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Anorexia nervosa is thought to be a risk
BASIC INFORMATION factor due to pulmonary parenchymal conse- DIAGNOSIS P
quences of malnutrition.
DEFINITION Established by the chest x-ray (Fig. P1-50).
A spontaneous pneumothorax (SP) is defined PHYSICAL FINDINGS & CLINICAL
as the accumulation of air into the pleural PRESENTATION DIFFERENTIAL DIAGNOSIS
space, collapsing the lung without a precipitat- Sudden onset of pleuritic chest pain (90%), Pleurisy.
ing event. This can be primary SP (without any usually at rest, which often becomes dull Pulmonary embolism.
obvious underlying lung disease) or secondary after a few hours. Myocardial infarction.
SP (with underlying lung disease). Pain is usually unilateral and can be sharp Pericarditis.
and agonizing and associated with consider- Asthma.
SYNONYMS able apprehension. Pneumonia.
Primary spontaneous pneumothorax Dyspnea (80%), which often resolves within
and Disorders
Diseases
Secondary spontaneous pneumothorax 24 hr, despite persistence of pneumothorax.
Cough (10%).
ICD-9CM CODES Asymptomatic (5%); may take up to 7 days to
512.0SSpontaneous tension pneumothorax come to medical attention.
512.8Other spontaneous pneumothorax Tachycardia.
ICD-10CM CODES
J93.83 Other pneumothorax
Hypoxemia.
Hypercapnia is rare because the alveolar venti- I
J93.9Pneumothorax, unspecified lation is maintained by the contralateral lung.
Decreased chest excursion on the affected
side.
EPIDEMIOLOGY & Diminished breath sounds.
DEMOGRAPHICS Subcutaneous emphysema may be present.
Approximately 20,000 new cases of SP occur Hyperresonance on percussion.
each year in the United States.
SP is more common in men than women ETIOLOGY
(6:1). In primary SP, rupture of small blebs, usually
Incidence of primary SP is 7.4 per 100,000 in located near the apex of the upper lobes, is a
men and 1.2 per 100,000 in women. common cause. The check-valve mechanism
Incidence of secondary SP is 6.3 per 100,000 is uncommon in this case; therefore, tension FIGURE P1-50 Chest radiograph shows right
in men and 2.0 per 100,000 in women. pneumothorax rarely occurs. hydropneumothorax.Horizontal line in lower
SP is commonly seen in tall, thin young men In secondary SP, chronic obstructive pulmo- right hemithorax is interface between air and liquid
aged 20 to 40 yr. nary disease is the most common cause, but in pleural space. Arrows point to visceral pleura
Risk factors include smoking, family history, it can also be associated with pneumonia, above level of effusion. There is air in pleural space
Marfans syndrome, homocystinuria, and tho- bronchogenic carcinoma, mesothelioma, sar- between visceral pleura and chest wall. (From
racic endometriosis. coidosis, tuberculosis, cystic fibrosis, and Weinberg SE etal: Principles of pulmonary medicine,
many other lung diseases (Fig. P1-49). ed 5, Philadelphia, 2008, Saunders.)
Normal lung
markings Absence
extend to of lung
periphery markings
of thorax
Pleural
line
A B
FIGURE P1-49 Pneumothorax. A, Schematic of normal lung. B, Schematic of pneumothorax. Pneumothoraces can range in size from tiny to massive. Because of
the variability in their size and location, pneumothoraces can be difficult to detect on chest x-ray. For example, a pneumothorax that is anterior or posterior rather than
lateral may be hidden on frontal chest x-ray, particularly one taken in the supine position. An upright chest x-ray should be obtained if possible. An expiratory film is
thought to be more sensitive, because the lung and thorax decrease in size during expiration, but air trapped in the pleural space remains the same size and thus appears
relatively larger. Subtle pneumothoraces may not be visible on chest x-ray. In some cases, subcutaneous air may be the only visible clue to underlying lung injury. CT is
extremely sensitive for pneumothorax, although controversy remains over the proper management of pneumothoraces seen only on CT. Ultrasound is also thought to be
more sensitive than chest x-ray for detection of pneumothorax, although, again, the management of pneumothorax seen only on ultrasound is uncertain because this
is a relatively newly described method of detection. The chest x-ray findings of pneumothorax include a lack of the normal lung markings, which should be visible to
the periphery of the chest wall. Sometimes a line marking the boundary of the lung and visceral pleura is visible, although this can be confused with ribs and with the
medial margin of the scapula. Depending on the degree of pneumothorax and lung collapse, the lung parenchyma may appear denser than the opposite side. In extreme
cases of tension pneumothorax, the pressure exerted by the air in the pleural space may begin to displace other structures, including the diaphragm and mediastinum.
