A pneumothorax is an abnormal collection of air in the
pleural space
The pleural cavity, pleural space, or interpleural space is the potential space between the pleurae of the pleural sac that surrounds each lung. A small amount of serous pleural fluid is maintained in the pleural cavity to enable lubrication bet ...
between the
lung and the
chest wall.
[ Symptoms typically include sudden onset of sharp, one-sided chest pain and ]shortness of breath
Shortness of breath (SOB), also medically known as dyspnea (in AmE) or dyspnoea (in BrE), is an uncomfortable feeling of not being able to breathe well enough. The American Thoracic Society defines it as "a subjective experience of breathing di ...
. In a minority of cases, a one-way valve is formed by an area of damaged tissue, and the amount of air in the space between chest wall and lungs increases; this is called a tension pneumothorax.[ This can cause a steadily worsening oxygen shortage and ]low blood pressure
Hypotension is low blood pressure. Blood pressure is the force of blood pushing against the walls of the arteries as the heart pumps out blood. Blood pressure is indicated by two numbers, the systolic blood pressure (the top number) and the di ...
. This leads to a type of shock called obstructive shock, which can be fatal unless reversed.[ Very rarely, both lungs may be affected by a pneumothorax. It is often called a "collapsed lung", although that term may also refer to ]atelectasis
Atelectasis is the collapse or closure of a lung resulting in reduced or absent gas exchange. It is usually unilateral, affecting part or all of one lung. It is a condition where the alveoli are deflated down to little or no volume, as distinct ...
.
A primary spontaneous pneumothorax is one that occurs without an apparent cause and in the absence of significant lung disease
The lungs are the primary organs of the respiratory system in humans and most other animals, including some snails and a small number of fish. In mammals and most other vertebrates, two lungs are located near the backbone on either side ...
.[ A secondary spontaneous pneumothorax occurs in the presence of existing lung disease.] Smoking increases the risk of primary spontaneous pneumothorax, while the main underlying causes for secondary pneumothorax are COPD
Chronic obstructive pulmonary disease (COPD) is a type of progressive lung disease characterized by long-term respiratory symptoms and airflow limitation. The main symptoms include shortness of breath and a cough, which may or may not produce ...
, asthma
Asthma is a long-term inflammatory disease of the airways of the lungs. It is characterized by variable and recurring symptoms, reversible airflow obstruction, and easily triggered bronchospasms. Symptoms include episodes of wheezing, co ...
, and tuberculosis
Tuberculosis (TB) is an infectious disease usually caused by '' Mycobacterium tuberculosis'' (MTB) bacteria. Tuberculosis generally affects the lungs, but it can also affect other parts of the body. Most infections show no symptoms, i ...
. A traumatic pneumothorax can develop from physical trauma to the chest
The thorax or chest is a part of the anatomy of humans, mammals, and other tetrapod animals located between the neck and the abdomen. In insects, crustaceans, and the extinct trilobites, the thorax is one of the three main divisions of the crea ...
(including a blast injury) or from a complication of a healthcare intervention.
Diagnosis of a pneumothorax by physical examination
In a physical examination, medical examination, or clinical examination, a medical practitioner examines a patient for any possible medical signs or symptoms of a medical condition. It generally consists of a series of questions about the pati ...
alone can be difficult (particularly in smaller pneumothoraces). A chest X-ray, computed tomography (CT) scan, or ultrasound
Ultrasound is sound waves with frequencies higher than the upper audible limit of human hearing. Ultrasound is not different from "normal" (audible) sound in its physical properties, except that humans cannot hear it. This limit varies ...
is usually used to confirm its presence. Other conditions that can result in similar symptoms include a hemothorax
A hemothorax (derived from hemo- lood+ thorax hest plural ''hemothoraces'') is an accumulation of blood within the pleural cavity. The symptoms of a hemothorax may include chest pain and difficulty breathing, while the clinical signs may incl ...
(buildup of blood
Blood is a body fluid in the circulatory system of humans and other vertebrates that delivers necessary substances such as nutrients and oxygen to the cells, and transports metabolic waste products away from those same cells. Blood in the cir ...
in the pleural space), pulmonary embolism
Pulmonary embolism (PE) is a blockage of an artery in the lungs by a substance that has moved from elsewhere in the body through the bloodstream ( embolism). Symptoms of a PE may include shortness of breath, chest pain particularly upon breathin ...
, and heart attack
A myocardial infarction (MI), commonly known as a heart attack, occurs when blood flow decreases or stops to the coronary artery of the heart, causing damage to the heart muscle. The most common symptom is chest pain or discomfort which ma ...
.[ A large bulla may look similar on a chest X-ray.][
A small spontaneous pneumothorax will typically resolve without treatment and requires only monitoring.][ This approach may be most appropriate in people who have no underlying lung disease.][ In a larger pneumothorax, or if there is shortness of breath, the air may be removed with a syringe or a ]chest tube
A chest tube (also chest drain, thoracic catheter, tube thoracostomy or intercostal drain) is a surgical drain that is inserted through the chest wall and into the pleural space or the mediastinum in order to remove clinically undesired substance ...
connected to a one-way valve system.[ Occasionally, surgery may be required if tube drainage is unsuccessful, or as a preventive measure, if there have been repeated episodes.][ The surgical treatments usually involve ]pleurodesis
Pleurodesis is a medical procedure in which part of the pleural space is artificially obliterated. It involves the adhesion of the visceral and the costal pleura. The mediastinal pleura is spared.
Uses
Pleurodesis is performed to prevent recurre ...
(in which the layers of pleura
The pulmonary pleurae (''sing.'' pleura) are the two opposing layers of serous membrane overlying the lungs and the inside of the surrounding chest walls.
The inner pleura, called the visceral pleura, covers the surface of each lung and dips b ...
are induced to stick together) or pleurectomy (the surgical removal of pleural membranes).[ About 17–23 cases of pneumothorax occur per 100,000 people per year.][ They are more common in men than women.][
]
Signs and symptoms
A primary spontaneous pneumothorax (PSP) tends to occur in a young adult without underlying lung problems, and usually causes limited symptoms. Chest pain and sometimes mild breathlessness are the usual predominant presenting features. In newborns tachypnea, cyanosis and grunting are the most common presenting symptoms. People who are affected by a PSP are often unaware of the potential danger and may wait several days before seeking medical attention. PSPs more commonly occur during changes in atmospheric pressure
Atmospheric pressure, also known as barometric pressure (after the barometer), is the pressure within the atmosphere of Earth. The standard atmosphere (symbol: atm) is a unit of pressure defined as , which is equivalent to 1013.25 millibars, ...
, explaining to some extent why episodes of pneumothorax may happen in clusters.[ It is rare for a PSP to cause a tension pneumothorax.][
Secondary spontaneous pneumothoraces (SSPs), by definition, occur in individuals with significant underlying lung disease. Symptoms in SSPs tend to be more severe than in PSPs, as the unaffected lungs are generally unable to replace the loss of function in the affected lungs. ]Hypoxemia
Hypoxemia is an abnormally low level of oxygen in the blood. More specifically, it is oxygen deficiency in arterial blood. Hypoxemia has many causes, and often causes hypoxia as the blood is not supplying enough oxygen to the tissues of the bod ...
(decreased blood-oxygen levels) is usually present and may be observed as cyanosis (blue discoloration of the lips and skin). Hypercapnia
Hypercapnia (from the Greek ''hyper'' = "above" or "too much" and ''kapnos'' = "smoke"), also known as hypercarbia and CO2 retention, is a condition of abnormally elevated carbon dioxide (CO2) levels in the blood. Carbon dioxide is a gaseous pro ...
(accumulation of carbon dioxide in the blood) is sometimes encountered; this may cause confusion
In medicine, confusion is the quality or state of being bewildered or unclear. The term "acute mental confusion" and – if very severe – may result in comas. The sudden onset of breathlessness in someone with chronic obstructive pulmonary disease
Chronic obstructive pulmonary disease (COPD) is a type of progressive lung disease characterized by long-term respiratory symptoms and airflow limitation. The main symptoms include shortness of breath and a cough, which may or may not produce ...
