Pneumothorax: Difference between revisions

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== Definition  ==
== Definition  ==
[[File:Pneumothorax.jpg|alt=By Photographed by User Clinical Cases 00:42, 7 November 2006 - Originally from tension pneumthorax page on clinicalcases.orgTransferred from en.wikipedia to Commons.; description page is/was here; uploader to en Wiki was Clinical Cases at en.wikipedia, CC BY-SA 2.5, |thumb|323x323px|Left pneumothorax. This X-ray is used on clinicalcases.org to illustrate a fictional case history of tension pneumothorax. Note the large, well-demarcated area devoid of lung markings, the tracheal deviation and movement of the heart away from the affected side. ]]
A pneumothorax can be defined as air in the pleural cavity<ref>Medicinenet.com. (2009). <nowiki>''</nowiki>Pneumothorax<nowiki>''</nowiki>. Retrieved April 6, 2009 fromhttp;//medicinenet.com/pneumothorax/page2.htm Oxford Concise Medical Dictionary.(2002). <nowiki>''</nowiki>Pneumothorax<nowiki>''</nowiki>.(6th ed).Oxford:Oxford University Press.p 544</ref>. This occurs when there is a breach of the lung surface or chest wall which allows air to enter the pleural cavity and consequently cause the lung to collapse.


According to the Oxford Concise Medical Dictionary<ref>Medicinenet.com. (2009). <nowiki>''</nowiki>Pneumothorax<nowiki>''</nowiki>. Retrieved April 6, 2009 fromhttp;//medicinenet.com/pneumothorax/page2.htm Oxford Concise Medical Dictionary.(2002). <nowiki>''</nowiki>Pneumothorax<nowiki>''</nowiki>.(6th ed).Oxford:Oxford University Press.p 544</ref>, a pneumothorax can be defined as "Air in the pleural cavity". This occurs when there is a breach of the lung surface or chest wall which allows air to enter the pleural cavity and consequently cause the lung to collapse.  
== Types of Pneumothorax ==
Various causes of pneumothoraces exist and each pneumothorax is classified according to its cause<ref name=":1">Gupta D, Hansell A, Nichols T, et al. [https://thorax.bmj.com/content/55/8/666 Epidemiology of pneumothorax in England]. Thorax 2000;55:666-671</ref><ref>Bascom, R.(2009). <nowiki>''</nowiki>Pneumothorax<nowiki>''</nowiki>. eMedicine. Retrieved February 22, 2009 from <nowiki>http://emedicine.medscape.com/article/424547-overview</nowiki></ref>. 
 
=== Primary Pneumothorax ===
Also referred to as a spontaneous pneumothorax or primary spontaneous pneumothorax. It is characterized by having no clear cause or no known underlying lung pathology.  
 
There may be contributing factors, such as cigarette smoke, family history, the rupture of the [[Pulmonary Bullae|bulla]] (small air-filled sacs in the lung tissue) but these will not cause pneumothorax itself.
[[File:Pneumothorax xray marked.jpg|thumb]] 
 
=== Secondary Pneumothorax ===
Also referred to as a non-spontaneous or complicated pneumothorax.  It occurs as a result of an underlying lung pathology such as [[COPD (Chronic Obstructive Pulmonary Disease)|COPD]], [[Asthma]], [[Tuberculosis]], [[Cystic Fibrosis]] or Whooping Cough. 
 
=== Tension or Non-tension Pneumothorax  ===
A pneumothorax can further be classified as tension or non-tension pneumothorax.<ref name=":3">BAUMANN, M.H. and NOPPEN, M. [https://onlinelibrary.wiley.com/doi/full/10.1111/j.1440-1843.2004.00577.x Pneumothorax.] Respirology, 2004. 9: 157-164</ref>
[[File:Tension Pneumothorax.png|thumb]]
A tension pneumothorax is caused by excessive pressure build up around the lung due to a breach in the lung surface which will admit air into the pleural cavity during inspiration but will not allow any air to escape during expiration. The breach acts as a one-way valve. This leads to lung collapse.  


== Types of Pneumothorax ==
The removal of the air is through the surgical incision by inserting an underwater drain in the pleural cavity. This excessive pressure can also prevent the heart from pumping effectively which may lead to shock. A non-tension pneumothorax is not considered as severe as there is no ongoing accumulation of air and therefore there is no increased pressure on the organs and the chest.  
Various causes of pneumothorax<ref>Bascom, R.(2009). <nowiki>''</nowiki>Pneumothorax<nowiki>''</nowiki>. eMedicine. Retrieved February 22, 2009 from <nowiki>http://emedicine.medscape.com/article/424547-overview</nowiki></ref> exist and each pneumothorax is classified according to its cause. 
# Primary pneumothorax: also referred to as a spontaneous pneumothorax or primary spontaneous pneumothorax, It is characterized by having no clear cause or no known underlying lung pathology. There may be contributing factors, such as cigarette smoke, family history, the rupture of the bulla (small air-filled sacs in the lung tissue) but these will not cause pneumothorax itself.
# Secondary pneumothorax: also referred to as a non-spontaneous or complicated pneumothorax. It occurs as a result of an underlying lung pathology such as [[COPD (Chronic Obstructive Pulmonary Disease)|COPD]], [[Asthma]], [[Tuberculosis]], [[Cystic Fibrosis]] or Whooping Cough.
A pneumothorax can further be classified as tension or non-tension pneumothorax. A tension pneumothorax is caused by excessive pressure build up around the lung due to a breach in the lung surface which will admit air into the pleural cavity during inspiration but will not allow any air to escape during expiration. The breach acts as a one-way valve. This leads to lung collapse. The removal of the air is through the surgical incision by inserting an underwater drain in the pleural cavity. This excessive pressure can also prevent the heart from pumping effectively which may lead to shock. A non-tension pneumothorax is not considered as severe as there is no ongoing accumulation of air and therefore there is no increased pressure on the organs and the chest.  


