The blood in the pleural space requires tube thoracostomy drainage. Because patients with catamenial pneumothoraces are typically young and without underlying parenchymal lung disease, highflow oxygen can be administered without fear of hypercapnic respiratory failure. The mainstay of treatment for catamenial pneumothorax is suppression of the ectopic endometrium by interfering with ovarian oestrogen secretion. This can be accomplished with oral contraceptives, gonadotrophin-releasing hormone analogues, progestogens, and danazol. Many patients who experience catamenial pneumothoraces will not suffer recurrences as long as ovulation and menstruation are suppressed. [53] If the patient cannot take ovulation-suppressing medications, wishes to discontinue this therapy to become pregnant, or fails hormonal manipulation, then an invasive procedure to prevent a recurrence of the catamenial pneumothorax should be considered. Video-assisted thoracoscopy or open thoracotomy can be performed. The pleura should be inspected for endometrial implants and the diaphragm examined for perforations. The implants should be excised and diaphragmatic defects repaired. Chemical or mechanical pleurodesis should also be undertaken to prevent recurrence.

Traumatic pneumothorax
First-line treatment involves percutaneous needle aspiration. If aspiration fails or the pneumothorax is large, a chest tube placement is usually required. Thoracotomy may be needed in some patients to repair tears in the lungs or air passages. A haemothorax may accompany and/or complicate a traumatic pneumothorax. The presence of a haemothorax necessitates chest tube placement. If bleeding continues, exploration of the thoracic cavity may be necessary to achieve haemostasis.

Pneumothorax ex vacuo

Pneumothorax ex vacuo occurs when rapid collapse of the lung produces a decrease in the intrapleural pressure. In this instance, the pleural gas is called pneumothorax ex vacuo, and it is most commonly seen in atelectasis of the right upper lobe. The increased negative intrapleural pressure causes gaseous nitrogen molecules to migrate from the pulmonary capillaries into the pleural space. [3] Bronchoscopy may be necessary to relieve the endobronchial obstruction. Tube thoracostomy is not indicated. [3]

Monitoring
There is no established guideline for monitoring patients following a spontaneous pneumothorax. Patient education is, therefore, an important aspect in the treatment of spontaneous pneumothoraces.

Patient Instructions
Patients with a primary spontaneous pneumothorax should understand that ipsilateral and contralateral pneumothoraces can occur. They should also be made aware that each recurrence increases their risk for subsequent ipsilateral pneumothoraces and that pleurodesis treatment can fail. These patients should, therefore, be instructed to seek immediate medical evaluation should their symptoms recur. Patients with a secondary spontaneous pneumothorax should be advised that each recurrence increases their risk for subsequent ipsilateral pneumothoraces. The patient should also be made aware that their underlying lung disease may result in a contralateral pneumothorax and that pleurodesis treatment can fail. The patient should be instructed to seek immediate medical attention should their symptoms recur. Cigarette smoking negatively influences the risk of recurrence. Thus, smoking cessation should be advised. Patients should be counselled regarding the dangers of sudden barometric pressure changes that might occur with high-altitude activity or underwater diving. Patients who have had a pneumothorax should be discouraged from underwater diving permanently, unless a definitive preventative procedure has been accomplished. Patients should be instructed not to fly for at least 1 week after resolution of a pneumothorax. However, the risk of a recurrence in a patient who has had a secondary spontaneous pneumothorax is not significantly reduced until 1 year has passed. In the lack of a definitive

preventative procedure, patients should be advised to minimise their risk by avoiding air travel accordingly.

Complications
Complicationhide all

re-expansion pulmonary oedema If the pneumothorax is large and has been present for more than 72 hours, then the patient is theoretically at risk for re-expansion pulmonary oedema after pleural space evacuation. It can also develop in the ipsilateral lung during or immediately following evacuation of air from the pleural space. In addition, the pulmonary oedema may be evident in the contralateral lung. The oedema may progress for 24 to 48 hours. Recovery is typically complete within the first 48 hours. The exact underlying mechanism for this is not known. Mechanical stress applied to the lung during reexpansion may damage the pulmonary capillaries and lead to the development of pulmonary oedema. Reperfusion injury with free radical formation may also play a significant role. [56] It is associated with variable degrees of hypoxaemia and hypotension, sometimes requiring intubation and mechanical ventilation, and occasionally leads to death. [44] Since the amount of intrapleural pressure necessary to induce re-expansion pulmonary oedema is not precisely known, most clinicians err on the side of safety for the patient and connect the chest tubes placed to a water seal device rather than to suction. If the lung does not fully re-expand with the water seal device, the chest tube can subsequently be placed to suction. talc pleurodesis-related ARDS see our comprehensive coverage of Acute respiratory distress syndrome It has been suggested that intrapleural injection of talc produces a systemic inflammatory response that may play a role in the pathogenesis of ARDS. [57] However, talc pleurodesis appears to be safe when sizecalibrated talc is used in the recommended dosages. [58]

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Prognosis
Primary spontaneous pneumothorax
Patients with primary spontaneous pneumothoraces are at risk for recurrent pneumothoraces. Between 30% and 50% of patients will have an ipsilateral recurrent pneumothorax. Unless an intervention is undertaken in a patient with a first recurrence, a third and fourth event can be expected in 62% and 83% of patients, respectively. These patients are also at risk of a contralateral primary spontaneous pneumothorax. [54] The recurrence rates of primary spontaneous pneumothorax after video-assisted thoracoscopy with stapling of the subpleural bleb and mechanical pleural abrasion and thoracoscopic talc poudrage are similar (approximately 5%). Chemical pleurodesis can be

accomplished via chest tube if video-assisted thoracoscopy is not readily available, or if the patient refuses video-assisted thoracoscopy. The failure rate of chemical pleurodesis is approximately 25%. [22]

Secondary spontaneous pneumothorax


Patients with secondary spontaneous pneumothoraces are at greater risk of recurrences. Since many lung diseases occur bilaterally, these patients are typically at risk for contralateral secondary spontaneous pneumothoraces. [55] The intervention taken for a persistent air leak or a recurrent ipsilateral pneumothorax may depend on available resources.
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Anterior-posterior chest x-ray demonstrating a right pneumothorax From author's personal collection