Pneumothorax: Definition, Causes, Symptoms, Diagnosis, Treatment
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SAVE TIME studying with your own copy of the lecture below! Example x-rays, simple explanations, and memory tricks included!
Example Case
A male patient presents 1 hour after developing pleuritic chest pain and shortness of breath. The patient states he had finished running errands, and upon his return home he developed sudden onset chest pain associated with dyspnea.
He denies previous chest pain but reports a history of COPD and smoking. He denies fevers, recent upper respiratory infections, cough, abdominal pain, nausea, or vomiting.
EKG does not show any signs of STEMI or acute ischemia. Blood work is overall unremarkable. Chest X-ray shows a right sided pneumothorax.
Pneumothorax Definition
There are many conditions that can cause chest pain or shortness of breath, one of which is a pneumothorax.
A pneumothorax is an abnormal collection of air in the pleural space, which is the space between the lung and chest wall.
An abnormal accumulation of air in the pleural space can result in the partial or complete collapse of a lung.
A pneumothorax is often referred to as a “collapsed lung”.
However, the lung does not have to be completely “collapsed” in order for there to be a pneumothorax.
Furthermore, the lung can collapse for reasons other than a pneumothorax.
This lecture will walk you through the main points of a pneumothorax including:
Definition
Types
Causes
Symptoms
Diagnosis
Treatment
As with every EZmed lecture, you will be given memory tricks to help you remember the content.
Today you will learn how to use one of the abbreviations for a pneumothorax (“PT”) to remember pneumothorax types, signs and symptoms, diagnosis, and treatment.
So let’s get right into it!
Chest x-ray of a right-sided pneumothorax. Note the absence of lung markings to the chest wall beyond the lung border.
Pneumothorax: Types and Causes
There are 2 main types of pneumothoraces:
Spontaneous
Traumatic
Spontaneous pneumothoraces can be broken down even further into primary or secondary:
Spontaneous
Primary
Secondary
Traumatic
A tension pneumothorax can develop from any type of pneumothorax (spontaneous or traumatic).
Spontaneous
Primary
Secondary
Traumatic
Tension (Can develop from any type of pneumothorax)
Let’s walk through each type below!
1. Spontaneous Pneumothorax
The first type of pneumothorax is a spontaneous pneumothorax.
As the name suggests, a spontaneous pneumothorax occurs spontaneously without any trauma.
A spontaneous pneumothorax develops when there is a hole in the lung parenchyma or bronchial tree, which can lead to air entering the pleural space.
There are 2 types of spontaneous pneumothoraces depending on the presence or absence of underlying lung disease:
Primary (Lung Disease Absent)
Secondary (Lung Disease Present)
Let’s look at the difference between a primary and secondary spontaneous pneumothorax.
1a. Primary Spontaneous Pneumothorax
A primary spontaneous pneumothorax is a spontaneous pneumothorax in an individual who has no underlying lung disease.
They typically occur in thin, young adults (males > females).
Risk factors for a primary spontaneous pneumothorax include:
Family History
Smoking History
Males
Hereditary conditions and connective tissue disorders (Marfan syndrome, Ehlers-Danlos syndrome, etc.) can predispose a patient to a spontaneous pneumothorax as well.
1b. Secondary Spontaneous Pneumothorax
A secondary spontaneous pneumothorax is a spontaneous pneumothorax in an individual with underlying lung pathology or disease (COPD, asthma, cystic fibrosis, malignancy, etc.).
The symptoms of a secondary spontaneous pneumothorax tend to be more severe than a primary.
The reason for this is because the unaffected lung is already impaired by the underlying lung disease.
Therefore, the patient may have a harder time compensating for the pneumothorax on the other side.
The patient’s symptoms may be more severe as a result, and the patient may experience greater levels of hypoxemia (low blood oxygen levels) and/or hypercapnia (high carbon dioxide blood levels).
**Of note, a primarily spontaneous pneumothorax can still be symptomatic and severe as well.
2. Traumatic Pneumothorax
The second major type of pneumothorax is a traumatic pneumothorax.
A traumatic pneumothorax (as the name suggests) is secondary to a traumatic event.
Penetrating trauma, such as a gunshot wound or stabbing, may result in external air entering the chest wall cavity and pleural space.
Blunt trauma, esophageal rupture, and tracheobronchial tree rupture are other possible forms of traumatic pneumothoraces.
A traumatic pneumothorax can be caused by iatrogenic trauma as well.
Iatrogenic causes may include central line placement, mechanical ventilator barotrauma, endoscopic esophageal rupture, etc.
3. Tension Pneumothorax
The final type of pneumothorax is a tension pneumothorax.
A tension pneumothorax may develop from a spontaneous or traumatic pneumothorax.
A tension pneumothorax occurs when there is a one-way valve that allows air to enter the pleural space but not exit.
This can lead to increased intrathoracic pressure and near collapse of the lung.
As the volume of air increases within the pleural space, it can exert pressure on the heart and vasculature.
The increased intrathoracic pressure can lead to compromise of venous return, which can negatively impact stroke volume, cardiac output, and blood pressure.
This can lead to a type of shock known as obstructive shock.
