Pneumothorax Treatment & Management

  • Author: Brian James Daley, MD, MBA, FACS, FCCP, CNSC; Chief Editor: Mary C Mancini, MD, PhD   more...
 
Updated: Feb 24, 2012
 

Approach Considerations

Despite general agreement on the management of pneumothorax, a full consensus about management of initial or recurrent pneumothorax does not exist. Professional societies differ in their approach to management and hospitalization.[38, 53]

This section presents a risk stratification framework as well as other approaches for choosing among options to restore lung volume and an air-free pleural space and to prevent recurrences.[54] These goals are applicable across diverse clinical presentations. The range of therapeutic options includes watchful waiting with or without supplemental oxygen, simple aspiration, tube drainage with or without medical pleurodesis, vacuum-assisted thoracostomy (VATS) with pleurodesis and/or closure of leaks and bullectomy, and open surgical procedures such as thoracotomy for pleurectomy or pleurodesis.

Selection between the various management options requires an understanding of the natural history of pneumothorax, the risk of recurrent pneumothorax, and the benefits and limitations of each treatment option and discussion with the patient.

See also Restoring an Air-Free Pleural Space in Pneumothorax.

Pharmacotherapy

Medication may be necessary to treat a pulmonary disorder that causes the pneumothorax. For example, intravenous antibiotics are included in the treatment of a pneumothorax that developed as a sequela of staphylococcal pneumonia. In addition, studies suggest that the administration of prophylactic antibiotics during chest tube insertion may reduce the incidence of complications such as emphysema. Clearly, the use of analgesics can provide patient comfort until the thoracostomy tube is removed. Some authors advocate the use of intercostal nerve blocks to increase patient comfort and decrease the need for narcotic analgesics.

In patients with repeated pneumothoraces who are not good candidates for surgery, sclerotherapy with talc or doxycycline may be necessary.

Next

Treatment Based on Risk Stratification

The decision to observe or to treat with an immediate intervention should be guided by a risk stratification that considers the patient's presentation and the likelihood of spontaneous resolution and recurrence.

Patient presentation

The following are possible presentations of patients with pneumothorax:

  • Asymptomatic (incidental finding): Treatment decisions are guided by estimate of long-term recurrence risk.
  • Symptomatic but clinically stable: Treatment is guided by local resources and conventions for the site of care. The British Thoracic Society (BTS) advocates for simple aspiration and deferring hospitalization in primary spontaneous pneumothorax (PSP) as initial management if the patient is stable.[53] A small bore catheter or chest tube placement is recommended by the American College of Chest Physicians (ACCP) Delphi consensus statement.[38]
  • Clinically fragile: Treatment is guided by local practice patterns for air evacuation and observation. Comorbid conditions may preclude observation because of decreased cardiopulmonary reserve.
  • Life threatening: Pneumothorax that causes hemodynamic instability is life-threatening and must be treated immediately with tube thoracostomy. All documents and recommendations call for intervention if a patient is unstable.

Likelihood of resolution

The likelihood of a pneumothorax resolving is classified as follows:

  • Very likely to resolve: Small pneumothorax in a hemodynamically stable patient without significant parenchymal lung disease; small iatrogenic pneumothorax
  • May resolve: Large pneumothorax in a normal lung (eg, PSP or iatrogenic pneumothorax)
  • Unlikely to resolve: Secondary pneumothorax, enlarging pneumothorax (suggests a continuing air leak)
  • Will not resolve, could be fatal: Tension pneumothorax; unrecognized air leak

Likelihood of recurrence

The following categories of pneumothorax recurrence likelihood should be assessed:

  • Unlikely to recur: Iatrogenic pneumothorax in normal lung
  • May recur, but patient will likely be clinically stable
  • May recur and the patient may be clinically unstable, but emergency care is readily accessible
  • Very likely to recur: Diffuse and progressive pulmonary pathology (eg, lymphangioleiomyomatosis [LAM])
  • Recurrence could be life-threatening: Poor cardiopulmonary reserve, limited access to emergency medical care

Selection of site of patient care

The following is a suggested guideline on determining where to administer care in a patient with a pneumothorax:

  • Outpatient care: This can occur in asymptomatic patients or those with a small pneumothorax and reliable follow-up.
  • Emergency department (ED) care: Prolonged periods of observation are inefficient and clinically suboptimal; efficacy studies of manual aspiration and placement of 1-way valves performed in EDs are an attempt to address these practical issues.
  • Inpatient care: This site of care is generally selected when high-flow oxygen is needed, the pneumothorax is larger but the patient is stable, or comorbidities increase concern about risk or follow-up. The average hospital stay is 2.8 days.
  • Intensive care unit (ICU): ICU treatment and observation is appropriate for patients who are unstable or intubated.

Interval of observation

No protocols regarding serial radiography or imaging exist; the clinician typically reviews serial vital signs and clinical assessments, using the direction and rate of change in the patient’s clinical status to select imaging frequency. Monitoring pneumothorax size during this time is important, as follows:

  • At 0-6 hours: The ACCP Delphi consensus statement recommends observation in an ED for 6 hours, and discharge to home if a follow-up chest radiograph shows no enlargement of the lesion, in reliable patients.[38] Emergency room observation with a repeat radiograph 6 hours later used to be common but may be used less often now.
  • At 24-96 hours: Additional follow up in 2 days is recommended, with preference given to a 24-48 hour follow-up radiograph in the outpatient setting. Outpatient follow-up during the 96-hour (4-d) window is essential to distinguish between a resolved pneumothorax and one that needs evacuation. A computed tomography (CT) scan at this time distinguishes between PSP and secondary spontaneous pneumothorax (SSP).
  • At 1 month: Full lung reexpansion can occur, on average, 3 weeks after the initial event.
Previous
Next

Restoring an Air-Free Pleural Space

Several options are available to restore an air-free pleural space, including observation without oxygen, administering supplemental oxygen, simple aspiration, chest tube placement, 1-way valve insertion, and thoracostomy with continuous suction.