(COPD), cystic fibrosis
Cystic fibrosis (CF) is a rare genetic disorder that affects mostly the lungs, but also the pancreas, liver, kidneys, and intestine. Long-term issues include difficulty breathing and coughing up mucus as a result of frequent lung infections. O ...
, or other serious lung diseases should therefore prompt investigations to identify the possibility of a pneumothorax.[
Traumatic pneumothorax most commonly occurs when the chest wall is pierced, such as when a ]stab wound
A stab wound is a specific form of penetrating trauma to the skin that results from a knife or a similar pointed object. While stab wounds are typically known to be caused by knives, they can also occur from a variety of implements, including brok ...
or gunshot wound
A gunshot wound (GSW) is a penetrating injury caused by a projectile (e.g. a bullet) from a gun (typically firearm or air gun). Damages may include bleeding, bone fractures, organ damage, wound infection, loss of the ability to move part of th ...
allows air to enter the pleural space
The pleural cavity, pleural space, or interpleural space is the potential space between the pleurae of the pleural sac that surrounds each lung. A small amount of serous pleural fluid is maintained in the pleural cavity to enable lubrication bet ...
, or because some other mechanical injury to the lung compromises the integrity of the involved structures. Traumatic pneumothoraces have been found to occur in up to half of all cases of chest trauma, with only rib fracture
A rib fracture is a break in a rib bone. This typically results in chest pain that is worse with inspiration. Bruising may occur at the site of the break. When several ribs are broken in several places a flail chest results. Potential complicatio ...
s being more common in this group. The pneumothorax can be occult (not readily apparent) in half of these cases, but may enlarge – particularly if mechanical ventilation
Mechanical ventilation, assisted ventilation or intermittent mandatory ventilation (IMV), is the medical term for using a machine called a ventilator to fully or partially provide artificial ventilation. Mechanical ventilation helps move air ...
is required.[ They are also encountered in people already receiving mechanical ventilation for some other reason.][
Upon ]physical examination
In a physical examination, medical examination, or clinical examination, a medical practitioner examines a patient for any possible medical signs or symptoms of a medical condition. It generally consists of a series of questions about the pati ...
, breath sounds
Respiratory sounds, also known as lung sounds or breath sounds, refer to the specific sounds generated by the movement of air through the respiratory system. These may be easily audible or identified through auscultation of the respiratory system ...
(heard with a stethoscope
The stethoscope is a medical device for auscultation, or listening to internal sounds of an animal or human body. It typically has a small disc-shaped resonator that is placed against the skin, and one or two tubes connected to two earpieces. ...
) may be diminished on the affected side, partly because air in the pleural space dampens the transmission of sound. Measures of the conduction of vocal vibrations to the surface of the chest may be altered. Percussion
A percussion instrument is a musical instrument that is sounded by being struck or scraped by a beater including attached or enclosed beaters or rattles struck, scraped or rubbed by hand or struck against another similar instrument. Exc ...
of the chest may be perceived as hyperresonant (like a booming drum), and vocal resonance Vocal resonance may be defined as "the process by which the basic product of phonation is enhanced in timbre and/or intensity by the air-filled cavities through which it passes on its way to the outside air." Throughout the vocal literature, various ...
and tactile fremitus can both be noticeably decreased. Importantly, the volume of the pneumothorax may not be well correlated
In statistics, correlation or dependence is any statistical relationship, whether causal or not, between two random variables or bivariate data. Although in the broadest sense, "correlation" may indicate any type of association, in statistics ...
with the intensity of the symptoms experienced by the victim,[ and physical signs may not be apparent if the pneumothorax is relatively small.][
]
Tension pneumothorax
Tension pneumothorax is generally considered to be present when a pneumothorax (primary spontaneous, secondary spontaneous, or traumatic) leads to significant impairment of respiration
Respiration may refer to:
Biology
* Cellular respiration, the process in which nutrients are converted into useful energy in a cell
** Anaerobic respiration, cellular respiration without oxygen
** Maintenance respiration, the amount of cellul ...
and/or blood circulation
The blood circulatory system is a system of organs that includes the heart, blood vessels, and blood which is circulated throughout the entire body of a human or other vertebrate. It includes the cardiovascular system, or vascular system, tha ...
. This causes a type of circulatory shock, called obstructive shock. Tension pneumothorax tends to occur in clinical situations such as ventilation, resuscitation, trauma, or in people with lung disease. It is a medical emergency
A medical emergency is an acute injury or illness that poses an immediate risk to a person's life or long-term health, sometimes referred to as a situation risking "life or limb". These emergencies may require assistance from another, qualified p ...
and may require immediate treatment without further investigations (see Treatment section).[
The most common findings in people with tension pneumothorax are chest pain and respiratory distress, often with an increased ]heart rate
Heart rate (or pulse rate) is the frequency of the heartbeat measured by the number of contractions (beats) of the heart per minute (bpm). The heart rate can vary according to the body's physical needs, including the need to absorb oxygen and excr ...
(tachycardia
Tachycardia, also called tachyarrhythmia, is a heart rate that exceeds the normal resting rate. In general, a resting heart rate over 100 beats per minute is accepted as tachycardia in adults. Heart rates above the resting rate may be normal (su ...
) and rapid breathing (tachypnea
Tachypnea, also spelt tachypnoea, is a respiratory rate greater than normal, resulting in abnormally rapid and shallow breathing.
In adult humans at rest, any respiratory rate of 1220 per minute is considered clinically normal, with tachypnea be ...
) in the initial stages. Other findings may include quieter breath sounds on one side of the chest, low oxygen levels and blood pressure
Blood pressure (BP) is the pressure of circulating blood against the walls of blood vessels. Most of this pressure results from the heart pumping blood through the circulatory system. When used without qualification, the term "blood pressure" r ...
, and displacement of the trachea
The trachea, also known as the windpipe, is a Cartilage, cartilaginous tube that connects the larynx to the bronchi of the lungs, allowing the passage of air, and so is present in almost all air-breathing animals with lungs. The trachea extends ...
away from the affected side. Rarely, there may be cyanosis (bluish discoloration of the skin due to low oxygen levels), altered level of consciousness
An altered level of consciousness is any measure of arousal other than normal. Level of consciousness (LOC) is a measurement of a person's arousability and responsiveness to stimuli from the environment.
A mildly depressed level of consciousn ...
, a hyperresonant percussion note on examination of the affected side with reduced expansion and decreased movement, pain in the epigastrium
In anatomy, the epigastrium (or epigastric region) is the upper central region of the abdomen. It is located between the costal margins and the subcostal plane. Pain may be referred to the epigastrium from damage to structures derived from the f ...
(upper abdomen), displacement of the apex beat
The apex is the highest point of something. The word may also refer to:
Arts and media Fictional entities
* Apex (comics), a teenaged super villainess in the Marvel Universe
* Ape-X, a super-intelligent ape in the Squadron Supreme universe
*Apex, ...
(heart impulse), and resonant sound when tapping the sternum
The sternum or breastbone is a long flat bone located in the central part of the chest. It connects to the ribs via cartilage and forms the front of the rib cage, thus helping to protect the heart, lungs, and major blood vessels from injury. Sh ...
.[
Tension pneumothorax may also occur in someone who is receiving mechanical ventilation, in which case it may be difficult to spot as the person is typically receiving ]sedation
Sedation is the reduction of irritability or agitation by administration of sedative drugs, generally to facilitate a medical procedure or diagnostic procedure. Examples of drugs which can be used for sedation include isoflurane, diethyl ether, ...
; it is often noted because of a sudden deterioration in condition.[ Recent studies have shown that the development of tension features may not always be as rapid as previously thought. Deviation of the trachea to one side and the presence of raised ]jugular venous pressure
The jugular venous pressure (JVP, sometimes referred to as ''jugular venous pulse'') is the indirectly observed pressure over the venous system via visualization of the internal jugular vein. It can be useful in the differentiation of different for ...