Other causes of a pneumothorax can be trauma or incorrect medical care. A traumatic pneumothorax is caused by trauma to the lungs. Some of the causes are the following: Stabwound, gunshot, or injury from a motor vehicle accident or any other trauma to the lungs. A pneumothorax which develops as a result of a medical procedure or incorrect medical care i.e. accidental puncture to the lung during surgery is termed as an iatrogenic pneumothorax.
=== Traumatic Pneumothorax ===
Other causes of a pneumothorax can be trauma or incorrect medical care.


A traumatic pneumothorax is caused by trauma to the lungs. Some of the causes are the following: Stab wound, gunshot, or injury from a motor vehicle accident or any other trauma to the lungs.<ref name=":3" /> 


A pneumothorax which develops as a result of a medical procedure or incorrect medical care i.e. accidental puncture to the lung during surgery is termed as an iatrogenic pneumothorax.<ref name=":3" />
== Causes and Risk Factors  ==
== Causes and Risk Factors  ==


The cause of primary spontaneous pneumothorax is unknown (idiopathic), but established risk factors<ref>Mamashealth.com.(2008). <nowiki>''</nowiki>Pneumothorax<nowiki>''</nowiki>. Retrieved April 6, 2009 from http;//www.mamashealth.com/lung/pneum.asp Mayo clinic staff. (2007). <nowiki>''</nowiki>Risk factors<nowiki>''</nowiki>. Retrieved February 22, 2009 from <nowiki>http://www.mayoclinic.com/health/pneumothorax/DS00943/DSECTION=risk-factor</nowiki></ref> include:  
The cause of primary spontaneous pneumothorax is unknown (idiopathic), but established risk factors include<ref name=":1" /><ref name=":2">Bintcliffe O, Maskell N. [https://www.bmj.com/content/348/bmj.g2928.short Spontaneous pneumothorax]. BMJ 2014; 348 :g2928</ref>:  
* Gender  
* Gender  
* Smoking (cannabis or tobacco) and,  
* Smoking (cannabis or tobacco) and,  
* Family history of pneumothorax. <br>  
* Family history of pneumothorax. <br>  
Secondary spontaneous pneumothorax occurs in the setting of a variety of lung diseases. The most common is a chronic obstructive pulmonary disease (COPD), which accounts for approximately 70% of cases. Known lung diseases that may significantly increase the risk for pneumothorax are:  
Secondary spontaneous pneumothorax occurs in the setting of a variety of lung diseases. The most common is a [[COPD (Chronic Obstructive Pulmonary Disease)|chronic obstructive pulmonary disease]] (COPD), which accounts for approximately 70% of cases<ref name=":2" />. Known lung diseases that may significantly increase the risk for pneumothorax are:  
* Chronic obstructive pulmonary disease.
* COPD
* Cystic fibrosis.
* [[Cystic Fibrosis|Cystic fibrosis]]
* Lung cancer.
* [[Lung Cancer|Lung cancer]]
* Asthma.
* [[Asthma]]
* Tuberculosis.
* [[Tuberculosis]]
* Emphysema.
* Bacterial [[pneumonia]]: certain forms of pneumonia caused by staphylococcus, streptococcus and other types of bacteria may cause a lung to collapse.
* Bacterial pneumonia: Certain forms of pneumonia caused by staphylococcus, streptococcus and other types of bacteria may cause a lung to collapse
Other traumatic factors may also lead to pneumothorax and eventually lung collapse<ref name=":3" />:
Other factors may also cause collapsed lung. These include:
* Injury or trauma to the chest area: Bullet or stab wounds, fractured ribs, or a blunt force injury can cause the lungs to collapse.
* Injury or trauma to the chest area: Bullet or stab wounds, fractured ribs, or a blunt force injury can cause the lungs to collapse.
* Certain medical procedures: These include procedures in which the lung may inadvertently be punctured (needle aspiration to drain fluid from the lung, biopsy or the insertion of a large intravenous catheter into a neck vein).
* Certain medical procedures: These include procedures in which the lung may inadvertently be punctured (needle aspiration to drain fluid from the lung, biopsy or the insertion of a large intravenous catheter into a neck vein).
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== Signs and Symptoms  ==
== Signs and Symptoms  ==


Symptoms of pneumothorax include:
*Sudden onset of chest pain - sharp pain worse on inspiration<ref name=":0">Roberts, D J. et al. [https://journals.lww.com/annalsofsurgery/Fulltext/2015/06000/Clinical_Presentation_of_Patients_With_Tension.9.aspx Clinical Presentation of Patients With Tension Pneumothorax,] Annals of Surgery: June 2015 - Volume 261 - Issue 6 - p 1068-1078</ref>
 
*[[Dyspnoea]] - shortness of breath  
*Sudden onset of chest pain (This is a sharp pain, which may lead to a feeling of tightness in the chest)
*Tachycardia - increased heart rate  
*Dyspnoea (shortness of breath)
*Tachypnoea - increased respiration rate  
*Tachycardia (rapid heart rate)
*Dry cough
*Tachypnoeas (rapid respiration rate)
*Coughing (dry)
*Fatigue  
*Fatigue  
*Signs of respiratory distress (nasal flaring, anxiety etc)
*Signs of respiratory distress -nasal flaring, anxiety, use of accessory muscles
*Hypotension  
*Hypotension  
*Subcutaneous emphysema
*Subcutaneous [[emphysema]]


== Prevalence Around the World ==
== Epidemiology ==


Primary spontaneous pneumothorax occurs most often in people between age 18 - 40 and Secondary spontaneous pneumothoraces occur more frequently after age 60 years.Prevalence of a pneumothorax in a newborn is a potentially serious problem and it occurs in about 1-2% of all births.  
Primary spontaneous pneumothorax occurs most often in people between age 18 - 40 and Secondary spontaneous pneumothoraces occur more frequently after age 60 years. Prevalence of a pneumothorax in a newborn is a potentially serious problem and it occurs in about 1-2% of all births.<ref name=":1" />