Contou et al recommend that clinicians consider drainage via a small-bore catheter as a first-line treatment for pneumothorax of any cause. The authors found that drainage via catheter or via chest tube is similarly effective for the management for the management of pneumothoraces, including primary spontaneous pneumothorax, secondary spontaneous pneumothorax, and traumatic and iatrogenic pneumothoraces.[55]

See also Restoring an Air-Free Pleural Space in Pneumothorax.

Observation without oxygen

Simple observation is appropriate for asymptomatic patients with a minimal pneumothorax (< 15-20% by Light criteria; 2-3 cm from apex to cupola by alternate criteria) with close follow-up, ensuring no enlargement (see Estimating the size of the pneumothorax under Chest Radiography). Air is reabsorbed spontaneously by 1.25% of size pneumothorax per day.[56]

An interesting multicenter, prospective, observational study reported on more than 500 trauma patients with occult pneumothorax identified on CT scan, with an initially normal chest radiograph. Controversy exists in the literature on the treatment of all patients with occult pneumothorax, whether to closely observe patients with occult pneumothorax or whether to place a chest tube. It is even more controversial in patients on positive pressure ventilation. It is generally accepted after trauma to treat pneumothorax seen on chest radiographs with chest tube thoracostomy. Conversion to tension pneumothorax is the worst feared complication if left untreated.

The study arms included observation versus chest tube thoracostomy. Only 6% of patients failed observation and developed pneumothorax, including only 15% failed observation on positive pressure ventilation. In multivariate regression analysis, failure of observation was seen in patients with chest radiographic evidence of pneumothorax progression and symptoms of respiratory distress. According to this study, it is safe to closely observe trauma patients with occult pneumothorax on chest radiographs, even if receiving mechanical ventilation.[57]

Supplemental oxygen

Oxygen administration at 3 L/min nasal canula or higher flow treats possible hypoxemia and is associated with a 4-fold increase in the rate of pleural air absorption compared with room air alone.

Simple aspiration

Simple aspiration in 131 cases of small spontaneous pneumothorax yielded successful results up to 87%.[58] Other studies have described more limited success in up to 70% cases.[59] A more recent emergency department (ED) study supports needle aspiration as safe and effective as chest tube placement for primary spontaneous pneumothorax (PSP), conferring the additional benefits of shorter length of stay and fewer hospital admissions.[60]

Chest tube placement

A tube inserted into the pleural space is connected to a device with 1-way flow for air removal. Examples of such devices are Heimlich valves or water seal canisters, and tubes connected to wall suction devices.

One-way valve insertion (portable system)

The typical goal of inserting 1-way valve systems is to avoid hospital admission and still treat the spontaneous pneumothorax. One-way valves may also expedite hospital discharge and be used during transport of an injured patient.

A Heimlich valve is a 1-way, rubber flutter valve that allows for complete evacuation of air that is not under tension. The proximal end attaches to the chest tube or catheter, and the distal end connects to a suction device or is left open to the atmosphere.

Heimlich valves do not require suction and thus eliminate the chance of a tension pneumothorax; they also allow greater mobility and less discomfort for the patient. By decreasing the length of the hospital stay and allowing for outpatient care, medical costs are reduced as well.

In a pilot study, Marquette et al determined that using a serial-steps approach with a single system (small-caliber catheter/Heimlich valve) in patients with a first episode of PSP was as effective as simple manual needle aspiration or a conventional chest tube thoracotomy.[61] In 41 thin, young, smoking males, a 1-way Heimlich valve was connected to the catheter, allowing the air to flow spontaneously outward for 24-48 hours; thereafter, if the lung failed to re-expand, wall suction was applied. Patients with an air leak persisting for more than 4 days were referred for surgery.

At 24 hours, the success rate was 61%, and at 1 week, it had risen to 85%; the actuarial 1-year recurrence rate was 24%.[61] When 24-hour and 1-week success rates and recurrence at 12 months were taken as end points, the method described above was effective as simple manual needle aspiration or a conventional chest tube thoracotomy.[61]

Heimlich valves are widely used in the care of patients with acquired immunodeficiency syndrome (AIDS) who have a median length of 20 days of chest tube placement to facilitate care and mobility.

Thoracostomy with continuous wall suction

First-time secondary spontaneous pneumothorax (SPS) (including chronic obstructive pulmonary disease [COPD]) and traumatic pneumothorax typically require this approach. A small-bore catheter (eg, 7-14F) is safe to use in most patients, whereas a larger chest tube (24F) is also appropriate initially, and increasing suction pressure can be used if the lung fails to inflate.

A larger tube (eg, 28F) can reduce resistance in patients who are ventilated and at greater risk for air leaks. Air leaks resolve within 7 days of treatment 80% of the time, with an average hospital stay of 5 days. Keep the tube in place for 24 hours after the air leak ceases.

Previous
Next

Prehospital Care

Assess the ABCs (airway, breathing, circulation), and evaluate the possibility of a tension pneumothorax. Assess the vital signs, and perform pulse oximetry. A tension pneumothorax is almost always associated with hypotension.

Administer oxygen to the patient, ventilate the patient, and establish an intravenous (IV) line.

Tension pneumothorax

Failure of the emergency medical service personnel (EMS) and medical control physician to make a correct diagnosis of tension pneumothorax and to promptly perform needle decompression in the prehospital setting can result in rapid clinical deterioration and cardiac arrest. Most paramedics are trained and protocolized to perform needle decompression for immediate relief of a tension pneumothorax.

However, if an incorrect diagnosis of tension pneumothorax is made in the prehospital setting, the patient's life may be endangered by unnecessary invasive procedures. Close cooperation and accurate communication between the emergency department (ED) and the EMS personnel is of paramount importance.

To prevent reentry of air into the pleural cavity after needle thoracostomy and decompression in the prehospital setting, a 1-way valve should be attached to the distal end of the Angiocath. If available, a Heimlich valve may be used. If a commercially prepared valve is not available, attach a finger condom or the finger of a rubber glove with its tip removed to serve as a makeshift 1-way valve device.

