Pneumothorax

A collapsed lung, or pneumothorax, is the collection of air in the space around the
lungs. This buildup of air puts pressure on the lung, so it cannot expand as much as it
normally does when you take a breath.

Pneumothorax is defined as the presence of air or gas in the pleural cavity (ie, the potential
space between the visceral and parietal pleura of the lung). The clinical results are dependent
on the degree of collapse of the lung on the affected side. Pneumothorax can impair
oxygenation and/or ventilation. If the pneumothorax is significant, it can cause a shift of the
mediastinum and compromise hemodynamic stability. Air can enter the intrapleural space
through a communication from the chest wall (ie, trauma) or through the lung parenchyma
across the visceral pleura

A pneumothorax is a collection of free air in the chest cavity (thoracic cavity) that
causes the lung to collapse.

Pneumothorax may occur on its own in the absence of underlying disease; this is
termed spontaneous pneumothorax

A small spontaneous pneumothorax may resolve without treatment; a pneumothorax

arising as a result of lung disease or injury requires immediate treatment.

A collapsed lung refers to a condition in which the space between the wall of the chest cavity and the
lung itself fills with air, causing all or a portion of the lung to collapse. Air usually enters this space,
called the pleural space, through an injury to the chest wall or a hole in the lung. This result is called
a pneumothorax.

There are two types of pneumothorax, tension and simple.

Tension pneumothorax

 This refers to a condition in which air builds up under pressure and usually totally collapses one
or both of the lungs. This causes severe dysfunction of the cardiovascular system.

 The pressure built up in the lung cavity slows or stops the return of blood to the heart from the
veins. Because the heart has less blood available to pump into the main arteries, blood pressure
drops, and other vital organs are rapidly affected.

 In an affected person does not receive emergency treatment, death may result.

Simple pneumothorax

 In a simple pneumothorax, there is usually only partial collapse of a lung. The pressure built up in
the lung cavity is not enough to cause cardiovascular dysfunction.
 The collapsed lung may be severe enough to lead to decreased amounts of oxygen in the blood,
causing the patient to feel short of breath.

 This type of pneumothorax can be small and "stable", and not require emergency treatment.
However, the pneumothorax may slowly or rapidly progress to cause more severe cardiovascular
impairment and may often need to be monitored

Primary and secondary spontaneous pneumothorax

Spontaneous pneumothorax is a commonly encountered problem with approaches to treatment that
vary from observation to aggressive intervention. Primary spontaneous pneumothorax (PSP) occurs
in people without underlying lung disease and in the absence of an inciting event (see the images
below).[1] In other words, air enters into the intrapleural space without preceding trauma and without
an underlying history of clinical lung disease. However, many patients whose condition is labeled as
primary spontaneous pneumothorax have subclinical lung disease, such as pleural blebs, that can
be detected by CT scanning. Patients are typically aged 18-40 years, tall, thin, and, often, are
smokers.

Secondary spontaneous pneumothorax (SSP) occurs in people with a wide variety of parenchymal
lung diseases.[1] These individuals have underlying pulmonary pathology that alters normal lung
structure (see the image below). Air enters the pleural space via distended, damaged, or
compromised alveoli. The presentation of these patients may include more serious clinical
symptoms and sequelae due to comorbid conditions.

Iatrogenic and traumatic pneumothorax

Iatrogenic pneumothorax is a traumatic pneumothorax that results from injury to the pleura, with air
introduced into the pleural space secondary to diagnostic or therapeutic medical intervention (see
the following image). Half a century ago, iatrogenic pneumothorax was predominantly the result of
deliberate injection of air into the pleural space for the treatment of tuberculosis (TB). The
terminology evolved to the preference for "induced" or "artificial" pneumothorax to indicate
pulmonary TB treatment, before arriving at the current classification. Pulmonary TB remains a
significant cause of secondary pneumothorax.

Traumatic pneumothorax results from blunt trauma or penetrating trauma that disrupts the parietal
or visceral pleura (see the images below). Management steps for traumatic pneumothoraces are
similar to those for other, nontraumatic causes. If hemodynamic or respiratory status is
compromised or an open (communicating to the atmosphere) and/or hemothorax are also present,
tube thoracostomy is performed to evacuate air and allow re-expansion of the lung. There is a
subset of traumatic pneumothoraces classified as occult; that is, they cannot be seen on chest
radiographs but can be seen on CT scans. In general, these can be observed and treated if they
become symptomatic.