According to Ch<ref name=":0">Chang, A. K. <nowiki>&</nowiki>amp; Mukherji, P. (2007). <nowiki>''</nowiki>Pneumothorax, Iatrogenic, Spontaneous and Pneumomediastinum<nowiki>''</nowiki>. eMedicine. Retrieved April 6, 2009 from <nowiki>http://emedicine.medscape.com/article/808162-overview</nowiki> Dictionary of physiotherapy.(2005). Pneumothorax</ref>ang and Mukherji (2007) the incidence of primary spontaneous pneumothorax in the USA (age-adjusted) is 7.4-18 cases per 100,000 persons per year for men and 1.2-6 cases per 100,000 persons per year for women. IThe icidence of secondary spontaneous pneumothorax (age-adjusted) is 6.3 cases per 100,000 persons per year for men and 2 cases per 100,000 persons per year for women. Chronic obstructive pulmonary disease (COPD) is a common cause of secondary spontaneous pneumothorax that carries an incidence of 26 cases per 100,000 persons. The incidence of iatrogenic pneumothorax is not known, but it probably occurs more often than primary and secondary spontaneous pneumothoraces combined.Incidence is higher in men than in women, at a ratio of 6.2:1 for primary pneumothorax and 3.2:1 for secondary pneumothorax.
The overall person consulting rate for pneumothorax (primary and secondary combined) in the GPRD was 24.0/100 000 each year for men and 9.8/100 000 each year for women. Hospital admissions for pneumothorax as a primary diagnosis occurred at an overall incidence of 16.7/100 000 per year and 5.8/100 000 per year for men and women, respectively. Mortality rates were 1.26/million per year for men and 0.62/million per year for women.<ref name=":1" />  
 
Although some view primary spontaneous pneumothorax as more of a nuisance than a major health threat, deaths have been reported. Secondary spontaneous pneumothorax can be life threatening, depending on the severity of the underlying disease and the size of the pneumothorax. Mortality percentages in patients with COPD and spontaneous pneumothorax vary from 1-17%. Iatrogenic pneumothorax may cause substantial morbidity and, rarely, death (Chang<ref name=":0" /> &amp; Mukerji, 2007).


== Pathology  ==
== Pathology  ==


The lungs are located inside the chest cavity and the air is drawn into the lungs by the diaphragm. The pleural cavity is the region between the chest wall and the lungs. If the air enters the pleural cavity, either from the outside (open pneumothorax) or from the lung (closed pneumothorax), the lung collapses and it becomes impossible for the person to breath, even if they have an open airway. If a piece of tissue forms a one way-valve whicthatows air to enter the pleural cavity, but not to escape, overpressure can build up with each breath (tension pneumothorax). This leads to severe shortness of breath and circulatory collapse.  
The pleural cavity is the region between the chest wall and the lungs. If the air enters the pleural cavity, either from the outside (open pneumothorax) or from the lung (closed pneumothorax), the lung collapses and it becomes difficult for the person to breath. Tissue can form a one way-valve which allows air to enter the pleural cavity, but not to escape, overpressure can build up with each breath (tension pneumothorax). This leads to severe shortness of breath, deviation of the heart and compression on the vena cava leading to shock.<ref name=":0" />


Air leaks from the lungs into other parts of the chest cavity can occur in newborns. Babies are normally born with collapsed lungs, and a large amount of pressure is generated as the newborn's body works to inflate their lungs with the first few breaths. For 98% of newborns there is no problem at all, but for some (2%)the lungs do not immediately open completely and the strong pressures generated to inflate the lung may cause small ruptures in the alveoli. The leaked air can be removed by the physician, and continual removal of this leaked air is required until the ruptures have healed.
There is a loss of intrapleural negative pressure that can result in a lung collapse. Due to this there is a decrease in vital capacity as well as a decrease in PaO2 which is the main consequence of a pneumothorax. The decrease in PaO2 results from various factors i.e low ventilation-perfusion ratios, anatomic shunts and alveolar hypoventilation. Most patients that suffer from a pneumothorax also have an increase in alveolar-arterial oxygen tension.<ref name=":0" />
 
{{#ev:youtube|ZYMcyyNMYrQ}}<ref>Medicosis Perfectionalis. Pneumothorax | Lung Physiology | Pulmonary Medicine. Available from: https://www.youtube.com/watch?v=ZYMcyyNMYrQ&feature=youtu.be [Last accessed 03/09/2019]</ref>
There is a loss of intrapleural negative pressure that can result in a lung collapse. Due to this there is a decrease in vital capacity as well as a decrease in PaO2 which is the main consequence of a pneumothorax. The decrease in PaO2 results from various factors i.e low ventilation-perfusion ratios, anatomic shunts and alveolar hypoventilation. Most patients that suffer from a pneumothorax also have an increase in alveolar-arterial oxygen tension.  
{{#ev:youtube|ZYMcyyNMYrQ}}


== Diagnosis  ==
== Diagnosis  ==
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Initially a complete medical and physical examination needs to be conducted.  
Initially a complete medical and physical examination needs to be conducted.  


On examination of the chest with a stethoscope, it will be noted that there is either decreased or absent breath sounds over the area of the affected lung, which may indicate that the lung is not unfolded in the pleural cavity. There is hyperrr esonance (highe p-itched sounds than normal) withpthep ercussion of the chest wall which is suggestive of pneumothorax diagnosis.  
=== Auscultation ===
On examination of the chest with a stethoscope, it will be noted that there is either decreased or absent breath sounds over the area of the affected lung, which may indicate that the lung is not inflated in that particular area<ref name=":5">Rankine JJ, Thomas AN, Fluechter D. [https://pmj.bmj.com/content/76/897/399 Diagnosis of pneumothorax in critically ill adults]. Postgraduate Medical Journal 2000;76:399-404.</ref>.


