Pneumothorax

Epidemiology
Incidence of primary pneumothorax 24/100 000 (men), 9.9/100 000
(women) per year.
Primary pneumothorax rarely occurs over the age of 40.
Secondary pneumothorax typically occurs between the age of 60 and 65.
Definition:
Air in the pleural space; leading to partial or complete collapse of lungs.
Occurs spontaneously or secondary to chest trauma.
Tension Pneumothorax
Rare, unless patient is on mechanical ventilation or nasal noninvasive ventilation.
Pleural tear acts as one-way valve air passes during inspiration but
unable to exit in expiration.
Leading to
Unilateral increase in intrapleural pressure
Increasing respiratory distress
Eventually shock and cardiorespiratory arrest.
Treatment
o Immediate decompression needle thoracocentesis (2 nd
intercostal space, mid clavicular line) and then intercostal tube.
Aetiology:
Spontaneous
o Typically in young men (usually tall and thin)
o As a result of rupture of pleural bleb due to a congenital defect in
alveolar wall connective tissue.
Secondary
o Associated with underlying lung disease, usually COPD.
Asthma, TB, pneumonia, lung abscess, carcinoma, CF, etc.
Others
Iatrogenic
o Subclavian CVP line insertion, pleural aspiration or biopsy,
transbronchial biopsy, percutaneous liver biopsy, positive pressure
ventilation.
Traumatic
o Penetrating chest trauma (e.g. stab wound).
Catamenial

o Pneumothorax at the time of menstruation underlying aetiology of

endomteriosis.
Pneumothorax vs Tension Pneumothorax
Pneumothorax
Tension Pneumothorax
Air in pleural space, volume
Air in pleural space, NO increase
CONTINUES to increase.
in volume.
On CXR
On CXR
Trachea may be DEVIATED
NO trachea deviation.
away from the side of
Lung collapse may be visible
pneumothorax.
(sometimes subtle decreased
Lung collapse likely to be more
vascular marking around the
obvious.
outer lung field)
Clinical features

Symptoms
May be asymptomatic (especially if fit, young and small pneumothorax).
Sudden onset of dyspnoea and/or pleuritic chest pain.
Patients with asthma or COPD
o Sudden deterioration.
Mechanically ventilated patients
o Hypoxia
o Increase in ventilation pressures.
Signs
Reduced expansion.
Hyper-resonance to percussion and diminished breath sounds on affected
side.

Investigations:
Standard PA CXR confirms diagnosis.
CT scan
o In patients with severe bullous lung disease differentiate
emphysematous bullae from pneumothoraces.
o Detect small pneumothoraces; cant be detected on CXR.

 Visible visceral-pleural edge

(blue arrow)
Lung markings not visible
beyond this edge.
Patient info fall from height.
Diagnosis
Large left pneumothorax due
to rib fracture.

Complications
Tension pneumothorax
o Presents with signs of respiratory distress, tachycardia, anxiety,
dyspnoea, and chest pain.
o Occasionally, rapidly becomes hypotensive, with peripheral cyanosis
and tracheal deviation.
Management:

Management of secondary pneumothoraces differs in four aspects:

Patients remain in hospital
Attempt aspiration only in minimally breathless patients, <50 years old
with small pneumothoraces.
Chest drain insertion indicated in all other patients.
Oxygen given via fixed-performance mask to patients with COPD.

Indications for surgical referral

Persistent air leaks
Recurrent pneumothorax and after a first pneumothorax in at-risk
professions (pilots, divers)
Smoking cessation reduces recurrence rate.
Patients are advised not to fly for 2 weeks after successful treatment of
pneumothorax.
Prognosis:
Death is rare; but recurrence rate is high.
Secondary pneumothorax is associated with higher morbidity and mortality
than primary pneumothorax.
Risk factors for recurrence
Primary Pneumothorax
Smoking, height and age over 60
years.

Secondary Pneumothorax
Age, pulmonary fibrosis and
emphysema.