Clothing covering a wound that communicates with the chest cavity can play a role in producing a 1-way valve effect, allowing air to enter the pleural cavity but hindering its exit. Removing such clothing items from the wound may facilitate decompression of a tension pneumothorax.

A tension pneumothorax is a contraindication to the use of military antishock trousers.

Prehospital ultrasonography

In a preliminary 2006 study from Norway, Busch evaluated the feasibility of using portable ultrasound in an air rescue setting, concluding that prehospital ultrasonography could provide diagnostic and therapeutic benefit when conducted by a proficient examiner who used goal-directed and time-sensitive protocols.[42] Further study in this area may help to determine the indications and role of prehospital ultrasonography.

Previous
Next

Hospital Management

Immediate attention to the ABCs (airway, breathing, circulation) while assessing vital signs and oxygen saturation is paramount, particularly in patients with thoracic trauma. Evaluate the patency of the airway and the adequacy of the ventilatory effort. Assess the circulatory status and the integrity of the chest wall. Carefully evaluate the cardiovascular system, because a tension pneumothorax and pericardial tamponade can cause similar findings.

Emergency department (ED) care depends on the hemodynamic stability of the patient. All patients should receive supplemental oxygen to increase oxygen saturation and to enhance the reabsorption of free air.

Note that ultrasonography is the only radiographic modality that allows patients with nonarrhythmogenic cardiac arrest to continue undergoing resuscitation while clinicians search for easily reversible causes of asystole or pulseless electrical activity (PEA).[62] A protocol (using the acronym CAUSE for cardiac arrest ultrasound exam) in which cardiac arrest patients, concurrent with resuscitation, receive bedside ultrasonography to look for cardiac tamponade, massive pulmonary embolus, severe hypovolemia, and tension pneumothorax has been proposed for further investigation. It is possible that the eventual adoption of ultrasonography in this setting may allow increased "real-time" diagnostic acumen, decreasing the time required to receive appropriate condition-related therapy.

Primary and secondary spontaneous pneumothorax

If the primary spontaneous pneumothorax (PSP) is smaller than 15% (or estimated as small) (see Estimating the size of the pneumothorax under Chest Radiography), and the patient is symptomatic but hemodynamically stable, needle aspiration is the treatment of choice.

If the PSP is smaller than 15% and if the patient is asymptomatic, many consider observation to be the treatment of choice. (If the patient is admitted, administer oxygen, as this has been shown to speed resolution of the pneumothorax.)

If the PSP is greater than 15% (or estimated as large) aspiration using a pigtail catheter left to low suction or water seal is recommended. Strong suction should not be used with a spontaneous pneumothorax because of an often-delayed presentation and, thus, an increased risk of reexpansion pulmonary edema (see Complications).

Spontaneous pneumothorax is a life-threatening condition in patients with severe underlying lung disease; thus, tube thoracostomy is the procedure of choice in secondary spontaneous pneumothorax (SSP).

Pleurodesis decreases the risk of recurrence, as does thoracotomy or video-assisted thoracoscopy (VAT) to excise the bullae.

Iatrogenic and traumatic pneumothorax

Aspiration is the technique of choice for iatrogenic pneumothoraces, because recurrence is usually not a factor. Tube thoracostomy is reserved for very symptomatic patients.

In general, traumatic pneumothoraces should be treated with insertion of a chest tube, particularly if the patient cannot be closely observed. Chest tubes are attached to a one-way valve apparatus that uses a water chamber to avoid a direct connection to atmospheric pressure (so that during inspiration, when negative pressure is generated, air does not rush into the pleural space) and allows for the continuous removal air from the pleural cavity during respiration. Changing the pressure above the water seal allows for below atmospheric suction to further remove air from the pleural space. The collapsed lung reexpands and heals, thereby preventing continued air leakage. After air leaks have ceased for 24 hours, the vacuum may be decreased and the chest tube removed.

The process of lung reexpansion and healing is not immediate and may be complicated by pulmonary edema; therefore, a chest tube is usually left in place until the clinical conditions are met; any complications warrant longer placement.

A subset of patients who have a small (< 15-20%), minimally symptomatic pneumothorax may be admitted, observed closely, and monitored by using serial chest radiographs. In these patients, administration of 100% oxygen promotes resolution by speeding the absorption of gas from the pleural cavity into the pulmonary vasculature.

Although commonly used, few data exist in the medical literature showing the efficacy of the procedure or reviewing the field-use and incidence of the needle decompression.

Tension pneumothorax

Tension pneumothorax remains a life-threatening condition diagnosed under difficult conditions, with a simple emergency procedure as treatment (ie, needle decompression). Make sure no contraindications exist for the placement of an emergency decompression catheter into the thorax. Previous thoracotomy, previous pneumonectomy, and presence of a coagulation disorder, for example, are relative contraindications, because failure to treat tension pneumothorax expectantly can result in patient death.

Under emergent circumstances, place decompression catheters in the second rib interspace in the midclavicular line. This site was confirmed by Wax and Leibowitz, who reviewed 100 thoracic computed tomography (CT) scans by measuring the distance from the midline to the internal mammary artery and the average thickness of the tissues.[63] This procedure punctures through the skin and, possibly, through the pectoralis major muscle, external intercostals, internal intercostals, and parietal pleura. Placement in the middle third of the clavicle minimizes the risk of injury to the internal mammary artery during the emergency procedure.[63] Place the catheter just above the cephalad border of the rib, because the intercostal vessels are largest on the lower edge of the rib.