Chest x- rays will then be used to confirm the diagnosis of the pneumothorax. In a supine chest x-ray, a deep sulcus sign is diagnostic and this is characterised by a low lateral costophrenic angle on the affected side. Also, the presence of air outside normal lung airways and movement or shifting of the organs away from the air leak in the thoracic cavity will be indicative of the presence of a pneumothorax.  
There is hyper resonance (higher pitched sounds than normal) with percussion of the chest wall which is suggestive of pneumothorax diagnosis.
 
=== Imaging ===
Chest x- rays will then be used to confirm the diagnosis of the pneumothorax.<ref name=":4">Wu Ding, Yuehong Shen, Jianxin Yang, Xiaojun He, Mao Zhang, [https://www.sciencedirect.com/science/article/abs/pii/S0012369211605217 Diagnosis of Pneumothorax by Radiography and Ultrasonography: A Meta-analysis,] Chest, Volume 140, Issue 4, 2011, Pages 859-866,</ref> In a supine chest x-ray, a deep sulcus sign is diagnostic and this is characterised by a low lateral costophrenic angle on the affected side<ref name=":5" />. Also, the presence of air outside normal lung airways and movement or shifting of the organs away from the air leak in the thoracic cavity will be indicative of the presence of a pneumothorax.  
 
Ultra sound scan can also provide diagnostic assistance<ref name=":4" />. 


[[Image:Pneumothorax_xray_marked.jpg|thumb|center|Diagram showing a neonate with a right tension pneumothorax. Note the tracheal deviation to the left.]]
[[Image:Pneumothorax_xray_marked.jpg|thumb|center|Diagram showing a neonate with a right tension pneumothorax. Note the tracheal deviation to the left.]]


Another procedure used is Transillumination. This is a procedure used in an emergency situation and makes use of a fiberoptic light probe that is placed on the baby's chest wall i.e. the side with the air leak will transmit a brighter light.
== Prognosis  ==
== Prognosis  ==


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== Medical and Surgical Management  ==
== Medical and Surgical Management  ==


The main aim is to relieve the pressure on the lung and allow it to expand. It is of vital importance to try and prevent the recurrence of pneumothorax.  
Pneumothorax is a medical emergency that needs to be addressed rapidly once diagnosed<ref>Zarogoulidis P, Kioumis I, Pitsiou G, Porpodis K, Lampaki S, Papaiwannou A, Katsikogiannis N, Zaric B, Branislav P, Secen N, Dryllis G, Machairiotis N, Rapti A, Zarogoulidis K. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4203989/ Pneumothorax: from definition to diagnosis and treatment.] J Thorac Dis. 2014 Oct;6(Suppl 4):S372-6. </ref>. The main aim is to relieve the pressure on the lung and allow it to expand. It is of vital importance to try and prevent the recurrence of pneumothorax.  


Treatmen<ref>Almoosa KF, Ryu JH, Mendez    J, Huggins JT, Young LR, Sullivan EJ, Maurer J, McCormack FX, Sahn SA.    Management of pneumothorax in lymphangioleiomyomatosis. Effects on    recurrence and lung transplantation complications. Chest 2006; 129:    1274-1281.</ref>t is determined by the severity of symptoms and indicators of acute illness, the presence of underlying lung disease, the estimated size of the pneumothorax on X-ray, and – in some instances – on the personal preference of the person involved. There are a variety of treatment options for a spontaneous pneumothorax including simple observation, chest tube placement, chemical pleurodesis through a chest tube, and surgery. Conservative management with observation until the air is naturally resorbed by the body or simple chest tube placement alone has a very high rate of recurrence (about 65%) in patients with LAM. Because of this, most thoracic surgeons recommend pleurodesis (a procedure which obliterates the pleural space to prevent future pneumothoraces) after the first episode of pneumothorax. Pleurodesis can be done mechanically (using physical abrasion) or chemically (using talc, doxycycline, bleomycin or other agents). While chemical pleurodesis through a chest tube can be successful, this may result in incomplete pleurodesis due to the unevthe distribution of the chemical. Surgical treatment, using video-assisted thoracoscopy (VATS), is the preferred approach.  
Treatment may be determined by the severity of symptoms and indicators:
# Acute illness - shortness of breath, tachycardia, reduction in O2 saturation,
# Presence of underlying lung disease such as COPD
# estimated size of the pneumothorax on X-ray  
# in some instances – on personal preference of the person involved.


