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Pneumothorax

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Pneumothorax

  • Types
  1. Spontaneous Pneumothorax (Simple Pneumothorax)
  2. Open Pneumothorax
  3. Tension Pneumothorax
  4. Hemothorax
  • 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
  • Causes
  • Adults
  1. Blunt Chest Trauma
  2. Penetrating Chest Trauma
  3. Spontaneous Pneumothorax
  4. Iatrogenic Pneumothorax (secondary to medical procedure)
  • Risk Factors
  • Newborns (1-3% of births)
  1. Premature Infant
  2. Respiratory distress syndrome
  3. Meconium Aspiration Syndrome
  • Signs
  1. Decreased breath sounds
  2. Hyperresonance to percussion
  • Imaging
  1. Chest XRay (End expiratory film)
    1. See Pneumothorax Imaging
  2. Ultrasound
    1. See Lung Ultrasound for Pneumothorax (Sliding Lung Sign)
    2. Part of Extended FAST Exam
  • 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
  • Management
  1. Non-Traumatic Pneumothorax
    1. See Spontaneous Pneumothorax
  2. 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]
  • Management
  • Air travel after Pneumothorax
  1. Precautions
    1. Gas (including that in a Pneumothorax) expands up to 30% at 8000 feet of elevation (maximal pressurization of an airplane cabin)
    2. Partial pressure of oxygen decreases from FIO2 of 21% to 15% at typical flight altitude
      1. Results in hypobaric Hypoxia
      2. Healthy patients may decrease Oxygen Saturation from 99 to 92%
      3. COPD patients with Oxygen Saturation of 92% may drop to 80%
  2. Guidelines for return to air travel
    1. Current Pneumothorax is a contraindication to commerical airline flight
    2. Criteria to allow return to air travel following Pneumothorax in otherwise healthy patients
      1. End-expiratory Chest XRay demonstrates Pneumothorax resolution AND
      2. Patient waits additional time beyond resolution on XRay prior to travel
        1. Spontaneous Pneumothorax: 1 week after Chest XRay shows resolution
        2. Traumatic Pneumothorax: 2 weeks after Chest XRay shows resolution
    3. Criteria to allow return to air travel with underlying lung disease (e.g. COPD)
      1. Above criteria AND
      2. Pulmonology assessment (may include hypoxic chamber test) to determine safety for flight
  3. Management of suspected in flight Pneumothorax
    1. May present as Pleuritic Chest Pain and Dyspnea
    2. Apply Supplemental Oxygen
    3. Discuss with flight crew regarding descending to lower altitude and possible diversion
  4. References
    1. Jhun and Herbert in Herbert (2014) EM:Rap 14(6): 15
    2. British Thoracic Society Pneumothorax Guidelines
      1. MacDuff (2010) Thorax 65(Suppl 2):ii18-ii31 [PubMed]