Harcke et al had similar results when they used CT scan analysis of deployed male military personnel to determine that, at the second right intercostal space in the midclavicular line, the mean horizontal thickness was 5.36 cm, and that an 8-cm angiocatheter would reach the pleural space in 99% of the male soldiers in this series.[64]

Unfortunately, in a 2005 study of emergency physicians, 21 of whom had completed advanced trauma and life support (ATLS) training, only 60% were able to correctly identify the second intercostal space when attempting to locate the needle thoracostomy site on a human volunteer, and all placed the thoracentesis needle medial to the midclavicular line.[62] In the same study, 8% of participants inappropriately identified the site used for needle pericardiocentesis and 4% inappropriately identified the fifth intercostal space in the anterior axillary line.[62]

A 2011 study by Sanchez et all suggests the anterior approach is typically more successful than the lateral approach when it comes to angiocatheters, although the anterior approach is not failsafe. Further, longer angiocatheters may increase the chances of decompression, but the risk of damage to surrounding vital structures is higher.[65]

Related to the development of apparent life-threatening hemorrhage after decompression in the second intercostal space at the anterior, midclavicular line in patients with no initial evidence of hemothorax on presentation, it has been suggested that a potentially safer option is to decompress a pneumothorax in the fifth intercostal space at the anterior axillary line, similar to recommendations for chest drain insertion.

If a hemothorax is associated with the pneumothorax, additional chest tubes may be needed to assist drainage of blood and clots. If the hemopneumothorax requires insertion of a second chest tube, the second tube should be directed inferiorly and should be posterior to the apex of the diaphragm.

Another point to take note of is that a significant number of patients have a larger chest wall than can be penetrated by a catheter length of 5 cm. In particular, men undergoing treatment for tension pneumothorax are more likely to have a larger body habitus with wider chest wall, such that performing needle thoracostomy may need a catheter longer than 5 cm to reliably penetrate into the pleural space.

In one study, a catheter length of patients at an American level 1 trauma center showed that a catheter length of 5 cm would reliably penetrate the pleural space in only 75% of patients.[66] A 2008 study analyzing average chest wall thickness at the second intercostal space in the midclavicular line concluded that a 4.5-cm catheter length may not penetrate the chest wall in approximately 10-35% of trauma patients, depending on age and sex.[67]

Catamenial pneumothorax

Oral contraceptives carry a high success rate in the treatment of catamenial pneumothorax, although this condition may also (rarely) be treated surgically. Most cases present during or shortly after menses, and the spontaneous pneumothorax is usually right-sided.

Pneumomediastinum

Most patients with pneumomediastinum should be observed for signs of serious complications (eg, pneumothorax, tension pneumothorax, mediastinitis). If the pneumomediastinum occurred from the inhalation of cocaine or smoking of marijuana, observation in the ED for progression may be indicated.

A follow-up chest radiograph should be obtained in 12-24 hours to detect any progression or complication, such as pneumothorax. If no progression occurs at 24 hours and if no evidence of mediastinitis exists, the patient may be discharged.

Previous
Next

Indications for Surgical Assistance

If the patient has had repeated episodes of pneumothorax or if the lung remains unexpanded after 5 days with a chest tube in place, operative therapy may be necessary. The surgeon may use treatment options such as thoracoscopy, electrocautery, laser treatment, resection of blebs or pleura, or open thoracotomy. Other surgical indications are as follows:

  • Persistent air leak for longer than 7 days
  • Recurrent, ipsilateral pneumothorax
  • Contralateral pneumothorax
  • Bilateral pneumothorax
  • First-time presentation in a patient with a high-risk occupation (eg, diver, pilot)
  • Patients with acquired immunodeficiency syndrome (AIDS) (often because of extensive underlying necrosis)
  • Unacceptable risk of recurrent pneumothorax for patients with plans for extended stays at remote sites
  • Lymphangiomyomatosis, a condition causing a high risk of pneumothorax[68]
Previous
Next

VATS

Video-assisted thoracoscopic surgery (VATS) is chosen for recurrent primary (PSP) or secondary spontaneous pneumothorax (SSP), particularly for pediatric patients, in whom it has been shown to have better outcomes and shorter recovery. VATS is an alternative to thoracotomy and is performed with the patient under general anesthesia using a camera and small trocar access ports. Other indications include an unexpanded lung 5 days after tube thoracostomy, bronchopleural fistula persisting for 5 days or longer, recurrent pneumothorax after chemical pleurodesis, and occupational reasons (eg, airplane pilots, deep-sea divers).

In a meta-analysis of 12 trials that randomized 670 patients, VATS was associated with shorter length of stay (reduction 1.0-4.2 d) and less pain or use of pain medication than thoracotomy in the 5 of 7 trials in which the technique was used for pneumothorax or minor lung resection.[69]

In the treatment of pneumothorax, VATS was associated with substantially fewer recurrences than pleural drainage in 2 trials.[69] VATS with resection of large bullous lesions is associated with a recurrence rate of 2-14%.

Previous
Next

Thoracotomy

While thoracotomy is the criterion standard, video-assisted thoracoscopic surgery (VATS) has been replacing thoracotomy in the treatment of chronic or persisting pneumothoraces due to the aforementioned reasons. Recurrence rates with thoracotomy are as low as 4%.[70]

Talc is the preferred agent for pleurodesis. It can be administered by insufflation or as a slurry. Insufflation of talc and thoracotomy has a recurrence rate of 0-7%.

Previous
Next

Pleurodesis

In patients with repeated pneumothoraces who are not good candidates for surgery, pleurodesis (or sclerotherapy) may be necessary. Pleurodesis decreases the chance of pneumothorax recurrence and should be performed in consultation with the surgeon. This procedure should be performed just after reinflation of the lung if the presence of an air leak is not a contraindication. The 2 major sclerosing agents are talc and tetracycline derivatives (eg, minocycline, doxycycline).

Talc (5-10 g in 250 mL sterile isotonic sodium chloride solution) is usually insufflated during video-assisted thoracoscopic surgery (VATS) or thoracotomy, but one study of 32 patients demonstrated findings of successful treatment with a chest tube (10% recurrence at 5 y).