For patients with recurrent pneumothorax<ref>Weill D, Benden C, Corris PA, Dark JH, David RD, Keshavjee S, Lederer DJ, Mulligan MJ, Patterson GA, Singer LG, Snell GI, Verleden GM, Zamora MR, Gianville AR. A consensus document for the selection of lung transplant candidates – an update from the Pulmonary Transplantation Council of the International Society for Heart and Lung Transplantation. J Heart Lung Transplant 2015; 34: 1-15</ref> after surgical intervention, there are several options. For patients with a total or near-total collapse, repeat surgical intervention is recommended. Options include a repeat mechanical pleurodesis if it is unclear whether appropriate mechanical pleurodesis was done initially or pleurectomy in which the pleura overlying the ribs is actually removed. Another option to consider for refractory pneumothorax is chemical pleurodesis in which a drug or other agent is used to create an inflammatory response that results in pleurodesis. Talc is the most commonly used agent due to its effectiveness. Historically, talc pleurodesis was considered a contraindication to future lung transplantation because of the intense inflammatory response that made surgery very difficult. However, in the 2014 consensus document for the selection of patients for lung transplant by the International Society for Heart and Lung Transplantation, pleurodesis was not considered a contraindication for transplantation. They recommended that “pneumothorax in a patient who may become a future transplant recipient should be given the best immediate management… and “the choice of intervention is unlikely to affect future acceptance for transplantation.” Patients who undergo lung transplantation after a pleural intervention are at higher risk of bleeding complications; therefore, a strategy of optimizing successful treatment of pneumothorax while minimizing the impact on potential future lung transplantation should be undertaken. Given the potential that any intervention could have an impact on future lung transplantation should this become necessary, it is critical that the patient, pulmonolog,is,d surgeon work together to develop the best treatment plan for each individual patient.  
=== Treatment ===
There are a variety of treatment options for a spontaneous pneumothorax. It has been shown that intervention has similar results to conservative management of pneumothorax including less days spent in hospital<ref>Simon G.A et al. [https://www.nejm.org/doi/full/10.1056/NEJMoa1910775 Conservative versus Interventional Treatment for Spontaneous Pneumothorax.] N Engl J Med 2020; 382:405-415
</ref><ref name=":7">Brims FJH, Maskell NA. [https://thorax.bmj.com/content/68/7/664 Ambulatory treatment in the management of pneumothorax: a systematic review of the literature.] Thorax 2013;68:664-669</ref>:
* Conservative management with observation until the air is naturally resorbed by the body
* Simple aspiration<ref name=":6">J-M. Tschopp, R. Rami-Porta, M. Noppen, P. Astoul. [https://erj.ersjournals.com/content/28/3/637.short Management of spontaneous pneumothorax: state of the art]. European Respiratory Journal Sep 2006, 28 (3) 637-650</ref>
* Chest drain placement - Simple chest drain placement alone has a very high rate of recurrence (about 65%) in patients with LAM.
* Heimlich valve (HV) insertion - a lightweight one-way valve designed for the ambulatory treatment of pneumothorax (with an intercostal catheter)<ref name=":7" />
* [[Pleurodesis]] through a chest tube -  a procedure which obliterates the pleural space to prevent future pneumothoraces<ref>Khalid F. Almoosa, et al. [https://www.sciencedirect.com/science/article/abs/pii/S0012369215507071 Management of Pneumothorax in Lymphangioleiomyomatosis: Effects on Recurrence and Lung Transplantation Complications], Chest, 2006, Volume 129, Issue 5, Pages 1274-1281,</ref>. 
** Mechanical (using physical abrasion)
** Chemical (using talc, doxycycline, bleomycin or other agents). While chemical pleurodesis through a chest tube can be successful, this may result in incomplete pleurodesis due to the uneven distribution of the chemical.
* Surgery - Surgical treatment, using video-assisted thoracoscopy (VATS), is the preferred approach.<ref name=":6" />
{{#ev:youtube|v=ubBYHfVGzJg}}<ref>FlippedEM. Treating a tension pneumothorax. Available from: https://www.youtube.com/watch?v=ubBYHfVGzJg [last accessed: 23/09/14]</ref>


{{#ev:youtube|I7a8mqDdjH0}}
=== Recurrent pneumothorax treatment ===
For patients with recurrent pneumothorax after surgical intervention, there are several options<ref>Weill D, Benden C, Corris PA, Dark JH, Davis RD, Keshavjee S et al. [https://research.monash.edu/en/publications/a-consensus-document-for-the-selection-of-lung-transplant-candida A consensus document for the selection of lung transplant candidates: 2014 - An update from the Pulmonary Transplantation Council of the International Society for Heart and Lung Transplantation.] Journal of Heart and Lung Transplantation. 2015 Jan;34(1):1-15.</ref>. For patients with a total or near-total lung collapse, repeat surgical intervention is recommended. 


Options include:
* Repeat mechanical pleurodesis if it is unclear whether appropriate mechanical pleurodesis was done initially
* Pleurectomy in which the pleura overlying the ribs is actually removed.
* Chemical pleurodesis in which a drug or other agent is used to create an inflammatory response that results in pleurodesis. Talc is the most commonly used agent due to its effectiveness. Historically, talc pleurodesis was considered a contraindication to future lung transplantation because of the intense inflammatory response that made surgery very difficult. <ref name=":6" />
* Lung transplant
== Physiotherapy Management  ==
== Physiotherapy Management  ==


=== '''Indications for Physiotherapy'''<ref>Pryor, J. A. <nowiki>&</nowiki>amp; Prasad, S. A.(2006).<nowiki>''</nowiki>Physiotherapy for Respiratory and Cardiac Problem<nowiki>''</nowiki>.(3rd Ed.).New york: Churchill Livingston. p 389</ref> ===
=== '''Indications for Physiotherapy''' ===
*Lung collapse
*Lung collapse<ref>Pryor, J. A. <nowiki>&</nowiki>amp; Prasad, S. A.(2006).<nowiki>''</nowiki>Physiotherapy for Respiratory and Cardiac Problem<nowiki>''</nowiki>.(3rd Ed.).New york: Churchill Livingston. p 389</ref>
*Sputum retention<ref name=":9">Selsby DS. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1835906/?page=1 Chest physiotherapy]. BMJ. 1989 Mar 4;298(6673):541-2. </ref>
*Ventilation/perfusion mismatch (V/Q)<ref name=":8">C Torre, A Silva, [https://academic.oup.com/eurpub/article-abstract/29/Supplement_1/ckz035.034/5480798 Physiotherapy Intervention after Surgical Treatment of Pneumothorax - Case Study], European Journal of Public Health, April 2019, Volume 29, Issue Supplement_1, </ref>
*Increased work of breathing  
*Increased work of breathing  
*Thick sputum plugs predisposing to ventilation difficulty
*Blood gas abnormalities  
*Blood gas abnormalities  
*Sputum retention
*Post operative ITU care<ref name=":8" />
 