A tension pneumothorax can also cause tracheal deviation away from the affected side.
Memory Trick
One of the abbreviations for a pneumothorax is “PT”.
You can use this abbreviation to remember the different types of pneumothoraces.
The “PT” abbreviation for types of pneumothoraces:
P = Primary and Secondary Spontaneous
T = Traumatic/Tension
Pneumothorax Signs and Symptoms
Pleuritic chest pain and shortness of breath (dyspnea) are the most common symptoms of a pneumothorax.
Other less common symptoms include cough and fever.
Signs of a pneumothorax may include tachycardia, tachypnea, hypotension, or hypoxia/hypoxemia.
There may be diminished breath sounds on the affected side, and hyperresonance to percussion may be present.
A tension pneumothorax may also result in tracheal deviation and/or jugular venous distension.
Memory Trick
We can again use the abbreviation “PT” to remember the signs and symptoms of a pneumothorax.
The “PT” abbreviation for symptoms of a pneumothorax:
P = Pleuritic Chest Pain
T = Trouble Breathing (Shortness of Breath)
The “PT” abbreviation for signs of a pneumothorax:
P = PO2 Low (Hypoxemia)/Pressure Low (Hypotension)
T = Tachypnea/Tachycardia/Tracheal Deviation
Chest x-ray showing a left-sided tension pneumothorax with tracheal deviation to the right.
Pneumothorax Diagnosis
A pneumothorax can be diagnosed using several different imaging modalities.
Chest X-Ray
First, a pneumothorax can be diagnosed with a chest x-ray.
The chest x-ray may show decreased lung markings extending to the chest wall, and the lung border may be visible.
CT Scan
While a CT scan of the chest is not always necessary, it can diagnose a pneumothorax as well.
A CT can be more accurate than a chest x-ray, especially for diagnosing a small pneumothorax.
A CT scan may also be necessary to better evaluate underlying lung pathology.
Ultrasound
A pneumothorax can be diagnosed using ultrasound as well.
The absence of lung sliding on ultrasound could indicate a pneumothorax.
When ultrasound is on M-mode, a normal lung will have a “sandy beach” appearance whereas a pneumothorax may have a “bar-code” sign.
**Important: A tension pneumothorax can be diagnosed clinically without imaging, and should be considered in a trauma patient with dyspnea, hypoxia, respiratory distress, and hemodynamic instability.
Memory Trick
Let’s again use the “PT” abbreviation to remember how to diagnose a pneumothorax.
The “PT” abbreviation for diagnosing a pneumothorax:
P = Pulmonary Ultrasound
T = Thoracic X-Ray or CT
Chest x-ray and CT both showing a right-sided pneumothorax.
Pneumothorax Treatment
The initial management includes assessing the patient’s airway, breathing, and circulation.
Vital signs should be obtained, and an EKG should be performed on arrival.
The patient should only be intubated if absolutely necessary, as mechanical ventilation may lead to increased intrathoracic pressure and worsening of the pneumothorax.
The treatment of a pneumothorax includes administration of supplemental oxygen.
Administration of 100% oxygen can increase the rate of pleural air reabsorption.
A patient with a small primary spontaneous pneumothorax, who is relatively asymptomatic, may only require supplemental oxygen without further intervention.
If the patient’s symptoms are improved on reassessment after observation, and the pneumothorax is improved on repeat chest x-ray, then the patient could potentially be discharged without requiring hospital admission.
Larger primary pneumothoraces, symptomatic pneumothoraces, and most secondary and traumatic pneumothoraces may require a chest tube in addition to supplemental oxygen.
The chest tube (thoracostomy) should be placed in the 4th-5th intercostal space in the mid/anterior axillary line.
The chest tube can be connected to a drainage device with water seal hooked to suction.
Both a tension pneumothorax and a patient with unstable vital signs may require more immediate treatment with needle decompression in the 2nd intercostal space at the mid-clavicular line.
Finally, persistent air leak into the pleural space may require surgical evaluation.
Recurrent pneumothoraces may benefit from pleurodesis (sticking the parietal and visceral pleural layers together).
Memory Trick
We can again use the “PT” abbreviation to remember the treatment of a pneumothorax.
The “PT” abbreviation for treating a pneumothorax:
P = PO2 (Oxygen), Pleurodesis
T = Tube Thoracostomy (Chest Tube)
Chest x-ray showing a right-sided chest tube in place.
Summary
Hopefully this provided you with a better understanding of what a pneumothorax is, the signs and symptoms of one, and how to best diagnose and manage one.
There are spontaneous (primary - no underlying lung disease; secondary - underlying lung disease present) and traumatic pneumothoraces.
A tension pneumothorax can occur if there is a one-way valve allowing air to enter the pleural space but not exit. This is an emergency.
The most common symptoms include pleuritic chest pain and shortness of breath.
Signs may include tachycardia, tachypnea, hypoxia, respiratory distress, and/or hemodynamic instability.
Diagnosis is typically made using a chest x-ray, but can also be diagnosed using a CT chest or thoracic ultrasound.
Management includes any combination of oxygen administration, needle decompression, chest tube placement, surgical evaluation, and/or pleurodesis.
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