In a large Department of Veterans Affairs study, tetracycline pleurodesis had a 25% recurrence in patients compared with 41% in control subjects. However, tetracycline no longer is available for pleurodesis because of stringent manufacturing requirements. Nonetheless, its derivatives minocycline and doxycycline have been shown to be successful sclerosing agents. Bleomycin was found to be ineffective in rabbits and is expensive.

Note that pleurodesis is painful, and the patient should be premedicated with benzodiazepine and intrapleural lidocaine (see Medications).

Previous
Next

Complications

Misdiagnosis is the most common complication of needle decompression. If a pneumothorax but not a tension pneumothorax is present, needle decompression creates an open pneumothorax. Alternatively, if no pneumothorax exists, the patient may develop a pneumothorax after the needle decompression is performed. Additionally, the needle may lacerate a lung, which, although rare, can cause significant pulmonary injury or hemothorax. If the needle is initially placed too medially to the sternum, needle decompression may cause a hemothorax by lacerating the inferior set of intercostal vessels or the internal mammary artery.

Damage to the intercostal neurovascular bundle and lung parenchymal injury can occur following thoracostomy tube placement, especially if trocars are used for placement, and there is an increased risk of postoperative bleeding after lung transplantation for medical pleurodesis and surgery (length of hospital stay not affected).[68]

Accidental disconnection and malpositioning of Heimlich valves can complicate an attempted outpatient treatment of pneumothorax via pigtail catheter.

Pneumothorax complications include the following:

  • Hypoxemic respiratory failure
  • Respiratory or cardiac arrest
  • Hemopneumothorax
  • Bronchopulmonary fistula
  • Pulmonary edema (following lung reexpansion)
  • Empyema
  • Pneumomediastinum
  • Pneumopericardium
  • Pneumoperitoneum
  • Pyopneumothorax

Complications of surgical procedures include the following:

  • Failure to cure the problem
  • Acute respiratory distress or failure
  • Infection of the pleural space
  • Cutaneous or systemic infection
  • Persistent air leak
  • Reexpansion pulmonary edema
  • Pain at the site of chest tube insertion
  • Prolonged tube drainage and hospital stay

Reexpansion pulmonary edema

Reexpansion pulmonary edema is a unilateral pulmonary edema that is seen after reinflation of a collapsed lung. It can also occur in the opposite lung. The incidence, etiology, risks, and mortality rates of this condition are controversial.

Findings from animal studies and several case reports in humans indicate that reexpansion pulmonary edema may occur more often if a pneumothorax is present for longer than 3 days, if the evacuation volume is greater than 2000 mL, and if suction is applied. This information is important because in one study, 46% of patients waited more than 2 days after their symptoms started to seek medical attention, and, in another study, 18% waited more than 7 days.

Tension pneumothorax

A worsening pneumothorax, usually with a 1-way valve phenomenon, can allow air into the intrapleural space and prevent its escape, causing mediastinal shift, pulmonary shunting, and circulatory collapse.

Treatment of tension pneumothorax is emergent and should be performed before confirmatory radiologic studies. Needle decompression is performed before definitive treatment with tube thoracostomy (see Tension pneumothorax under Hospital Management).

In mechanically ventilated patients, high pressures and air trapping place patients at risk for tension pneumothorax if the thoracostomy is not functioning. Patients with smaller pneumothoraces that would otherwise be managed with aspiration or observation sometimes undergo thoracostomy because of the need for mechanical ventilation.

Previous
Next

Prevention of Recurrent Pneumothorax

Strategies for the prevention of recurrent pneumothorax include observation, surgical and nonsurgical pleurodesis, and bleb resection. Other important points to keep in mind include the following:

  • Prompt recognition and treatment of bronchopulmonary infections decreases the risk of progression to a pneumothorax.
  • When subclavian vein cannulation is required, use the supraclavicular approach rather than the infraclavicular approach when possible to help decrease the likelihood of pneumothorax formation.
  • The incidence of iatrogenic tension pneumothorax may be decreased with prophylactic insertion of a chest tube in patients with a simple pneumothorax that requires positive pressure ventilation.
  • Pleurodesis decreases the risk of recurrence of spontaneous pneumothorax, as does thoracotomy or video-assisted thoracoscopy (VAT) to excise the bullae.

A study by Chen et al found that pleural abrasion with minocycline pleurodesis was as effective as apical pleurectomy for patients with PSP with high recurrence risk. Patients undergoing both procedures had similar durations of postoperative chest drainage, lengths of hospital stay, complication rates, long-term residual chest pain, and long-term pulmonary function. The rate of recurrence was 3.8% for both procedures.[71]

An Italian study reported on a new fibrin sealant that has proven to be a safe and effective tool for preventing alveolar air leaks after lung resections. The sealant also reportedly shortens the duration of postoperative alveolar air leaks.[72]

Observation

Observation is appropriate for iatrogenic pneumothorax in an individual with normal lungs who has responded to treatment with observation or simple aspiration. Simple aspiration or chest tube drainage of pneumothorax does not prevent recurrence. In fact, recurrences have been reported to occur in up to 32% of primary spontaneous pneumothorax (PSP).[73, 70]

One study showed that a Heimlich valve with small-caliber catheter was less effective in preventing recurrence than closed thoracostomy. In another study, the recurrence rate after 1 year with Heimlich valve versus chest tube placement was not significantly different.[74] Recurrent spontaneous pneumothorax requires more definitive treatment to prevent recurrence. Recurrence rates are higher with secondary spontaneous pneumothorax (SSP) than PSP; hence, observation is less often chosen as an approach in SSP.