===  '''Goals for Physiotherapy''' ===
*To reinflate atelectatic lung areas
 
*To improve ventilation
 
*To increase oxygenation
 
*Maintain airway clearance
 
*Improve exercise tolerance
 
====  '''To reduce work and difficulty of breathing''' ====
*Body positioning
 
*Breathing control


*Relaxation technique
=== '''Goals for [[Respiratory Physiotherapy|Physiotherapy]]''' ===
 
1.To improve ventilation and increase PaO2 levels
==== '''To improve ventilation''' ====
*Localized thoracic expansion exercise
*Physical activity (stairs, walking, moderate-intensity aerobic exercise)
*Physical activity (stairs, walking, moderate-intensity aerobic exercise)
*[[Active Cycle of Breathing Technique|Active cycle of breathing exercises]]
*Sputum removal techniques i.e. [[percussion]], cough assist
*PEP devices
*PEP devices
*Incentive spirometry
*[[Incentive Spirometry|Incentive spirometry]]
 
*Non invasive ventilation (NIV)
==== '''Sputum mobilization techniques''' ====
2. To assist in sputum removal<ref name=":9" />
*Postural drainage
*Postural drainage
*Deep breathing exercises
*[[Active Cycle of Breathing Technique|Active cycle of breathing exercises]]
*Percussion, shaking, and vibrations
*Percussion, shaking, and [[Vibration|vibrations]]
*PEP devices
*[[Positive Expiratory Pressure (PEP) Devices|PEP devices]]
*Physical activity (stairs, walking, moderate-intensity aerobic exercise)
*Physical activity (stairs, walking, moderate-intensity aerobic exercise)
 
*Coughing and huffing (forced expiratory breath)
==== '''Sputum removal techniques''' ====
*Coughing and huffing
*Airway suctioning
*Airway suctioning
3. To reduce work of breathing
*Body positioning
*Breathing control
*Relaxation techniques
*Accessory muscle use
4. Improve exercise tolerance
*Early mobilisation and positioning
*Graded exercise program
*Breathing exercises


====  '''Physiotherapy outcome evaluation includes''' ====
===  '''Physiotherapy outcome evaluation includes''' ===
*Respiratory rate
*Respiratory rate
 
*O2 saturation
*Breathing pattern
*Arterial blood gases
 
*Additional O2 requirements
*Sputum quantity
 
*Auscultation
*Auscultation
 
*Chest x-ray  
*Cough sound
*Mobility status
 
*Oxygen requirement
 
*SpO2
 
*Arterial blood gases
 
*Chest x-ray changes
 
*Muscle strength
 
*Functional performance<div class="researchbox"> </div>
== References  ==
== References  ==


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[[Category:Conditions]]
[[Category:Conditions]]
[[Category:Acute Respiratory Disorders - Conditions]]
[[Category:Acute Respiratory Disorders - Conditions]]
[[Category:Respiratory]]
[[Category:Respiratory Disease]]

Latest revision as of 07:01, 29 April 2023

Original Editor - The Open Physio project.

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Definition[edit | edit source]

By Photographed by User Clinical Cases 00:42, 7 November 2006 - Originally from tension pneumthorax page on clinicalcases.orgTransferred from en.wikipedia to Commons.; description page is/was here; uploader to en Wiki was Clinical Cases at en.wikipedia, CC BY-SA 2.5,
Left pneumothorax. This X-ray is used on clinicalcases.org to illustrate a fictional case history of tension pneumothorax. Note the large, well-demarcated area devoid of lung markings, the tracheal deviation and movement of the heart away from the affected side.

A pneumothorax can be defined as air in the pleural cavity[1]. This occurs when there is a breach of the lung surface or chest wall which allows air to enter the pleural cavity and consequently cause the lung to collapse.

Types of Pneumothorax[edit | edit source]

Various causes of pneumothoraces exist and each pneumothorax is classified according to its cause[2][3].

Primary Pneumothorax[edit | edit source]

Also referred to as a spontaneous pneumothorax or primary spontaneous pneumothorax. It is characterized by having no clear cause or no known underlying lung pathology.

There may be contributing factors, such as cigarette smoke, family history, the rupture of the bulla (small air-filled sacs in the lung tissue) but these will not cause pneumothorax itself.

Pneumothorax xray marked.jpg

Secondary Pneumothorax[edit | edit source]

Also referred to as a non-spontaneous or complicated pneumothorax. It occurs as a result of an underlying lung pathology such as COPD, Asthma, Tuberculosis, Cystic Fibrosis or Whooping Cough.

Tension or Non-tension Pneumothorax[edit | edit source]

A pneumothorax can further be classified as tension or non-tension pneumothorax.[4]

Tension Pneumothorax.png

A tension pneumothorax is caused by excessive pressure build up around the lung due to a breach in the lung surface which will admit air into the pleural cavity during inspiration but will not allow any air to escape during expiration. The breach acts as a one-way valve. This leads to lung collapse.

The removal of the air is through the surgical incision by inserting an underwater drain in the pleural cavity. This excessive pressure can also prevent the heart from pumping effectively which may lead to shock. A non-tension pneumothorax is not considered as severe as there is no ongoing accumulation of air and therefore there is no increased pressure on the organs and the chest.

Traumatic Pneumothorax[edit | edit source]

Other causes of a pneumothorax can be trauma or incorrect medical care.

A traumatic pneumothorax is caused by trauma to the lungs. Some of the causes are the following: Stab wound, gunshot, or injury from a motor vehicle accident or any other trauma to the lungs.[4]

A pneumothorax which develops as a result of a medical procedure or incorrect medical care i.e. accidental puncture to the lung during surgery is termed as an iatrogenic pneumothorax.[4]

Causes and Risk Factors[edit | edit source]

The cause of primary spontaneous pneumothorax is unknown (idiopathic), but established risk factors include[2][5]:

  • Gender
  • Smoking (cannabis or tobacco) and,
  • Family history of pneumothorax.

