Pneumothorax
last authored: April 2012, David LaPierre
last reviewed:
Introduction
The Case of Brent N.
Mr N. is a 27 year-old man who experiences worsening chest pain and shortness of breath after going for a run. His symptoms worsen over the next 30 min, and he travels to the emergency department, where a chest X-ray is done suggesting pneumothorax.
- how could this have happened?
- what treatments should be considered?
Causes and Risk Factors
Spontaneous (stretching and ripping of apical)
- primarily idiopathic
- tall, slender males ages 18-35
- first occurrence: 25% chance of recurrence
COPD
AIDS, CF, LAM
iatrogenic (central line, lung biopsy)
trauma: usually blunt or penetrating
Tension pneumothorax
- positive pressure ventilation following lung injury
Pathophysiology
The lung is normally adherent with the pleural space due to surface tension. Air entry into this space leads to lung collapse.
With entry of air into the pleural space, pleural pressure moves from -5 to 0 mmHg (I think) as the lungs collapse inward and the chest springs outward.
With a tension pneumothorax, decreased venous return and cardiac output leads to a compressed contralateral lung.
Signs and Symptoms
Pneumothorax can easily be a medical emergency. Do not delay on trivial details if the patient appears compromised.
- history
- physical exam
History
Ask brief questions regarding the history of presentation:
- mechanism
- pain
- shortness of breath
Physical Exam
Primary survey
Focus on the ABCs'
Airway:
- are they in respiratory distress? Can they talk?
Breathing (are they oxygenating?):
- level of consciousness
- cyanosis
- pulse oxymetry
- oxygen saturation
- auscultation of lung fields
Circulation:
- heart rate
- blood pressure
- peripheral pulses
Secondary survey
Head and neck:
- tracheal deviation
- cyanosis
Respiratory:
- decreased or absent breath sounds
- chest wall deformity, trauma
- subcutaneous emphysema
- chest wall expansion: symmetrical?
- tactile fremitus
- percussion: tympanic hemithorax
Cardiovascular:
- apex beat displaced
- distended neck veins
Investigations
- lab investigations
- diagnostic imaging
Lab Investigations
Diagnostic Imaging
Expiratory PA is the best CXR view
Differential Diagnosis
Treatments
Tension pneumothorax
Needle in 2nd intercostal space, mid clavicular line, followed by a chest tube in the fourth or fifth intercostal space, anterior to the midaxillary line.
Spontaneous
First occurrence:
- <20% - conservative
- >20% - chest tube with Heimlic valve
- surgery if bilateral, diver, flyer, isolated environment, third world travel, common in airline attendants
Second occurrence: surgery (often video-assisted VATS procedure)
Appreciate their perspective experiences when considering offering medications of any type. Some may choose Naturopathic approaches to prevention and treatments.
Consider patients experiences with working environments where smokers were present (ie: furniture moving company with co-workers who smoked pipes and cigars and other CO2 exhaled substances).
Consequences and Course
Resources and References
Topic Development
created:
authors: David LaPierre, Paul Brett Nissen
editors: Paul Brett Nissen
reviewers:
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