Pneumothorax Disease

DESCRIPTION

Accumulation of air or gas between the parietal and visceral pleurae.

Spontaneous pneumothorax - may be primary or secondary
- Primary in young and otherwise healthy patients
- Secondary - as a complication of an underlying lung disease
Traumatic pneumothorax - may coexist with hemothorax
Tension pneumothorax - the air in the pleural space is under higher pressure than air in adjacent lung and vascular structures
System(s) affected: Pulmonary, Cardiovascular
Genetics: No known genetic pattern, possible congenital predisposition in thin, tall young men
Incidence/Prevalence in USA: 9/100,000
Predominant age: Adults 20-40 years
Predominant sex: Male > Female

SIGNS AND SYMPTOMS

Chest pain, sudden, sharp, made worse by breathing, coughing or moving the chest
Chest movements - asymmetrical
Dyspnea
Cyanosis (sometimes)
Moderate to severe - profound respiratory distress
Tension pneumothorax - weak, rapid pulse, pallor, neck vein distension, anxiety, tracheal deviation
Shock
Circulatory collapse
Diminished breath sounds and voice sounds

CAUSES

Perforation of the visceral pleura and entry of gas from the lung
Gas generated by microorganisms in an empyema
Penetration of the chest wall, diaphragm, mediastinum, or esophagus
Blunt trauma to thorax

RISK FACTORS

Trauma (broken rib, ruptured bronchus, perforated esophagus)
Rupture of superficial lung bulla following cough or blowing a musical instrument
Vigorous or stretching exercises
Flying (high altitude) after loss of pressurization
Diving (at ascension or rapid decompression)
Pneumoconioses
Tuberculosis
Pneumonia due to TB, Klebsiella, Staph aureus
Subpleural Pneumocystis carinii pneumonia (PCP) (in AIDS patients on PCP prophylaxis via pentamidine aerosol)
Bronchial obstruction
COPD (particularly emphysema)
Asthma
Neoplasms
Endometriosis (during menstruation)
Rare diseases (Marfan's, Ehlers-Danlos)
Rupture of an infected abscess
Lymphangioleiomyomatosis
Cystic fibrosis
Cigarette smoking
Intubation ventilation

LABORATORY

Arterial blood gases in significant pneumothorax
- pH < 7.35
- pO2 < 80 mm Hg (10.6 kPa)
- pCO2 > 45 mm Hg (6.0 kPa)

Drugs that may alter lab results: N/A
Disorders that may alter lab results: N/A

PATHOLOGICAL FINDINGS

N/A

SPECIAL TESTS

N/A

IMAGING

Chest x-ray:
- Air without lung markings peripherally, mediastinal shift to contralateral side
- Small pneumothorax may be evident only with expiratory or lateral decubitus film

DIAGNOSTIC PROCEDURES

Careful history and physical. The physical findings depend on size of pneumothorax.

APPROPRIATE HEALTH CARE

Outpatient - lung collapse less than 30%, no dyspnea, no signs of tension pneumothorax, no underlying lung disease
Inpatient - if more than 30% collapse, tension or underlying lung disease

GENERAL MEASURES

Outpatient
- Bed rest
- Monitoring blood pressure, pulse rate, respirations
- Oxygen at high concentration will accelerate rate of absorption by 4 times
- Treatment of any underlying condition

SURGICAL MEASURES

Inpatient
- Simple aspiration - insert 16 gauge cannula into 2nd anterior intercostal space at midclavicular line and attach a 3-way stopcock and 60 mL syringe. Withdraw air manually until no more can be aspirated.
- Thoracotomy tube - inserted in 4th, 5th or 6th intercostal space at midaxillary line and connect underwater seal
- Tension pneumothorax - insert 19 gauge or larger needle into the chest and attach a 3-way stopcock. Use a large syringe to withdraw air. Follow with tube insertion
- Pulmonary edema can be a complication of re-expansion
Recurrent pneumothorax (more often occurs with larger pneumothoraces)
- Can cause severe disability
- Consider thoracoscopy or thoracotomy following 2 or more spontaneous pneumothoraces, if lungs not expanded after 7 days therapy or persistent bronchopleural fistula
- Consider pleurodesis with talc or other agents

ACTIVITY

Bed rest until re-expanded
No air travel until x-ray normal

DIET

No special diet

PATIENT EDUCATION

Stop smoking

PREVENTION/AVOIDANCE

No preventive measures known, but patients may avoid some risk factors, e.g., exposure to high altitudes, flying in unpressurized aircraft, scuba diving, smoking

POSSIBLE COMPLICATIONS

Re-expansion pulmonary edema following suction
Bronchopleural fistulae requiring surgical repair
Surgery indicated following 2 spontaneous pneumothoraces on the same side

EXPECTED COURSE AND PROGNOSIS

Air reabsorbed from small spontaneous pneumothorax in a few days
Air reabsorbed from larger air space in 2-4 weeks
Risk of recurrence is 30-50%

ASSOCIATED CONDITIONS

Listed with Causes

AGE-RELATED FACTORS

Pediatric: Unusual in this age group except following trauma
Geriatric: Higher morbidity and mortality
Others: N/A

PREGNANCY

A known, but unusual complication of labor and delivery. It should be suspected in the pregnant patient with dyspnea and chest pain.

OTHER NOTES

Chest pain may simulate an acute MI or acute abdomen

ABBREVIATIONS

MI = myocardial infarction

Clinical Investigations

ROLE OF HOMOEOPATHY

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