Secondary spontaneous pneumothorax occurs in the setting of a variety of lung diseases. The most common is a chronic obstructive pulmonary disease (COPD), which accounts for approximately 70% of cases[5]. Known lung diseases that may significantly increase the risk for pneumothorax are:

Other traumatic factors may also lead to pneumothorax and eventually lung collapse[4]:

  • Injury or trauma to the chest area: Bullet or stab wounds, fractured ribs, or a blunt force injury can cause the lungs to collapse.
  • Certain medical procedures: These include procedures in which the lung may inadvertently be punctured (needle aspiration to drain fluid from the lung, biopsy or the insertion of a large intravenous catheter into a neck vein).
  • Activities in which there are sharp changes in air pressure: Flying in an airplane or deep-sea diving may result in a collapsed lung

Signs and Symptoms[edit | edit source]

  • Sudden onset of chest pain - sharp pain worse on inspiration[6]
  • Dyspnoea - shortness of breath
  • Tachycardia - increased heart rate
  • Tachypnoea - increased respiration rate
  • Dry cough
  • Fatigue
  • Signs of respiratory distress -nasal flaring, anxiety, use of accessory muscles
  • Hypotension
  • Subcutaneous emphysema

Epidemiology[edit | edit source]

Primary spontaneous pneumothorax occurs most often in people between age 18 - 40 and Secondary spontaneous pneumothoraces occur more frequently after age 60 years. Prevalence of a pneumothorax in a newborn is a potentially serious problem and it occurs in about 1-2% of all births.[2]

The overall person consulting rate for pneumothorax (primary and secondary combined) in the GPRD was 24.0/100 000 each year for men and 9.8/100 000 each year for women. Hospital admissions for pneumothorax as a primary diagnosis occurred at an overall incidence of 16.7/100 000 per year and 5.8/100 000 per year for men and women, respectively. Mortality rates were 1.26/million per year for men and 0.62/million per year for women.[2]

Pathology[edit | edit source]

The pleural cavity is the region between the chest wall and the lungs. If the air enters the pleural cavity, either from the outside (open pneumothorax) or from the lung (closed pneumothorax), the lung collapses and it becomes difficult for the person to breath. Tissue can form a one way-valve which allows air to enter the pleural cavity, but not to escape, overpressure can build up with each breath (tension pneumothorax). This leads to severe shortness of breath, deviation of the heart and compression on the vena cava leading to shock.[6]

There is a loss of intrapleural negative pressure that can result in a lung collapse. Due to this there is a decrease in vital capacity as well as a decrease in PaO2 which is the main consequence of a pneumothorax. The decrease in PaO2 results from various factors i.e low ventilation-perfusion ratios, anatomic shunts and alveolar hypoventilation. Most patients that suffer from a pneumothorax also have an increase in alveolar-arterial oxygen tension.[6]

[7]

Diagnosis[edit | edit source]

Initially a complete medical and physical examination needs to be conducted.

Auscultation[edit | edit source]

On examination of the chest with a stethoscope, it will be noted that there is either decreased or absent breath sounds over the area of the affected lung, which may indicate that the lung is not inflated in that particular area[8].

There is hyper resonance (higher pitched sounds than normal) with percussion of the chest wall which is suggestive of pneumothorax diagnosis.

Imaging[edit | edit source]

Chest x- rays will then be used to confirm the diagnosis of the pneumothorax.[9] In a supine chest x-ray, a deep sulcus sign is diagnostic and this is characterised by a low lateral costophrenic angle on the affected side[8]. Also, the presence of air outside normal lung airways and movement or shifting of the organs away from the air leak in the thoracic cavity will be indicative of the presence of a pneumothorax.

Ultra sound scan can also provide diagnostic assistance[9].

Diagram showing a neonate with a right tension pneumothorax. Note the tracheal deviation to the left.

Prognosis[edit | edit source]

Up to 50% of patients who suffer from a pneumothorax will have another or a recurring pneumothorax. However, there are no long-term complications after successful treatment.

Medical and Surgical Management[edit | edit source]

Pneumothorax is a medical emergency that needs to be addressed rapidly once diagnosed[10]. The main aim is to relieve the pressure on the lung and allow it to expand. It is of vital importance to try and prevent the recurrence of pneumothorax.

Treatment may be determined by the severity of symptoms and indicators:

  1. Acute illness - shortness of breath, tachycardia, reduction in O2 saturation,
  2. Presence of underlying lung disease such as COPD
  3. estimated size of the pneumothorax on X-ray
  4. in some instances – on personal preference of the person involved.

Treatment[edit | edit source]

There are a variety of treatment options for a spontaneous pneumothorax. It has been shown that intervention has similar results to conservative management of pneumothorax including less days spent in hospital[11][12]:

  • Conservative management with observation until the air is naturally resorbed by the body
  • Simple aspiration[13]
  • Chest drain placement - Simple chest drain placement alone has a very high rate of recurrence (about 65%) in patients with LAM.
  • Heimlich valve (HV) insertion - a lightweight one-way valve designed for the ambulatory treatment of pneumothorax (with an intercostal catheter)[12]
  • Pleurodesis through a chest tube - a procedure which obliterates the pleural space to prevent future pneumothoraces[14].
    • Mechanical (using physical abrasion)
    • Chemical (using talc, doxycycline, bleomycin or other agents). While chemical pleurodesis through a chest tube can be successful, this may result in incomplete pleurodesis due to the uneven distribution of the chemical.
  • Surgery - Surgical treatment, using video-assisted thoracoscopy (VATS), is the preferred approach.[13]

[15]

Recurrent pneumothorax treatment[edit | edit source]

For patients with recurrent pneumothorax after surgical intervention, there are several options[16]. For patients with a total or near-total lung collapse, repeat surgical intervention is recommended.