(distended neck veins) are not reliable as clinical signs.[
]
Cause
Primary spontaneous
Spontaneous pneumothoraces are divided into two types: ''primary'', which occurs in the absence of known lung disease, and ''secondary'', which occurs in someone with underlying lung disease. The cause of primary spontaneous pneumothorax is unknown, but established risk factors include being of the male sex, smoking
Smoking is a practice in which a substance is burned and the resulting smoke is typically breathed in to be tasted and absorbed into the bloodstream. Most commonly, the substance used is the dried leaves of the tobacco plant, which have bee ...
, and a family history
Genealogy () is the study of families, family history, and the tracing of their Lineage (anthropology), lineages. Genealogists use oral interviews, historical records, genetic analysis, and other records to obtain information about a family a ...
of pneumothorax.[ Smoking either ]cannabis
''Cannabis'' () is a genus of flowering plants in the family Cannabaceae. The number of species within the genus is disputed. Three species may be recognized: ''Cannabis sativa'', '' C. indica'', and '' C. ruderalis''. Alternatively ...
or tobacco
Tobacco is the common name of several plants in the genus '' Nicotiana'' of the family Solanaceae, and the general term for any product prepared from the cured leaves of these plants. More than 70 species of tobacco are known, but the ...
increases the risk.[ The various suspected underlying mechanisms are discussed ]below
Below may refer to:
*Earth
*Ground (disambiguation)
*Soil
*Floor
*Bottom (disambiguation)
Bottom may refer to:
Anatomy and sex
* Bottom (BDSM), the partner in a BDSM who takes the passive, receiving, or obedient role, to that of the top or ...
.[
]
Secondary spontaneous
Secondary spontaneous pneumothorax occurs in the setting of a variety of lung diseases. The most common is chronic obstructive pulmonary disease
Chronic obstructive pulmonary disease (COPD) is a type of progressive lung disease characterized by long-term respiratory symptoms and airflow limitation. The main symptoms include shortness of breath and a cough, which may or may not produce ...
(COPD), which accounts for approximately 70% of cases.[ Known lung diseases that may significantly increase the risk for pneumothorax are
In children, additional causes include ]measles
Measles is a highly contagious infectious disease caused by measles virus. Symptoms usually develop 10–12 days after exposure to an infected person and last 7–10 days. Initial symptoms typically include fever, often greater than , cough, ...
, echinococcosis
Echinococcosis is a parasitic disease of tapeworms of the ''Echinococcus'' type. The two main types of the disease are ''cystic echinococcosis'' and '' alveolar echinococcosis''. Less common forms include ''polycystic echinococcosis'' and ''uni ...
, inhalation of a foreign body
A foreign body (FB) is any object originating outside the body of an organism. In machinery, it can mean any unwanted intruding object.
Most references to foreign bodies involve propulsion through natural orifices into hollow organs.
Foreign bo ...
, and certain congenital malformation
A birth defect, also known as a congenital disorder, is an abnormal condition that is present at childbirth, birth regardless of its cause. Birth defects may result in disability, disabilities that may be physical disability, physical, intellect ...
s (congenital pulmonary airway malformation
Congenital pulmonary airway malformation (CPAM), formerly known as congenital cystic adenomatoid malformation (CCAM), is a congenital disorder of the lung similar to bronchopulmonary sequestration. In CPAM, usually an entire lobe of lung is replac ...
and congenital lobar emphysema).
11.5% of people with a spontaneous pneumothorax have a family member who has previously experienced a pneumothorax. The hereditary conditions – Marfan syndrome
Marfan syndrome (MFS) is a multi-systemic genetic disorder that affects the connective tissue. Those with the condition tend to be tall and thin, with long arms, legs, fingers, and toes. They also typically have exceptionally flexible joints a ...
, homocystinuria
Homocystinuria or HCU is an inherited disorder of the metabolism of the amino acid methionine due to a deficiency of cystathionine beta synthase or methionine synthase. It is an inherited autosomal recessive trait, which means a child needs to inh ...
, Ehlers–Danlos syndromes
Ehlers–Danlos syndromes (EDS) are a group of 13 genetic connective-tissue disorders in the current classification, with the latest type discovered in 2018. Symptoms include loose joints, joint pain, stretchy velvety skin, and abnormal scar fo ...
, alpha 1-antitrypsin deficiency
Alpha-1 antitrypsin deficiency (A1AD or AATD) is a genetic disorder that may result in lung disease or liver disease. Onset of lung problems is typically between 20 and 50 years of age. This may result in shortness of breath, wheezing, or an inc ...
(which leads to emphysema
Emphysema, or pulmonary emphysema, is a lower respiratory tract disease, characterised by air-filled spaces ( pneumatoses) in the lungs, that can vary in size and may be very large. The spaces are caused by the breakdown of the walls of the alve ...
), and Birt–Hogg–Dubé syndrome
Birt–Hogg–Dubé syndrome (BHD), also Hornstein–Birt–Hogg–Dubé syndrome, Hornstein–Knickenberg syndrome, and fibrofolliculomas with trichodiscomas and acrochordons is a human autosomal dominant genetic disorder that can cause suscept ...
– have all been linked to familial pneumothorax. Generally, these conditions cause other signs and symptoms as well, and pneumothorax is not usually the primary finding.[ Birt–Hogg–Dubé syndrome is caused by mutations in the ''FLCN'' ]gene
In biology, the word gene (from , ; "...Wilhelm Johannsen coined the word gene to describe the Mendelian units of heredity..." meaning ''generation'' or ''birth'' or ''gender'') can have several different meanings. The Mendelian gene is a ba ...
(located at chromosome 17
Chromosome 17 is one of the 23 pairs of chromosomes in humans. People normally have two copies of this chromosome. Chromosome 17 spans more than 83 million base pairs (the building material of DNA) and represents between 2.5 and 3% of the total D ...
p11.2), which encodes a protein named folliculin
The tumor suppressor gene ''FLCN'' encodes the protein folliculin, also known as Birt–Hogg–Dubé syndrome protein, which functions as an inhibitor of Lactate dehydrogenase A, Lactate Dehydrogenase-A and a regulator of the Warburg effect (onco ...
.[ ''FLCN'' mutations and lung lesions have also been identified in familial cases of pneumothorax where other features of Birt–Hogg–Dubé syndrome are absent.][ In addition to the genetic associations, the HLA ]haplotype
A haplotype ( haploid genotype) is a group of alleles in an organism that are inherited together from a single parent.
Many organisms contain genetic material ( DNA) which is inherited from two parents. Normally these organisms have their DNA or ...
A2B40 is also a genetic predisposition to PSP.
Traumatic
A traumatic pneumothorax may result from either blunt trauma
Blunt trauma, also known as blunt force trauma or non-penetrating trauma, is physical traumas, and particularly in the elderly who fall. It is contrasted with penetrating trauma which occurs when an object pierces the skin and enters a tissue ...
or penetrating injury to the chest wall.[ The most common mechanism is due to the penetration of sharp bony points at a new ]rib fracture
A rib fracture is a break in a rib bone. This typically results in chest pain that is worse with inspiration. Bruising may occur at the site of the break. When several ribs are broken in several places a flail chest results. Potential complicatio ...
, which damages lung tissue. Traumatic pneumothorax may also be observed in those exposed to blasts, even though there is no apparent injury to the chest.[
They may be classified as "open" or "closed". In an open pneumothorax, there is a passage from the external environment into the pleural space through the chest wall. When air is drawn into the pleural space through this passageway, it is known as a "sucking chest wound". A closed pneumothorax is when the chest wall remains intact.]
Pneumothorax was also reported as an adverse event caused by misplaced nasogastric feeding tubes. Avanos Medical
Avanos Medical, Inc. is a medical technology company making clinical medical devices. The company consists of two franchises – Pain Management and Chronic Care – that address reducing the use of opioids while helping patients recover faster an ...
's feeding tube placement system, the CORTRAK* 2 EAS, was recalled in May 2022 by the FDA
The United States Food and Drug Administration (FDA or US FDA) is a federal agency of the Department of Health and Human Services. The FDA is responsible for protecting and promoting public health through the control and supervision of food ...
due to adverse events reported including pneumothorax, total of 60 injuries and 23 patient deaths as communicated by the FDA.