Tension pneumothorax
A tension pneumothorax is a life-threatening condition that develops when air is trapped in the
pleural cavity under positive pressure, displacing mediastinal structures and compromising
cardiopulmonary function. Prompt recognition of this condition is life saving, both outside the hospital
and in a modern ICU. Because tension pneumothorax occurs infrequently and has a potentially
 devastating outcome, a high index of suspicion and knowledge of basic emergency thoracic
decompression procedures are important for all healthcare personnel. Immediate decompression of
the thorax is mandatory when tension pneumothorax is suspected. This should not be delayed for
radiographic confirmation.

Pneumomediastinum
Pneumomediastinum is the presence of gas in the mediastinal tissues occurring spontaneously or
following procedures or trauma (see the following images). A pneumothorax may occur secondary to
pneumomediastinum.

What are the types of pneumothorax?

A spontaneous pneumothorax, also referred to as a primary pneumothorax, occurs in

the absence of a traumatic injury to the chest or a known lung disease. A secondary
(also termed complicated) pneumothorax occurs as a result of an underlying condition.

Collapsed Lung Causes

The primary cause of a pneumothorax is trauma to the chest cavity. A fractured rib, for example,
could puncture the lung. In addition, penetrating trauma from a bullet, knife, or other sharp object
can directly puncture the lung.

Sometimes, very tall, thin people are prone to a spontaneous pneumothorax. In this condition, the
lung collapses after minimal or no trauma. Other risk factors are cigarette smoking and recreational
drug use or abuse.

Spontaneous pneumothorax

 This refers to a condition in which the lung collapses with no apparent injury or trauma.

 Abnormal, small, air-filled sacs in the lung called "blebs" typically rupture and leak air into the
pleural space, leading to the spontaneous pneumothorax. This happens in the cases of tall and
thin people, who because of the shape of their lungs and chest cavity, are seemingly more prone
to these defects.

 Shortness of breath and sharp, stabbingchest pain develop in apparently healthy people.

 Cigarette smokers are at greater risk for spontaneous pneumothorax.

 Recreational drug users who inhale deeply and forcefully are also at greater risk.

Traumatic pneumothorax

 Direct trauma to the chest wall from either blunt or penetrating trauma causes this condition.
 Trauma can also result from diagnostic or therapeutic medical procedures, such as needle
aspiration of fluid from the pleural space, a lung biopsy, or insertion of a large IV catheter into a
vein near the neck.

Disease-related pneumothorax can occur due to abnormalities in the lung tissue.

 A collapsed lung can arise as a complication of the following conditions:

o Asthma

o Cystic fibrosis

o Chronic obstructive pulmonary disease (COPD), for example,emphysema or

chronic bronchitis

o Pneumocystis carinii pneumonia (PCP), an opportunistic infection of the lungs often seen in
people with AIDS

Causes, incidence, and risk factors

A collapsed lung occurs when air escapes from the lung and fills up the space outside
of the lung, inside the chest. It may be caused by a gunshot or knife wound to the chest,
rib fracture, or certain medical procedures.
In some cases, a collapsed lung occurs without any cause. This is called a spontaneous
pneumothorax. A small area in the lung that is filled with air, called a bleb, can rupture,
sending air into the space around the lung.
Tall, thin people are more likely to have a collapsed lung.
Lung diseases such as COPD, asthma, cystic fibrosis, tuberculosis, and whooping
cough also increase your risk for a collapsed lung.

The lungs normally inflate by increasing the size of the chest cavity, resulting in a
negative (vacuum) pressure in the pleural space (the area within the chest cavity but
outside the lungs). If air enters the pleural space either by a hole in the lung or the chest
wall, the pressure in the pleural space equals the pressure outside the body. Thus, the
vacuum is lost and the lung collapses.

Spontaneous pneumothorax is caused by a rupture of a cyst or a small sac (bleb) on

the surface of the lung. Pneumothorax may also occur following an injury to the chest
wall such as a fractured rib, any penetrating injury (gun shot or stabbing), surgical
invasion of the chest, or may be deliberately induced in order to collapse the lung. A
pneumothorax can also develop as a result of underlying lung diseases, including cystic
 fibrosis, chronic obstructive pulmonary disease (COPD), lung cancer, asthma, and
infections of the lungs.