Options include:

  • Repeat mechanical pleurodesis if it is unclear whether appropriate mechanical pleurodesis was done initially
  • Pleurectomy in which the pleura overlying the ribs is actually removed.
  • Chemical pleurodesis in which a drug or other agent is used to create an inflammatory response that results in pleurodesis. Talc is the most commonly used agent due to its effectiveness. Historically, talc pleurodesis was considered a contraindication to future lung transplantation because of the intense inflammatory response that made surgery very difficult. [13]
  • Lung transplant

Physiotherapy Management[edit | edit source]

Indications for Physiotherapy[edit | edit source]

  • Lung collapse[17]
  • Sputum retention[18]
  • Ventilation/perfusion mismatch (V/Q)[19]
  • Increased work of breathing
  • Blood gas abnormalities
  • Post operative ITU care[19]

Goals for Physiotherapy[edit | edit source]

1.To improve ventilation and increase PaO2 levels

2. To assist in sputum removal[18]

3. To reduce work of breathing

  • Body positioning
  • Breathing control
  • Relaxation techniques
  • Accessory muscle use

4. Improve exercise tolerance

  • Early mobilisation and positioning
  • Graded exercise program
  • Breathing exercises

Physiotherapy outcome evaluation includes[edit | edit source]

  • Respiratory rate
  • O2 saturation
  • Arterial blood gases
  • Additional O2 requirements
  • Auscultation
  • Chest x-ray
  • Mobility status

References[edit | edit source]

  1. ↑ Medicinenet.com. (2009). ''Pneumothorax''. Retrieved April 6, 2009 fromhttp;//medicinenet.com/pneumothorax/page2.htm Oxford Concise Medical Dictionary.(2002). ''Pneumothorax''.(6th ed).Oxford:Oxford University Press.p 544
  2. ↑ 2.0 2.1 2.2 2.3 Gupta D, Hansell A, Nichols T, et al. Epidemiology of pneumothorax in England. Thorax 2000;55:666-671
  3. ↑ Bascom, R.(2009). ''Pneumothorax''. eMedicine. Retrieved February 22, 2009 from http://emedicine.medscape.com/article/424547-overview
  4. ↑ 4.0 4.1 4.2 4.3 BAUMANN, M.H. and NOPPEN, M. Pneumothorax. Respirology, 2004. 9: 157-164
  5. ↑ 5.0 5.1 Bintcliffe O, Maskell N. Spontaneous pneumothorax. BMJ 2014; 348 :g2928
  6. ↑ 6.0 6.1 6.2 Roberts, D J. et al. Clinical Presentation of Patients With Tension Pneumothorax, Annals of Surgery: June 2015 - Volume 261 - Issue 6 - p 1068-1078
  7. ↑ Medicosis Perfectionalis. Pneumothorax | Lung Physiology | Pulmonary Medicine. Available from: https://www.youtube.com/watch?v=ZYMcyyNMYrQ&feature=youtu.be [Last accessed 03/09/2019]
  8. ↑ 8.0 8.1 Rankine JJ, Thomas AN, Fluechter D. Diagnosis of pneumothorax in critically ill adults. Postgraduate Medical Journal 2000;76:399-404.
  9. ↑ 9.0 9.1 Wu Ding, Yuehong Shen, Jianxin Yang, Xiaojun He, Mao Zhang, Diagnosis of Pneumothorax by Radiography and Ultrasonography: A Meta-analysis, Chest, Volume 140, Issue 4, 2011, Pages 859-866,
  10. ↑ Zarogoulidis P, Kioumis I, Pitsiou G, Porpodis K, Lampaki S, Papaiwannou A, Katsikogiannis N, Zaric B, Branislav P, Secen N, Dryllis G, Machairiotis N, Rapti A, Zarogoulidis K. Pneumothorax: from definition to diagnosis and treatment. J Thorac Dis. 2014 Oct;6(Suppl 4):S372-6.
  11. ↑ Simon G.A et al. Conservative versus Interventional Treatment for Spontaneous Pneumothorax. N Engl J Med 2020; 382:405-415
  12. ↑ 12.0 12.1 Brims FJH, Maskell NA. Ambulatory treatment in the management of pneumothorax: a systematic review of the literature. Thorax 2013;68:664-669
  13. ↑ 13.0 13.1 13.2 J-M. Tschopp, R. Rami-Porta, M. Noppen, P. Astoul. Management of spontaneous pneumothorax: state of the art. European Respiratory Journal Sep 2006, 28 (3) 637-650
  14. ↑ Khalid F. Almoosa, et al. Management of Pneumothorax in Lymphangioleiomyomatosis: Effects on Recurrence and Lung Transplantation Complications, Chest, 2006, Volume 129, Issue 5, Pages 1274-1281,
  15. ↑ FlippedEM. Treating a tension pneumothorax. Available from: https://www.youtube.com/watch?v=ubBYHfVGzJg [last accessed: 23/09/14]
  16. ↑ Weill D, Benden C, Corris PA, Dark JH, Davis RD, Keshavjee S et al. A consensus document for the selection of lung transplant candidates: 2014 - An update from the Pulmonary Transplantation Council of the International Society for Heart and Lung Transplantation. Journal of Heart and Lung Transplantation. 2015 Jan;34(1):1-15.
  17. ↑ Pryor, J. A. & Prasad, S. A.(2006).''Physiotherapy for Respiratory and Cardiac Problem''.(3rd Ed.).New york: Churchill Livingston. p 389
  18. ↑ 18.0 18.1 Selsby DS. Chest physiotherapy. BMJ. 1989 Mar 4;298(6673):541-2.
  19. ↑ 19.0 19.1 C Torre, A Silva, Physiotherapy Intervention after Surgical Treatment of Pneumothorax - Case Study, European Journal of Public Health, April 2019, Volume 29, Issue Supplement_1,
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