Medical procedures, such as the insertion of a central venous catheter
A central venous catheter (CVC), also known as a central line(c-line), central venous line, or central venous access catheter, is a catheter placed into a large vein. It is a form of venous access. Placement of larger catheters in more central ...
into one of the chest veins or the taking of biopsy
A biopsy is a medical test commonly performed by a surgeon, interventional radiologist, or an interventional cardiologist. The process involves extraction of sample cells or tissues for examination to determine the presence or extent of a diseas ...
samples from lung tissue, may lead to pneumothorax. The administration of positive pressure ventilation
Modes of mechanical ventilation are one of the most important aspects of the usage of mechanical ventilation. The mode refers to the method of inspiratory support. In general, mode selection is based on clinician familiarity and institutional pref ...
, either mechanical ventilation
Mechanical ventilation, assisted ventilation or intermittent mandatory ventilation (IMV), is the medical term for using a machine called a ventilator to fully or partially provide artificial ventilation. Mechanical ventilation helps move air ...
or non-invasive ventilation
Non-invasive ventilation (NIV) is the use of breathing support administered through a face mask, nasal mask, or a helmet. Air, usually with added oxygen, is given through the mask under positive pressure; generally the amount of pressure is alter ...
, can result in barotrauma
Barotrauma is physical damage to body tissues caused by a difference in pressure between a gas space inside, or contact with, the body and the surrounding gas or liquid. The initial damage is usually due to over-stretching the tissues in tensio ...
(pressure-related injury) leading to a pneumothorax.[
]Divers
Diver or divers may refer to:
*Diving (sport), the sport of performing acrobatics while jumping or falling into water
*Practitioner of underwater diving, including:
**scuba diving,
**freediving,
**surface-supplied diving,
**saturation diving, a ...
who breathe from an underwater apparatus are supplied with breathing gas at ambient pressure
Ambient or Ambiance or Ambience may refer to:
Music and sound
* Ambience (sound recording), also known as atmospheres or backgrounds
* Ambient music, a genre of music that puts an emphasis on tone and atmosphere
* ''Ambient'' (album), by Moby
* ...
, which results in their lungs containing gas at higher than atmospheric pressure. Divers breathing compressed air (such as when scuba diving
Scuba diving is a mode of underwater diving whereby divers use breathing equipment that is completely independent of a surface air supply. The name "scuba", an acronym for "Self-Contained Underwater Breathing Apparatus", was coined by Chris ...
) may develop a pneumothorax as a result of barotrauma
Barotrauma is physical damage to body tissues caused by a difference in pressure between a gas space inside, or contact with, the body and the surrounding gas or liquid. The initial damage is usually due to over-stretching the tissues in tensio ...
from ascending just while breath-holding with their lungs fully inflated. An additional problem in these cases is that those with other features of decompression sickness
Decompression sickness (abbreviated DCS; also called divers' disease, the bends, aerobullosis, and caisson disease) is a medical condition caused by dissolved gases emerging from solution as bubbles inside the body tissues during decompressio ...
are typically treated in a diving chamber
A diving chamber is a vessel for human occupation, which may have an entrance that can be sealed to hold an internal pressure significantly higher than ambient pressure, a pressurised gas system to control the internal pressure, and a supply of ...
with hyperbaric therapy; this can lead to a small pneumothorax rapidly enlarging and causing features of tension.[
]
Newborn infants
Pneumothorax is more common in neonates than in any other age group. The incidence of symptomatic neonatal is estimated to be around 1-3 per 1000 live births. Prematurity, low birth weight and asphyxia are the major risk factors and a majority of the cases occur during the first 72 h of life.
Mechanism
The thoracic cavity
The thoracic cavity (or chest cavity) is the chamber of the body of vertebrates that is protected by the thoracic wall (rib cage and associated skin, muscle, and fascia). The central compartment of the thoracic cavity is the mediastinum. There ...
is the space inside the chest that contains the lungs, heart, and numerous major blood vessels. On each side of the cavity, a pleural membrane covers the surface of lung (visceral pleura
The pulmonary pleurae (''sing.'' pleura) are the two opposing layers of serous membrane overlying the lungs and the inside of the surrounding chest walls.
The inner pleura, called the visceral pleura, covers the surface of each lung and dips b ...
) and also lines the inside of the chest wall (parietal pleura
The pulmonary pleurae (''sing.'' pleura) are the two opposing layers of serous membrane overlying the lungs and the inside of the surrounding chest walls.
The inner pleura, called the visceral pleura, covers the surface of each lung and dips be ...
). Normally, the two layers are separated by a small amount of lubricating serous fluid
In physiology, serous fluid or serosal fluid (originating from the Medieval Latin word ''serosus'', from Latin ''serum'') is any of various body fluids resembling Serum (blood), serum, that are typically pale yellow or transparent and of a benign ...
. The lungs are fully inflated within the cavity because the pressure inside the airways ( intrapulmonary pressure) is higher than the pressure inside the pleural space (intrapleural pressure In physiology, intrapleural pressure refers to the pressure within the pleural cavity. Normally, the pressure within the pleural cavity is slightly less than the atmospheric pressure, which is known as ''negative pressure''.Khanorkar, p. 205 When th ...
). Despite the low pressure in the pleural space, air does not enter it because there are no natural connections to an air-containing passage, and the pressure of gases in the bloodstream is too low for them to be forced into the pleural space.[ Therefore, a pneumothorax can only develop if air is allowed to enter, through damage to the chest wall or damage to the lung itself, or occasionally because ]microorganism
A microorganism, or microbe,, ''mikros'', "small") and ''organism'' from the el, ὀργανισμός, ''organismós'', "organism"). It is usually written as a single word but is sometimes hyphenated (''micro-organism''), especially in olde ...
s in the pleural space produce gas.[ Once air enters the pleural cavity, the intrapleural pressure increases resulting in the difference between the intrapulmonary pressure and the intrapleural pressure (defined as the ]transpulmonary pressure Transpulmonary pressure is the difference between the alveolar pressure and the intrapleural pressure in the pleural cavity. During human ventilation, air flows because of pressure gradients.
Ptp = Palv – Pip. Where Ptp is transpulmonary pressur ...
) to equal zero which cause the lungs to deflate in contrast to a normal transpulmonary pressure of ~4 mm Hg.
Chest-wall defects are usually evident in cases of injury to the chest wall, such as stab or bullet wounds ("open pneumothorax"). In secondary spontaneous pneumothoraces, vulnerabilities in the lung tissue are caused by a variety of disease processes, particularly by rupturing of bullae (large air-containing lesions) in cases of severe emphysema
Emphysema, or pulmonary emphysema, is a lower respiratory tract disease, characterised by air-filled spaces ( pneumatoses) in the lungs, that can vary in size and may be very large. The spaces are caused by the breakdown of the walls of the alve ...
. Areas of necrosis
Necrosis () is a form of cell injury which results in the premature death of cells in living tissue by autolysis. Necrosis is caused by factors external to the cell or tissue, such as infection, or trauma which result in the unregulated dige ...
(tissue death) may precipitate episodes of pneumothorax, although the exact mechanism is unclear.[ Primary spontaneous pneumothorax (PSP) has for many years been thought to be caused by " blebs" (small air-filled lesions just under the pleural surface), which were presumed to be more common in those classically at risk of pneumothorax (tall males) due to mechanical factors. In PSP, blebs can be found in 77% of cases, compared to 6% in the general population without a history of PSP.][ As these healthy subjects do not all develop a pneumothorax later, the hypothesis may not be sufficient to explain all episodes; furthermore, pneumothorax may recur even after surgical treatment of blebs.][ It has therefore been suggested that PSP may also be caused by areas of disruption (porosity) in the pleural layer, which are prone to rupture.] Smoking may additionally lead to inflammation
Inflammation (from la, wikt:en:inflammatio#Latin, inflammatio) is part of the complex biological response of body tissues to harmful stimuli, such as pathogens, damaged cells, or Irritation, irritants, and is a protective response involving im ...
and obstruction
Obstruction may refer to:
Places
* Obstruction Island, in Washington state
* Obstruction Islands, east of New Guinea
Medicine
* Obstructive jaundice
* Obstructive sleep apnea
* Airway obstruction, a respiratory problem
** Recurrent airway o ...
of small airways, which account for the markedly increased risk of PSPs in smokers.[ Once air has stopped entering the pleural cavity, it is gradually reabsorbed.][
Tension pneumothorax occurs when the opening that allows air to enter the pleural space functions as a one-way valve, allowing more air to enter with every breath but none to escape. The body compensates by increasing the ]respiratory rate
The respiratory rate is the rate at which breathing occurs; it is set and controlled by the respiratory center of the brain. A person's respiratory rate is usually measured in breaths per minute.