Surgical pleurodesis

A patient treated with surgical pleurodesis has a recurrence prevention rate of greater than 90%. Talc is the preferred agent for pleurodesis, and it can be administered by insufflation or as a slurry. Practice variation depends on local practitioner experience, resources, and success with approaches ranging from video-assisted thoracotomy [VAT] (recommended by the American College of Chest Physicians [ACCP])[38] to surgical thoracotomy and pleurectomy (recommended by the British Thoracic Society [BTS] because of the absolute lowest recurrence rates).[37]

Nonsurgical pleurodesis

"Medical" thoracoscopy requires only local anesthesia or conscious sedation, in an endoscopy suite, using nondisposable rigid instruments. Thus, this procedure is considerably less invasive and less expensive, but it is also less effective, particularly in inexperienced hands. Patient comorbidity plays a role in selection of appropriate intervention. The main diagnostic and therapeutic indications for medical thoracoscopy are pleural effusions and pneumothorax.[75]

Tetracycline and talc are well-studied effective agents for medical pleurodesis; talc was 5% more effective in one randomized study.[76] Success rates for chemical sclerosing agents are up to 91% versus 95-100% in surgical techniques.[77] in an early study, chemical pleurodesis resulted in a significant reduction of recurrence compared to chest tube drainage alone.[78] Chemical pleurodesis and surgery were equally effective and were both superior to conservative therapy in preventing the recurrence of pneumothorax in lymphangioleiomyomatosis (LAM).

Previous
Next

Consultations

Physicians from various services may be needed to care for patients who require tube thoracostomy, pleurodesis, or surgical thoracotomy and admission. A surgeon and a pulmonologist should evaluate patients underlying lung disease or with recurrent disease to determine the cause and further management.

Treatment of tension pneumothorax should commence immediately after diagnosis, without waiting for further consultation and/or evaluation.

A trauma or general surgeon should evaluate patients with trauma, and the patient is often admitted for observation.

Previous
Next

Long-Term Monitoring

When a patient is on positive-pressure ventilation and normal respiratory function is preserved, routinely follow up decompressed tension pneumothoraces by watching for recurrence of the condition. Chest radiography is helpful but not required.

Direct patients indicating a readiness to quit smoking to their primary care physician or offer referral for cessation management. This may include nicotine replacement and non-nicotine pharmacotherapy such as bupropion or varenicline.

Patients should receive follow-up care from a pulmonary physician within 7-10 days.

Previous
Proceed to Medication
 
 
Contributor Information and Disclosures
Author

Brian James Daley, MD, MBA, FACS, FCCP, CNSC  Professor and Program Director, Department of Surgery, Chief, Division of Trauma and Critical Care, University of Tennessee Health Science Center College of Medicine

Brian James Daley, MD, MBA, FACS, FCCP, CNSC is a member of the following medical societies: American Association for the Surgery of Trauma, American College of Chest Physicians, American College of Surgeons, American Medical Association, Association for Academic Surgery, Association for Surgical Education, Eastern Association for the Surgery of Trauma, Shock Society, Society of Critical Care Medicine, Southeastern Surgical Congress, and Tennessee Medical Association

Disclosure: Nothing to disclose.

Coauthor(s)

Shabir Bhimji, MD, PhD  Locum Cardiothoracic and Vascular Surgeon, Saudi Arabia and Middle East Hospitals

Shabir Bhimji, MD, PhD is a member of the following medical societies: American Cancer Society, American College of Chest Physicians, American Lung Association, and Texas Medical Association

Disclosure: Nothing to disclose.

Rebecca Bascom, MD, MPH  Professor of Medicine, Department of Medicine, Division of Pulmonary, Allergy, and Critical Care Medicine, Pennsylvania State College of Medicine, Milton S Hershey Medical Center; Graduate Faculty Member, Pennsylvania State University College of Medicine and The Huck Institutes of the Life Sciences

Rebecca Bascom, MD, MPH is a member of the following medical societies: American College of Chest Physicians, American Public Health Association, American Thoracic Society, and Pennsylvania Thoracic Society

Disclosure: Pfizer Ownership interest Other; Teva Pharmaceuticals Ownership interest Other; Bristol Myers Squibb Ownership interest None; Broncus, Inc Consulting fee Consulting

Michael G Benninghoff, DO, MS  Attending Physician in Pulmonary and Critical Care Medicine, Christiana Medical Center

Michael G Benninghoff, DO, MS is a member of the following medical societies: American College of Chest Physicians, American College of Physicians, American Osteopathic Association, American Thoracic Society, and Society of Critical Care Medicine

Disclosure: Nothing to disclose.

Shoaib Alam, MD  Staff Clinician, Pulmonary and Vascular Medicine, National Heart, Lung, and Blood Institute, National Institutes of Health

Shoaib Alam, MD is a member of the following medical societies: American College of Chest Physicians, American Thoracic Society, European Respiratory Society, International Society for Magnetic Resonance in Medicine, Pennsylvania Thoracic Society, and Society of Critical Care Medicine

Disclosure: Nothing to disclose.

Chief Editor

Mary C Mancini, MD, PhD  Professor and Chief of Cardiothoracic Surgery, Department of Surgery, Louisiana State University School of Medicine in Shreveport

Mary C Mancini, MD, PhD is a member of the following medical societies: American Association for Thoracic Surgery, American College of Surgeons, American Surgical Association, Phi Beta Kappa, Society of Thoracic Surgeons, and Southern Surgical Association

Disclosure: Nothing to disclose.

Additional Contributors

Erik D Barton, MD, MS Associate Director, Assistant Professor, Department of Surgery, Division of Emergency Medicine, University of Utah Health Sciences Center

Erik D Barton, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American College of Sports Medicine, American Medical Association, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Marc D Basson, MD, PhD, MBA, FACS Professor, Chair, Department of Surgery, Assistant Dean for Faculty Development in Research, Michigan State University College of Human Medicine

Marc D Basson, MD, PhD, MBA, FACS is a member of the following medical societies: Alpha Omega Alpha, American College of Surgeons, American Gastroenterological Association, Phi Beta Kappa, and Sigma Xi

Disclosure: Nothing to disclose.

