Pneumothorax

Aka: Pneumothorax

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II. Types

  1. Spontaneous Pneumothorax (Simple Pneumothorax)
  2. Open Pneumothorax
  3. Tension Pneumothorax
  4. Hemothorax

III. Pathophysiology

  1. Air enters potential space between the visceral pleura and the parietal pleura
  2. Tension Pneumothorax may result
    1. Air accumulates in the pleural space with each breath taken
    2. Pressure compresses the lung tissue and inhibits venous return with secondary decreased Cardiac Output

IV. Causes: Adults

  1. Blunt Chest Trauma
    1. Most common cause of sports-related Pneumothorax
    2. Consider other concurrent injuries (e.g. Pulmonary Contusion)
  2. Penetrating Chest Trauma
  3. Spontaneous Pneumothorax
  4. Iatrogenic Pneumothorax (secondary to medical procedure)

V. Risk Factors: Newborns (1-3% of births)

  1. Premature Infant
  2. Respiratory distress syndrome
  3. Meconium Aspiration Syndrome

VI. Signs

  1. See Spontaneous Pneumothorax (Simple Pneumothorax)
  2. See Open Pneumothorax
  3. See Tension Pneumothorax
  4. Decreased breath sounds
  5. Hyperresonance to percussion

VII. Imaging

  1. See Pneumothorax Imaging
  2. Chest XRay
    1. Upright and end expiratory films are preferred
    2. Supine Chest XRay is unreliable and likely to yield a False Negative study
    3. Even large pneumothoraces on CT may be missed on Chest XRay
      1. Rodriguez (2019) Ann Emerg Med 73(1):58-65 +PMID:30287121 [PubMed]
  3. Ultrasound
    1. See Lung Ultrasound for Pneumothorax (Sliding Lung Sign)
    2. Part of Extended FAST Exam
  4. Chest CT
    1. See Nexus Chest CT Decision Rule in Blunt Trauma
    2. Gold standard in Pneumothorax
    3. Indicated where Chest XRay cannot distinguish bleb in COPD from Pneumothorax
    4. Identifies associated Traumatic Injury (e.g. multiple contiguous Rib Fractures)

VIII. Precautions

  1. Until a Chest Tube is placed, Tension Pneumothorax is a risk
  2. Do not perform Positive Pressure Ventilation, general Anesthesia or air transport until Pneumothorax decompression
  3. Consider Esophageal Rupture in the injured patient with a left Pneumothorax or Hemothorax without a Rib Fracture

IX. Management

  1. See Trauma Evaluation
  2. See Spontaneous Pneumothorax (includes disposition and restrictions)
  3. See Tension Pneumothorax
  4. See Open Pneumothorax
  5. See Hemothorax
  6. Non-Traumatic Pneumothorax
    1. See Spontaneous Pneumothorax
  7. Traumatic Pneumothorax
    1. Chest Tube at 4-5th intercostal space at the mid-axillary line
      1. Confirm Chest Tube placement with Chest XRay
    2. Outside of Hemothorax (and hemopneumothorax), Small Caliber Chest Tubes appear safe in uncomplicated Traumatic Pneumothorax
      1. Small Caliber Chest Tubes are as effective and significantly less painful than standard Chest Tubes in Pneumothorax
      2. Kulvatunyou (2014) Br J Surg 101(2): 17-22 [PubMed]

X. Complications

  1. Tension Pneumothorax

XI. References

  1. Noppen (2003) Respiration 70(4): 431-8 [PubMed]
  2. Majoewsky (2012) EM:RAPC3 2(2): 3-4
  3. Tranchell (2013) Crit Dec Emerg Med 27(7): 11-8

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