Measurement
The respiratory rate in humans is mea ...
and tidal volume
Tidal volume (symbol VT or TV) is the volume of air moved into or out of the lungs during a normal breath. In a healthy, young human adult, tidal volume is approximately 500 ml per inspiration or 7 ml/kg of body mass.
Mechanical vent ...
(size of each breath), worsening the problem. Unless corrected, hypoxia (decreased oxygen levels) and respiratory arrest
Respiratory arrest is a sickness caused by apnea (cessation of breathing) or respiratory dysfunction severe enough it will not sustain the body (such as agonal breathing). Prolonged apnea refers to a patient who has stopped breathing for a long p ...
eventually follow.[
]
Diagnosis
The symptoms of pneumothorax can be vague and inconclusive, especially in those with a small PSP; confirmation with medical imaging
Medical imaging is the technique and process of imaging the interior of a body for clinical analysis and medical intervention, as well as visual representation of the function of some organs or tissues (physiology). Medical imaging seeks to rev ...
is usually required.[ In contrast, tension pneumothorax is a medical emergency and may be treated before imaging – especially if there is severe hypoxia, very low blood pressure, or an impaired level of consciousness. In tension pneumothorax, X-rays are sometimes required if there is doubt about the anatomical location of the pneumothorax.][
]
Chest X-ray
A plain chest radiograph
A chest radiograph, called a chest X-ray (CXR), or chest film, is a projection radiograph of the chest used to diagnose conditions affecting the chest, its contents, and nearby structures. Chest radiographs are the most common film taken in med ...
, ideally with the X-ray
An X-ray, or, much less commonly, X-radiation, is a penetrating form of high-energy electromagnetic radiation. Most X-rays have a wavelength ranging from 10 picometers to 10 nanometers, corresponding to frequencies in the range 30&nb ...
beams being projected from the back (posteroanterior, or "PA"), and during maximal inspiration (holding one's breath), is the most appropriate first investigation. It is not believed that routinely taking images during expiration would confer any benefit. Still, they may be useful in the detection of a pneumothorax when clinical suspicion is high but yet an inspiratory radiograph appears normal. Also, if the PA X-ray does not show a pneumothorax but there is a strong suspicion of one, lateral X-rays (with beams projecting from the side) may be performed, but this is not routine practice.[
File:X-ray subtle pneumothorax in inspiration - annotated.jpg, Anteroposterior inspired X-ray, showing subtle left-sided pneumothorax caused by ]port
A port is a maritime facility comprising one or more wharves or loading areas, where ships load and discharge cargo and passengers. Although usually situated on a sea coast or estuary, ports can also be found far inland, such as Ham ...
insertion
File:Lateral X-ray of pneumothorax in inspiration - annotated.jpg, Lateral inspired X-ray at the same time, more clearly showing the pneumothorax posteriorly in this case
File:Expired X-ray of pneumothorax.jpg, Anteroposterior expired X-ray at the same time, more clearly showing the pneumothorax in this case
File:Rt_sided_pneumoD.jpg, Chest X-ray showing a pneumothorax on the right (left in the image), where the absence of lung markings indicates that there is free air inside the chest
File:x-ray of pneumothorax signs.jpg, Chest X-ray showing the features of pneumothorax on the left side of the person (right in image)
It is not unusual for the mediastinum
The mediastinum (from ) is the central compartment of the thoracic cavity. Surrounded by loose connective tissue, it is an undelineated region that contains a group of structures within the thorax, namely the heart and its vessels, the esophagu ...
(the structure between the lungs that contains the heart, great blood vessels, and large airways) to be shifted away from the affected lung due to the pressure differences. This is ''not'' equivalent to a tension pneumothorax, which is determined mainly by the constellation of symptoms, hypoxia, and shock
Shock may refer to:
Common uses Collective noun
*Shock, a historic commercial term for a group of 60, see English numerals#Special names
* Stook, or shock of grain, stacked sheaves
Healthcare
* Shock (circulatory), circulatory medical emergen ...
.[
The size of the pneumothorax (i.e. the volume of air in the pleural space) can be determined with a reasonable degree of accuracy by measuring the distance between the chest wall and the lung. This is relevant to treatment, as smaller pneumothoraces may be managed differently. An air rim of 2 cm means that the pneumothorax occupies about 50% of the hemithorax.][ British professional guidelines have traditionally stated that the measurement should be performed at the level of the hilum (where blood vessels and airways enter the lung) with 2 cm as the cutoff,][ while American guidelines state that the measurement should be done at the ]apex
The apex is the highest point of something. The word may also refer to:
Arts and media Fictional entities
* Apex (comics), a teenaged super villainess in the Marvel Universe
* Ape-X, a super-intelligent ape in the Squadron Supreme universe
*Apex ...
(top) of the lung with 3 cm differentiating between a "small" and a "large" pneumothorax. The latter method may overestimate the size of a pneumothorax if it is located mainly at the apex, which is a common occurrence.[ The various methods correlate poorly but are the best easily available ways of estimating pneumothorax size.][ CT scanning (see below) can provide a more accurate determination of the size of the pneumothorax, but its routine use in this setting is not recommended.][
Not all pneumothoraces are uniform; some only form a pocket of air in a particular place in the chest.][ Small amounts of fluid may be noted on the chest X-ray (]hydropneumothorax
Hydropneumothorax is defined as the presence of both air and fluid within the pleural space. An upright chest x-ray will show air fluid levels. The horizontal fluid level is usually well defined and extends across the whole length of one of the he ...
); this may be blood (hemopneumothorax
Hemopneumothorax, or haemopneumothorax, is the condition of having both air (pneumothorax) and blood (hemothorax) in the chest cavity. A hemothorax, pneumothorax, or the combination of both can occur due to an injury to the lung or chest.
Cause
T ...
).[ In some cases, the only significant abnormality may be the " deep sulcus sign", in which the normally small space between the chest wall and the diaphragm appears enlarged due to the abnormal presence of fluid.][
]
Computed tomography
A CT scan is not necessary for the diagnosis of pneumothorax, but it can be useful in particular situations. In some lung diseases, especially emphysema, it is possible for abnormal lung areas such as bullae (large air-filled sacs) to have the same appearance as a pneumothorax on chest X-ray, and it may not be safe to apply any treatment before the distinction is made and before the exact location and size of the pneumothorax is determined.[ In trauma, where it may not be possible to perform an upright film, chest radiography may miss up to a third of pneumothoraces, while CT remains very sensitive.][
A further use of CT is in the identification of underlying lung lesions. In presumed primary pneumothorax, it may help to identify blebs or cystic lesions (in anticipation of treatment, see below), and in secondary pneumothorax, it can help to identify most of the causes listed above.][
]
Ultrasound
Ultrasound
Ultrasound is sound waves with frequency, frequencies higher than the upper audible limit of human hearing range, hearing. Ultrasound is not different from "normal" (audible) sound in its physical properties, except that humans cannot hea ...
is commonly used in the evaluation of people who have sustained physical trauma, for example with the FAST protocol The FAST protocol ( FIX Adapted for STreaming) is a technology standard developed by FIX Protocol Ltd., specifically aimed at optimizing data representation on the network. It is used to support high-throughput, low latency data communications betwe ...
. Ultrasound may be more sensitive than chest X-rays in the identification of pneumothorax after blunt trauma
Blunt trauma, also known as blunt force trauma or non-penetrating trauma, is physical traumas, and particularly in the elderly who fall. It is contrasted with penetrating trauma which occurs when an object pierces the skin and enters a tissue ...
to the chest. Ultrasound may also provide a rapid diagnosis in other emergency situations, and allow the quantification of the size of the pneumothorax. Several particular features on ultrasonography of the chest can be used to confirm or exclude the diagnosis.