H Scott Bjerke, MD, FACS Clinical Associate Professor, Department of Surgery, University of Missouri-Kansas City School of Medicine; Medical Director of Trauma Services, Research Medical Center; Clinical Professor, Department of Surgery, Kansas City University of Medicine and Biosciences

H Scott Bjerke, MD, FACS is a member of the following medical societies: American Association for the History of Medicine, American Association for the Surgery of Trauma, American College of Surgeons, Association for Academic Surgery, Eastern Association for the Surgery of Trauma, Midwest Surgical Association, National Association of EMS Physicians, Pan-Pacific Surgical Association, Royal Society of Medicine, Southwestern Surgical Congress, andWilderness Medical Society

Disclosure: Nothing to disclose.

Paul Blackburn, DO, FACOEP, FACEP Attending Physician, Department of Emergency Medicine, Maricopa Medical Center

Paul Blackburn, DO, FACOEP, FACEP is a member of the following medical societies: American College of Emergency Physicians, American College of Osteopathic Emergency Physicians, American Medical Association, and Arizona Medical Association

Disclosure: Nothing to disclose.

Jeffrey Glenn Bowman, MD, MS Consulting Staff, Highfield MRI

Disclosure: Nothing to disclose.

Andrew K Chang, MD Associate Professor, Department of Emergency Medicine, Albert Einstein College of Medicine, Montefiore Medical Center

Andrew K Chang, MD is a member of the following medical societies: American Academy of Emergency Medicine, American Academy of Neurology, American College of Emergency Physicians, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

John Geibel, MD, DSc, MA Vice Chair and Professor, Department of Surgery, Section of Gastrointestinal Medicine, and Department of Cellular and Molecular Physiology, Yale University School of Medicine; Director, Surgical Research, Department of Surgery, Yale-New Haven Hospital

John Geibel, MD, DSc, MA is a member of the following medical societies: American Gastroenterological Association, American Physiological Society, American Society of Nephrology, Association for Academic Surgery, International Society of Nephrology, New York Academy of Sciences, and Society for Surgery of the Alimentary Tract

Disclosure: AMGEN Royalty Consulting; ARdelyx Ownership interest Board membership

Tunc Iyriboz, MD Chief, Division of Clinical Image Management, Assistant Professor, Department of Radiology, Hershey Medical Center, Pennsylvania State University

Tunc Iyriboz, MD is a member of the following medical societies: American College of Radiology, American Medical Association, and Radiological Society of North America

Disclosure: Nothing to disclose.

Seema Jain Pennsylvania State University College of Medicine

Disclosure: Nothing to disclose.

Rick Kulkarni, MD Attending Physician, Department of Emergency Medicine, Cambridge Health Alliance, Division of Emergency Medicine, Harvard Medical School

Rick Kulkarni, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: WebMD Salary Employment

Eric L Legome, MD Chief, Department of Emergency Medicine, Kings County Hospital Center; Associate Professor, Department of Emergency Medicine, New York Medical College

Eric L Legome, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, Council of Emergency Medicine Residency Directors, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Pinaki Mukherji, MD Assistant Professor, Attending Physician, Department of Emergency Medicine, Montefiore Medical Center

Pinaki Mukherji, MD is a member of the following medical societies: American College of Emergency Physicians

Disclosure: Nothing to disclose.

Robert E O'Connor, MD, MPH Professor and Chair, Department of Emergency Medicine, University of Virginia Health System

Robert E O'Connor, MD, MPH is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American College of Physician Executives, American Heart Association, American Medical Association, Medical Society of Delaware, National Association of EMS Physicians, Society for Academic Emergency Medicine, and Wilderness Medical Society

Disclosure: Nothing to disclose.

Benson B Roe, MD Emeritus Chief, Division of Cardiothoracic Surgery, Emeritus Professor, Department of Surgery, University of California at San Francisco Medical Center

Benson B Roe, MD is a member of the following medical societies: Alpha Omega Alpha, American Association for Thoracic Surgery, American College of Cardiology, American College of Surgeons, American Heart Association, American Medical Association, American Society for Artificial Internal Organs, American Surgical Association, California Medical Association, Society for Vascular Surgery, Society of Thoracic Surgeons, and Society of University Surgeons

Disclosure: Nothing to disclose.

Joseph A Salomone III, MD Associate Professor and Attending Staff, Truman Medical Centers, University of Missouri-Kansas City School of Medicine; EMS Medical Director, Kansas City, Missouri

Joseph A Salomone III, MD is a member of the following medical societies: American Academy of Emergency Medicine, National Association of EMS Physicians, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Daniel S Schwartz, MD, FACS Assistant Clinical Professor of Cardiothoracic Surgery, Mount Sinai School of Medicine; Chief of Thoracic Surgery, Huntington Hospital

Daniel S Schwartz, MD, FACS is a member of the following medical societies: American College of Chest Physicians, American College of Surgeons, Society of Thoracic Surgeons, and Western Thoracic Surgical Association

Disclosure: Nothing to disclose.

Robert L Sheridan, MD Assistant Chief of Staff, Chief of Burn Surgery, Shriners Burns Hospital; Associate Professor of Surgery, Department of Surgery, Division of Trauma and Burns, Massachusetts General Hospital and Harvard Medical School

Robert L Sheridan, MD is a member of the following medical societies: American Academy of Pediatrics, American Association for the Surgery of Trauma, American Burn Association, and American College of Surgeons

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Milos Tucakovic, MD Fellow, Department of Internal Medicine, Sections of Pulmonary Disease, Allergy and Critical Care Medicine, Milton S Hershey Medical Center, Pennsylvania State College of Medicine

Milos Tucakovic, MD is a member of the following medical societies: American College of Physicians and American Medical Association

Disclosure: Nothing to disclose.

References

  1. Sahn SA, Heffner JE. Spontaneous pneumothorax. N Engl J Med. Mar 23 2000;342(12):868-74. [Medline].

  2. Noppen M, Dekeukeleire T, Hanon S, Stratakos G, Amjadi K, Madsen P. Fluorescein-enhanced autofluorescence thoracoscopy in patients with primary spontaneous pneumothorax and normal subjects. Am J Respir Crit Care Med. Jul 1 2006;174(1):26-30. [Medline].