Symptoms
Common symptoms of a collapsed lung include:
 Sharp chest pain, made worse by a deep breath or a cough
 Shortness of breath
A larger pneumothorax will cause more severe symptoms, including:
 Chest tightness
 Easy fatigue
 Rapid heart rate
 Bluish color of the skin caused by lack of oxygen
Other symptoms that can occur with a collapsed lung include:
 Nasal flaring
 Low blood pressure (hypotension)

Collapsed Lung Symptoms

 Sharp, stabbing chest pain that worsens on breathing or with deep inspiration. This is referred to
as "pleuritic" because it comes from irritation of nerve endings in the pleura (inner lining of the rib
wall). Interestingly, the lung tissue itself does not contain pain-sensing nerve endings.

 Pain often radiates to the shoulder and or back

 A dry, hacking cough may occur because of irritation of the diaphragm.

 If a tension pneumothorax is present, signs of cardiovascular collapse and shock will occur. This
is immediately life threatening.

o The large veins in the neck may stick out, or the skin may be a bluish color because of lack of
oxygen (calledcyanosis). The pulse may be rapid and the blood pressure decreased. The
person appears quite anxious and may have difficulty speaking. If untreated for more than
several minutes, loss of consciousness, shock, and death occur.

Signs and tests

There are decreased or no breath sounds on the affected side when heard through a
stethoscope.
Tests include:
  Chest x-ray
 Arterial blood gases

Exams and Tests

 Examination of the chest by listening with a stethoscope and tapping techniques can suggest
pneumothorax. If a tension pneumothorax is present, the signs that can occur are as follows:

o The blood pressure will fall as the result of decreased heart output.

o Cyanosis or blueness of the skin will occur as the tissues lose their oxygen.

o Decreased levels of consciousness may occur because of the low blood pressure, decreased
brain perfusion, and low oxygenation.
 Definitive diagnosis is made with chest x-rays.

o A very small pneumothorax can be missed on routine chest x-ray.

o The doctor may take multiple films, including x-rays in full expiration, or even a CT scan of the
chest, to look for a collapsed lung

Treatment
A small pneumothorax may go away on its own. You may only need oxygen and rest.
The health care provider may use a needle to pull the extra air out from around the lung
so it can expand more fully. You may be allowed to go home if you live near the
hospital.
If you have a large pneumothorax, a chest tube will be placed between the ribs into the
space around the lungs to help drain the air and allows the lung to re-expand.
The chest tube can be left in place for several days. You may need to stay in the
hospital. However, you may be able to go home if a small chest tube is used.
Some patients with a collapsed lung need extra oxygen.
Lung surgery may be needed to treat your pneumothorax or to prevent future episodes.
The area where the leak occurred may be repaired. Sometimes, a special chemical is
placed into the area of the collapsed lung. This chemical causes a scar to form.

A small pneumothorax without underlying lung disease may resolve on its own in one to two
weeks. A larger pneumothorax and a pneumothorax associated with underlying lung
disease often require aspiration of the free air and/or placement of a chest tube to evacuate
the air. Possible complications of chest tube insertion include pain, infection of the space
between the lung and chest wall (the pleural space), hemorrhage (bleeding), fluid
 accumulation in the lung, and low blood pressure (hypotension). In some cases, the leak
does not close on its own. This is called a bronchopleural fistula, and may require chest
surgery to repair the hole in the lung

Medical Treatment
Tension pneumothorax

 A tension pneumothorax is treated with emergency removal of air under pressure, by inserting a
needle attached to a syringe into the chest cavity. If needle decompression is performed before
the person gets to the emergency department, transport to the nearest hospital is necessary.

 Definitive treatment involves placing a plastic tube ("chest tube") within the chest cavity, through a
small incision near the armpit, under suction and water seal. This chest tube may need to stay in
place for a few days before it can be removed.

Simple pneumothorax

 A simple pneumothorax often is treated in a similar fashion to the tension pneumothorax with a
chest tube and admission to the hospital.

 If the simple pneumothorax is small, and not expanding, the doctor may try various inhalation
techniques with 100% oxygen to cause spontaneous re-expansion of the collapsed lung
segment.

 A small catheter can be placed in the chest and the air removed via suction techniques with a
syringe and a 3-way stopcock.

 After multiple collapsed lungs or persistent collapse, chemical or surgical adhesion of the lung to
the chest wall (called pleurodesis) may be necessary and is performed by a pulmonary specialist