File:UOTW 6 - Ultrasound of the Week 1.webm, Ultrasound showing a pneumothorax
File:UOTW 62 - Ultrasound of the Week 1.webm, Ultrasound showing a false lung point and not a pneumothorax
Treatment
The treatment of pneumothorax depends on a number of factors and may vary from discharge with early follow-up to immediate needle decompression or insertion of a chest tube
A chest tube (also chest drain, thoracic catheter, tube thoracostomy or intercostal drain) is a surgical drain that is inserted through the chest wall and into the pleural space or the mediastinum in order to remove clinically undesired substance ...
. Treatment is determined by the severity of symptoms and indicators of acute
Acute may refer to:
Science and technology
* Acute angle
** Acute triangle
** Acute, a leaf shape in the glossary of leaf morphology
* Acute (medicine), a disease that it is of short duration and of recent onset.
** Acute toxicity, the adverse eff ...
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.[
In traumatic pneumothorax, chest tubes are usually inserted. If mechanical ventilation is required, the risk of tension pneumothorax is greatly increased and the insertion of a chest tube is mandatory.] Any open chest wound should be covered with an airtight seal, as it carries a high risk of leading to tension pneumothorax. Ideally, a dressing called the "Asherman seal" should be utilized, as it appears to be more effective than a standard "three-sided" dressing. The Asherman seal is a specially designed device that adheres to the chest wall and, through a valve-like mechanism, allows air to escape but not to enter the chest.
Tension pneumothorax is usually treated with urgent needle decompression. This may be required before transport to the hospital, and can be performed by an emergency medical technician
An emergency medical technician (EMT), also known as an ambulance technician, is a health professional that provides emergency medical services. EMTs are most commonly found working in ambulances. In English-speaking countries, paramedics are ...
or other trained professional.[ The needle or ]cannula
A cannula (; Latin meaning 'little reed'; plural or ) is a tube that can be inserted into the body, often for the delivery or removal of fluid or for the gathering of samples. In simple terms, a cannula can surround the inner or outer surfaces ...
is left in place until a chest tube can be inserted.[ Critical care teams are able to incise the chest to create a larger conduit as performed when placing a chest drain, but without inserting the chest tube. This is called a simple thoracostomy. If tension pneumothorax leads to ]cardiac arrest
Cardiac arrest is when the heart suddenly and unexpectedly stops beating. It is a medical emergency that, without immediate medical intervention, will result in sudden cardiac death within minutes. Cardiopulmonary resuscitation (CPR) and possib ...
, needle decompression or simple thoracostomy is performed as part of resuscitation as it may restore cardiac output
In cardiac physiology, cardiac output (CO), also known as heart output and often denoted by the symbols Q, \dot Q, or \dot Q_ , edited by Catherine E. Williamson, Phillip Bennett is the volumetric flow rate of the heart's pumping output: t ...
.
Conservative
Small spontaneous pneumothoraces do not always require treatment, as they are unlikely to proceed to respiratory failure
Respiratory failure results from inadequate gas exchange by the respiratory system, meaning that the arterial oxygen, carbon dioxide, or both cannot be kept at normal levels. A drop in the oxygen carried in the blood is known as hypoxemia; a rise ...
or tension pneumothorax, and generally resolve spontaneously. This approach is most appropriate if the estimated size of the pneumothorax is small (defined as <50% of the volume of the hemithorax), there is no breathlessness
Shortness of breath (SOB), also medically known as dyspnea (in AmE) or dyspnoea (in BrE), is an uncomfortable feeling of not being able to breathe well enough. The American Thoracic Society defines it as "a subjective experience of breathing dis ...
, and there is no underlying lung disease.[ It may be appropriate to treat a larger PSP conservatively if the symptoms are limited.][ Admission to hospital is often not required, as long as clear instructions are given to return to hospital if there are worsening symptoms. Further investigations may be performed as an ]outpatient
A patient is any recipient of health care services that are performed by healthcare professionals. The patient is most often ill or injured and in need of treatment by a physician, nurse, optometrist, dentist, veterinarian, or other health care ...
, at which time X-rays are repeated to confirm improvement, and advice given with regard to preventing recurrence (see below).[ Estimated rates of resorption are between 1.25% and 2.2% the volume of the cavity per day. This would mean that even a complete pneumothorax would spontaneously resolve over a period of about 6 weeks.][ There is, however, no high quality evidence comparing conservative to non conservative management.
Secondary pneumothoraces are only treated conservatively if the size is very small (1 cm or less air rim) and there are limited symptoms. Admission to the hospital is usually recommended. ]Oxygen
Oxygen is the chemical element with the symbol O and atomic number 8. It is a member of the chalcogen group in the periodic table, a highly reactive nonmetal, and an oxidizing agent that readily forms oxides with most elements as wel ...
given at a high flow rate may accelerate resorption as much as fourfold.
Aspiration
In a large PSP (>50%), or in a PSP associated with breathlessness, some guidelines recommend that reducing the size by aspiration is equally effective as the insertion of a chest tube. This involves the administration of local anesthetic
A local anesthetic (LA) is a medication that causes absence of pain sensation. In the context of surgery, a local anesthetic creates an absence of pain in a specific location of the body without a loss of consciousness, as opposed to a general an ...
and inserting a needle connected to a three-way tap; up to 2.5 liters of air (in adults) are removed. If there has been significant reduction in the size of the pneumothorax on subsequent X-ray, the remainder of the treatment can be conservative. This approach has been shown to be effective in over 50% of cases.[ Compared to tube drainage, first-line aspiration in PSP reduces the number of people requiring hospital admission, without increasing the risk of complications.
Aspiration may also be considered in secondary pneumothorax of moderate size (air rim 1–2 cm) without breathlessness, with the difference that ongoing observation in hospital is required even after a successful procedure.][ American professional guidelines state that all large pneumothoraces – even those due to PSP – should be treated with a chest tube.][ Moderately sized ]iatrogenic
Iatrogenesis is the causation of a disease, a harmful complication, or other ill effect by any medical activity, including diagnosis, intervention, error, or negligence. "Iatrogenic", ''Merriam-Webster.com'', Merriam-Webster, Inc., accessed 2 ...
traumatic pneumothoraces (due to medical procedures) may initially be treated with aspiration.[
]
Chest tube
A chest tube
A chest tube (also chest drain, thoracic catheter, tube thoracostomy or intercostal drain) is a surgical drain that is inserted through the chest wall and into the pleural space or the mediastinum in order to remove clinically undesired substance ...
(or intercostal drain) is the most definitive initial treatment of a pneumothorax. These are typically inserted in an area under the axilla
The axilla (also, armpit, underarm or oxter) is the area on the human body directly under the shoulder joint. It includes the axillary space, an anatomical space within the shoulder girdle between the arm and the thoracic cage, bounded superior ...
(armpit) called the " safe triangle", where damage to internal organs can be avoided; this is delineated by a horizontal line at the level of the nipple and two muscles of the chest wall (latissimus dorsi
The latissimus dorsi () is a large, flat muscle on the back that stretches to the sides, behind the arm, and is partly covered by the trapezius on the back near the midline. The word latissimus dorsi (plural: ''latissimi dorsorum'') comes from L ...
and pectoralis major
The pectoralis major () is a thick, fan-shaped or triangular convergent muscle, situated at the chest of the human body. It makes up the bulk of the chest muscles and lies under the breast. Beneath the pectoralis major is the pectoralis minor, a ...
). Local anesthetic is applied. Two types of tubes may be used. In spontaneous pneumothorax, small-bore (smaller than 14 F, 4.7 mm diameter) tubes may be inserted by the Seldinger technique
The Seldinger technique, also known as Seldinger wire technique, is a medical procedure to obtain safe access to blood vessels and other hollow organs. It is named after Sven Ivar Seldinger (1921–1998), a Swedish radiologist who introduced th ...