In tension pneumothorax, the hyperinflated hemithorax may also have abnormally positioned ribs, with a position more horizontal than usual. (From Broder JS: Diagnostic
imaging for the emergency physician, Philadelphia, 2011, Saunders.)
PREVENTION
Approximately 25% to 50% of patients with
primary SP with have a recurrence within 1 yr.
Multiple techniques have been used to pre-
vent recurrence, including intrapleural instil-
lation of sclerosing agents, pleurectomy,
laser abrasion of parietal pleura, and pleural
abrasion with dry gauze.
The current recommended approach is the use
of video-assisted thoracoscopy (VATS) with an
aim to excise the associated bullae or perform
guided pleurodesis or treatment. Most pulmo-
nologists recommend definitive management
after the first recurrence. However, high-risk
occupations such as divers or pilots should
be considered for surgery after their first
pneumothorax. Similarly, complex conditions
such as patients with persistent bronchopleu-
ral fistula suggested by a persistent air leak
from the chest tube should also be considered
for VATS and early surgical intervention. The
overall recurrence rate is estimated at <5%
after VATS.
The recurrence rates for the instillation of
sclerosing agents (minocycline 5 mg/kg in
50 ml of normal saline or doxycycline 500 mg
in 50 ml of normal saline) are higher than
for VATS-guided therapy (<25%). Therefore
this mode of therapy should be reserved for
FIGURE P1-51 Tension pneumothorax.On this PA chest radiograph, the left hemithorax is very dark patients who are poor surgical candidates.
or lucent because the left lung has collapsed completely (white arrows). The tension pneumothorax can be Talc has also been used as a sclerosing agent
identified by the fact that the mediastinal contents, including the heart, are shifted toward the right (black with favorable results; however, concerns
arrows), and the left hemidiaphragm is flattened and depressed. (From Mettler FA etal: Primary care radiology, persist due to case reports describing acute
Philadelphia, 2000, Elsevier.)
Spontaneous pneumothorax
P
Yes
Signs of tension PTX Immediate
decompression
No Yes
and Disorders
Diseases
Primary pneumothorax Secondary pneumothorax
Yes No Yes No
I
Observation for 3 hours Simple small (14-16 g) Intrapleural space Small (14 Fr)
Repeat CXR catheter aspiration at level of hilum? percutaneous chest
Follow-up in tube to water seal
24-48 hours Admit
Less than
Successful Unsuccessful 1 cm 1-2 cm
Unsuccessful
If discharged with Small (14 Fr) Consider observation Simple small (14-16 g)
Heimlich valve, percutaneous chest versus catheter aspiration
follow-up in tube to water seal simple small
48-72 hours Admit (14-16 g)
Or admit catheter aspiration
Successful
Admit
SUGGESTED READINGS
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in patients with anorexia nervosa: A case report and review of the literature,
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Noppen M etal.: Music: a new cause of primary spontaneous pneumothorax,
Thorax 59(8):722, 2004.
Sahn SA, Heffner JE: Spontaneous pneumothorax, N Engl J Med 342:868, 2000.
Wakai A: Spontaneous pneumothorax, Clin Evid 13:2005, 1884.
FIGURE EP1-52 Chest radiograph showing left pneumothorax with shift of the mediastinum and trachea to the right side (white arrows). The left lung is not completely
collapsed, suggesting the presence of a loculated tension pneumothorax. (From Siu Wa Chan, S: Tension pneumothorax managed without immediate needle decompres-
sion, Am J Emerg Med 36(3):242-245, 2009.