, and larger tubes do not have an advantage.[ In traumatic pneumothorax, larger tubes (28 F, 9.3 mm) are used.][ When chest tubes are placed due to either blunt or penetrating trauma, ]antibiotic
An antibiotic is a type of antimicrobial substance active against bacteria. It is the most important type of antibacterial agent for fighting bacterial infections, and antibiotic medications are widely used in the treatment and prevention of ...
s decrease the risks of infectious complications.
Chest tubes are required in PSPs that have not responded to needle aspiration, in large SSPs (>50%), and in cases of tension pneumothorax. They are connected to a one-way valve
A check valve, non-return valve, reflux valve, retention valve, foot valve, or one-way valve is a valve that normally allows fluid ( liquid or gas) to flow through it in only one direction.
Check valves are two-port valves, meaning they have ...
system that allows air to escape, but not to re-enter, the chest. This may include a bottle with water that functions like a water seal, or a Heimlich valve
A flutter valve (also known as the Heimlich valve after its inventor, Henry Heimlich) is a one-way valve used in respiratory medicine to prevent air from travelling back along a chest tube. One can also use a chest drainage management system, w ...
. They are not normally connected to a negative pressure circuit, as this would result in rapid re-expansion of the lung and a risk of pulmonary edema
Pulmonary edema, also known as pulmonary congestion, is excessive edema, liquid accumulation in the parenchyma, tissue and pulmonary alveolus, air spaces (usually alveoli) of the lungs. It leads to impaired gas exchange and may cause hypoxemia an ...
("re-expansion pulmonary edema"). The tube is left in place until no air is seen to escape from it for a period of time, and X-rays confirm re-expansion of the lung.[
If after 2–4 days there is still evidence of an air leak, various options are available. Negative pressure suction (at low pressures of –10 to –20 cmH2O) at a high flow rate may be attempted, particularly in PSP; it is thought that this may accelerate the healing of the leak. Failing this, surgery may be required, especially in SSP.][
Chest tubes are used first-line when pneumothorax occurs in people with ]AIDS
Human immunodeficiency virus infection and acquired immunodeficiency syndrome (HIV/AIDS) is a spectrum of conditions caused by infection with the human immunodeficiency virus (HIV), a retrovirus. Following initial infection an individual m ...
, usually due to underlying pneumocystis pneumonia
''Pneumocystis'' pneumonia (PCP), also known as ''Pneumocystis jirovecii'' pneumonia (PJP), is a form of pneumonia that is caused by the yeast-like fungus ''Pneumocystis jirovecii''.
''Pneumocystis'' specimens are commonly found in the lungs of ...
(PCP), as this condition is associated with prolonged air leakage. Bilateral pneumothorax (pneumothorax on both sides) is relatively common in people with pneumocystis pneumonia, and surgery is often required.[
It is possible for a person with a chest tube to be managed in an ]ambulatory care
Ambulatory care or outpatient care is medical care provided on an outpatient basis, including diagnosis, observation, consultation, treatment, intervention, and rehabilitation services. This care can include advanced medical technology and procedu ...
setting by using a Heimlich valve, although research to demonstrate the equivalence to hospitalization has been of limited quality.
Pleurodesis and surgery
Pleurodesis
Pleurodesis is a medical procedure in which part of the pleural space is artificially obliterated. It involves the adhesion of the visceral and the costal pleura. The mediastinal pleura is spared.
Uses
Pleurodesis is performed to prevent recurre ...
is a procedure that permanently eliminates the pleural space and attaches the lung to the chest wall. No long-term study (20 years or more) has been performed on its consequences. Good results in the short term are achieved with a thoracotomy
A thoracotomy is a surgical procedure to gain access into the pleural space of the chest. It is performed by surgeons (emergency physicians or paramedics under certain circumstances) to gain access to the thoracic organs, most commonly the hea ...
(surgical opening of the chest) with identification of any source of air leakage and stapling of blebs followed by pleurectomy (stripping of the pleural lining) of the outer pleural layer and pleural abrasion (scraping of the pleura) of the inner layer. During the healing process, the lung adheres to the chest wall, effectively obliterating the pleural space. Recurrence rates are approximately 1%.[ Post-thoracotomy pain is relatively common.
]
A less invasive approach is thoracoscopy
Thoracoscopy is a medical procedure involving internal examination, biopsy and/or resection/drainage of disease or masses within the pleural cavity, usually with video assistance. Thoracoscopy may be performed either under general anaesthe ...
, usually in the form of a procedure called video-assisted thoracoscopic surgery
Video-assisted thoracoscopic surgery (VATS) is a type of minimally invasive thoracic surgery performed using a small video camera mounted to a fiberoptic thoracoscope (either 5 mm or 10 mm caliber), with or without angulated visualizat ...
(VATS). The results from VATS-based pleural abrasion are slightly worse than those achieved using thoracotomy in the short term, but produce smaller scars in the skin.[ Compared to open thoracotomy, VATS offers a shorter in-hospital stays, less need for postoperative pain control, and a reduced risk of lung problems after surgery.][ VATS may also be used to achieve chemical pleurodesis; this involves insufflation of ]talc
Talc, or talcum, is a Clay minerals, clay mineral, composed of hydrated magnesium silicate with the chemical formula Mg3Si4O10(OH)2. Talc in powdered form, often combined with corn starch, is used as baby powder. This mineral is used as a thi ...
, which activates an inflammatory reaction that causes the lung to adhere to the chest wall.[
If a chest tube is already in place, various agents may be instilled through the tube to achieve chemical ]pleurodesis
Pleurodesis is a medical procedure in which part of the pleural space is artificially obliterated. It involves the adhesion of the visceral and the costal pleura. The mediastinal pleura is spared.
Uses
Pleurodesis is performed to prevent recurre ...
, such as talc, tetracycline
Tetracycline, sold under various brand names, is an oral antibiotic in the tetracyclines family of medications, used to treat a number of infections, including Acne vulgaris, acne, cholera, brucellosis, plague (disease), plague, malaria, and sy ...
, minocycline
Minocycline, sold under the brand name Minocin among others, is a tetracycline antibiotic medication used to treat a number of bacterial infections such as pneumonia. It is generally less preferred than the tetracycline doxycycline. It is also ...
or doxycycline
Doxycycline is a broad-spectrum tetracycline class antibiotic used in the treatment of infections caused by bacteria and certain parasites. It is used to treat bacterial pneumonia, acne, chlamydia infections, Lyme disease, cholera, typhus, an ...
. Results of chemical pleurodesis tend to be worse than when using surgical approaches,[ but talc pleurodesis has been found to have few negative long-term consequences in younger people.][
]
Aftercare
If pneumothorax occurs in a smoker, this is considered an opportunity to emphasize the markedly increased risk of recurrence in those who continue to smoke, and the many benefits of smoking cessation
Smoking cessation, usually called quitting smoking or stopping smoking, is the process of discontinuing tobacco smoking. Tobacco smoke contains nicotine, which is addictive and can cause dependence. As a result, nicotine withdrawal often make ...
.[ It may be advisable for someone to remain off work for up to a week after a spontaneous pneumothorax. If the person normally performs heavy manual labor, several weeks may be required. Those who have undergone pleurodesis may need two to three weeks off work to recover.]
Air travel
Air travel is a form of travel in vehicles such as airplanes, jet aircraft, helicopters, hot air balloons, blimps, gliders, hang gliders, parachutes, or anything else that can sustain flight. is discouraged for up to seven days after complete resolution of a pneumothorax if recurrence does not occur.[ ]Underwater diving
Underwater diving, as a human activity, is the practice of descending below the water's surface to interact with the environment. It is also often referred to as diving, an ambiguous term with several possible meanings, depending on context ...
is considered unsafe after an episode of pneumothorax unless a preventive procedure has been performed. Professional guidelines suggest that pleurectomy be performed on both lungs and that lung function tests
Pulmonary function testing (PFT) is a complete evaluation of the respiratory system including patient history, physical examinations, and tests of pulmonary function. The primary purpose of pulmonary function testing is to identify the severity ...
and CT scan normalize before diving is resumed.[ Aircraft pilots may also require assessment for surgery.][
]
Neonatal period
For newborn infants with pneumothorax, different management strategies have been suggested including careful observation, thoracentesis
Thoracentesis , also known as thoracocentesis (from Greek ''thōrax'' 'chest, thorax'—GEN ''thōrakos''—and ''kentēsis'' 'pricking, puncture'), pleural tap, needle thoracostomy, or needle decompression (often used term), is an invasive med ...
(needle aspiration), or insertion of a chest tube
A chest tube (also chest drain, thoracic catheter, tube thoracostomy or intercostal drain) is a surgical drain that is inserted through the chest wall and into the pleural space or the mediastinum in order to remove clinically undesired substance ...
. Needle aspiration may reduce the need for a chest tube, however, the effectiveness and safety of both invasive procedures have not been fully studied.
Prevention
A preventative procedure (thoracotomy
A thoracotomy is a surgical procedure to gain access into the pleural space of the chest. It is performed by surgeons (emergency physicians or paramedics under certain circumstances) to gain access to the thoracic organs, most commonly the hea ...
or thoracoscopy with pleurodesis) may be recommended after an episode of pneumothorax, with the intention to prevent recurrence. Evidence
Evidence for a proposition is what supports this proposition. It is usually understood as an indication that the supported proposition is true. What role evidence plays and how it is conceived varies from field to field.
In epistemology, evidenc ...
on the most effective treatment is still conflicting in some areas, and there is variation between treatments available in Europe and the US.[ Not all episodes of pneumothorax require such interventions; the decision depends largely on estimation of the risk of recurrence. These procedures are often recommended after the occurrence of a second pneumothorax.] Surgery may need to be considered if someone has experienced pneumothorax on both sides ("bilateral"), sequential episodes that involve both sides, or if an episode was associated with pregnancy.[
]
Epidemiology
The annual age-adjusted incidence rate
In epidemiology, incidence is a measure of the probability of occurrence of a given medical condition in a population within a specified period of time. Although sometimes loosely expressed simply as the number of new cases during some time peri ...
(AAIR) of PSP is thought to be three to six times as high in males as in females. Fishman cites AAIR's of 7.4 and 1.2 cases per 100,000 person-years in males and females, respectively. Significantly above-average height is also associated with increased risk of PSP – in people who are at least 76 inches (1.93 meters) tall, the AAIR is about 200 cases per 100,000 person-years. Slim build also seems to increase the risk of PSP.
The risk of contracting a first spontaneous pneumothorax is elevated among male and female smokers by factors of approximately 22 and 9, respectively, compared to matched non-smokers of the same sex. Individuals who smoke at higher intensity are at higher risk, with a "greater-than-linear" effect; men who smoke 10 cigarettes per day have an approximate 20-fold increased risk over comparable non-smokers, while smokers consuming 20 cigarettes per day show an estimated 100-fold increase in risk.
In secondary spontaneous pneumothorax, the estimated annual AAIR is 6.3 and 2.0 cases per 100,000 person-years for males and females, respectively, with the risk of recurrence depending on the presence and severity of any underlying lung disease. Once a second episode has occurred, there is a high likelihood of subsequent further episodes.[ The incidence in children has not been well studied,][ but is estimated to be between 5 and 10 cases per 100,000 person-years.]
Death from pneumothorax is very uncommon (except in tension pneumothoraces). British statistics show an annual mortality rate of 1.26 and 0.62 deaths per million person-years in men and women, respectively.[ A significantly increased risk of death is seen in older patients and in those with secondary pneumothoraces.][
]
History
An early description of traumatic pneumothorax secondary to rib fractures appears in ''Imperial Surgery'' by Turkish surgeon Şerafeddin Sabuncuoğlu (1385–1468), which also recommends a method of simple aspiration.
Pneumothorax was described in 1803 by Jean Marc Gaspard Itard
Jean Marc Gaspard Itard (24 April 1774, Oraison, Alpes-de-Haute-Provence – 5 July 1838, Paris) was a French physician born in Provence. He is perhaps best known for his work with Victor of Aveyron.
Biography
Itard, without a university e ...
, a student of René Laennec
René-Théophile-Hyacinthe Laennec (; 17 February 1781 – 13 August 1826) was a French physician and musician. His skill at carving his own wooden flutes led him to invent the stethoscope in 1816, while working at the Hôpital Necker ...
, who provided an extensive description of the clinical picture in 1819. While Itard and Laennec recognized that some cases were not due to tuberculosis
Tuberculosis (TB) is an infectious disease usually caused by '' Mycobacterium tuberculosis'' (MTB) bacteria. Tuberculosis generally affects the lungs, but it can also affect other parts of the body. Most infections show no symptoms, i ...
(then the most common cause), the concept of spontaneous pneumothorax in the absence of tuberculosis (primary pneumothorax) was reintroduced by the Danish physician Hans Kjærgaard in 1932.[ In 1941, the surgeons Tyson and Crandall introduced pleural abrasion for the treatment of pneumothorax.][
Prior to the advent of anti-tuberculous medications, pneumothoraces were intentionally caused by healthcare providers in people with tuberculosis in an effort to collapse a ]lobe
Lobe may refer to:
People with the name
* Lobe (surname)
Science and healthcare
* Lobe (anatomy)
* Lobe, a large-scale structure of a radio galaxy
* Glacial lobe, a lobe-shaped glacier
* Lobation, a characteristic of the nucleus of certain biolo ...
, or entire lung, around a cavitating lesion
A lesion is any damage or abnormal change in the tissue of an organism, usually caused by disease or trauma. ''Lesion'' is derived from the Latin "injury". Lesions may occur in plants as well as animals.
Types
There is no designated classifi ...
. This was known as "resting the lung". It was introduced by the Italian surgeon Carlo Forlanini
Carlo Forlanini (11 June 1847 – 26 May 1918) was a medical doctor and professor at the Universities of Turin and Pavia. He was also the inventor of artificial pneumothorax, which was the primary treatment method of pulmonary tuberculosis for t ...
in 1888 and publicized by the American surgeon John Benjamin Murphy
John Benjamin Murphy, born John Murphy (December 21, 1857 – August 11, 1916) was an American physician and abdominal surgeon noted for advocating early surgical intervention in appendicitis appendectomy, and several eponyms: Murphy’s button, ...
in the early 20th century (after discovering the same procedure independently). Murphy used the (then) recently discovered X-ray technology to create pneumothoraces of the correct size.
Etymology
The word pneumothorax is from the Greek '' pneumo-'' meaning air and ''thorax
The thorax or chest is a part of the anatomy of humans, mammals, and other tetrapod animals located between the neck and the abdomen. In insects, crustaceans, and the extinct trilobites, the thorax is one of the three main divisions of the cre ...
'' meaning chest. Its plural is pneumothoraces.
Other animals
Non-human animals may experience both spontaneous and traumatic pneumothorax. Spontaneous pneumothorax is, as in humans, classified as primary or secondary, while traumatic pneumothorax is divided into open and closed (with or without chest wall damage). The diagnosis may be apparent to the veterinary physician
A veterinarian (vet), also known as a veterinary surgeon or veterinary physician, is a medical professional who practices veterinary medicine. They manage a wide range of health conditions and injuries in non-human animals. Along with this, vet ...
because the animal exhibits difficulty breathing in, or has shallow breathing. Pneumothoraces may arise from lung lesions (such as bullae) or from trauma to the chest wall. In horses, traumatic pneumothorax may involve both hemithoraces, as the mediastinum
The mediastinum (from ) is the central compartment of the thoracic cavity. Surrounded by loose connective tissue, it is an undelineated region that contains a group of structures within the thorax, namely the heart and its vessels, the esophagu ...
is incomplete and there is a direct connection between the two halves of the chest. Tension pneumothorax – the presence of which may be suspected due to rapidly deteriorating heart function, absent lung sounds throughout the thorax, and a barrel-shaped chest – is treated with an incision in the animal's chest to relieve the pressure, followed by insertion of a chest tube. For spontaneous pneumothorax the use of CT for diagnosis has been described for dogs and Kunekune pigs.
References
{{Authority control
Chest trauma
Disorders of fascia
Medical emergencies
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