  3. Tabakoglu E, Ciftci S, Hatipoglu ON, Altiay G, Caglar T. Levels of superoxide dismutase and malondialdehyde in primary spontaneous pneumothorax. Mediators Inflamm. Jun 2004;13(3):209-10. [Medline].

  4. Haraguchi S, Fukuda Y. Histogenesis of abnormal elastic fibers in blebs and bullae of patients with spontaneous pneumothorax: ultrastructural and immunohistochemical studies. Acta Pathol Jpn. Dec 1993;43(12):709-22. [Medline].

  5. Gunji Y, Akiyoshi T, Sato T, Kurihara M, Tominaga S, Takahashi K. Mutations of the Birt Hogg Dube gene in patients with multiple lung cysts and recurrent pneumothorax. J Med Genet. Sep 2007;44(9):588-93. [Medline].

  6. Lal A, Anderson G, Cowen M, Lindow S, Arnold AG. Pneumothorax and pregnancy. Chest. Sep 2007;132(3):1044-8. [Medline].

  7. Chiu HT, Garcia CK. Familial spontaneous pneumothorax. Curr Opin Pulm Med. Jul 2006;12(4):268-72. [Medline].

  8. Feldman AL, Sullivan JT, Passero MA, Lewis DC. Pneumothorax in polysubstance-abusing marijuana and tobacco smokers: three cases. J Subst Abuse. 1993;5(2):183-6. [Medline].

  9. Sihoe AD, Wong RH, Lee AT, et al. Severe acute respiratory syndrome complicated by spontaneous pneumothorax. Chest. Jun 2004;125(6):2345-51. [Medline].

  10. Metersky ML, Colt HG, Olson LK, Shanks TG. AIDS-related spontaneous pneumothorax. Risk factors and treatment. Chest. Oct 1995;108(4):946-51. [Medline].

  11. Flume PA, Strange C, Ye X, Ebeling M, Hulsey T, Clark LL. Pneumothorax in cystic fibrosis. Chest. Aug 2005;128(2):720-8. [Medline].

  12. Leslie MD, Napier M, Glaser MG. Pneumothorax as a complication of tumour response to chemotherapy. Clin Oncol (R Coll Radiol). 1993;5(3):181-2. [Medline].

  13. Lee CC, Lee SH, Chang IJ, et al. Spontaneous pneumothorax associated with ankylosing spondylitis. Rheumatology (Oxford). Dec 2005;44(12):1538-41. [Medline].

  14. Korom S, Canyurt H, Missbach A, et al. Catamenial pneumothorax revisited: clinical approach and systematic review of the literature. J Thorac Cardiovasc Surg. Oct 2004;128(4):502-8. [Medline].

  15. Plewa MC, Ledrick D, Sferra JJ. Delayed tension pneumothorax complicating central venous catheterization and positive pressure ventilation. Am J Emerg Med. Sep 1995;13(5):532-5. [Medline].

  16. de Lassence A, Timsit JF, Tafflet M, et al. Pneumothorax in the intensive care unit: incidence, risk factors, and outcome. Anesthesiology. Jan 2006;104(1):5-13. [Medline].

  17. Miller JS, Itani KM, Oza MD, Wall MJ. Gastric rupture with tension pneumoperitoneum: a complication of difficult endotracheal intubation. Ann Emerg Med. Sep 1997;30(3):343-6. [Medline].

  18. Hashmi S, Rogers SO. Tension pneumothorax with pneumopericardium. J Trauma. Jun 2003;54(6):1254. [Medline].

  19. Iannoli ED, Litman RS. Tension pneumothorax during flexible fiberoptic bronchoscopy in a newborn. Anesth Analg. Mar 2002;94(3):512-3; table of contents. [Medline]. [Full Text].

  20. Peuker E. Case report of tension pneumothorax related to acupuncture. Acupunct Med. Mar 2004;22(1):40-3. [Medline]. [Full Text].

  21. Whale C, Hallam C. Tension pneumothorax related to acupuncture. Acupunct Med. Jun 2004;22(2):101; author reply 101-2. [Medline].

  22. Zhao DY, Zhang GL. [Clinical analysis on 38 cases of pneumothorax induced by acupuncture or acupoint injection]. Zhongguo Zhen Jiu. Mar 2009;29(3):239-42. [Medline].

  23. Dalton AM, Hodgson RS, Crossley C. Bochdalek hernia masquerading as a tension pneumothorax. Emerg Med J. May 2004;21(3):393-4. [Medline]. [Full Text].

  24. Hearnshaw SA, Oppong K, Jaques B, Thompson NP. Tension pneumothorax as a complication of colonoscopy. Endoscopy. Feb 2004;36(2):190. [Medline]. [Full Text].

  25. Brander L, Takala J. Tracheal tear and tension pneumothorax complicating bronchoscopy-guided percutaneous tracheostomy. Heart Lung. Mar-Apr 2006;35(2):144-5. [Medline].

  26. McPherson JJ, Feigin DS, Bellamy RF. Prevalence of tension pneumothorax in fatally wounded combat casualties. J Trauma. Mar 2006;60(3):573-8. [Medline].

  27. Yamashita H, Tsukayama H, Tanno Y, Nishijo K. Adverse events related to acupuncture. JAMA. Nov 11 1998;280(18):1563-4. [Medline].

  28. Melton LJ 3rd, Hepper NG, Offord KP. Incidence of spontaneous pneumothorax in Olmsted County, Minnesota: 1950 to 1974. Am Rev Respir Dis. Dec 1979;120(6):1379-82. [Medline].

  29. Gupta D, Hansell A, Nichols T, Duong T, Ayres JG, Strachan D. Epidemiology of pneumothorax in England. Thorax. Aug 2000;55(8):666-71. [Medline].

  30. Bense L, Eklund G, Wiman LG. Smoking and the increased risk of contracting spontaneous pneumothorax. Chest. Dec 1987;92(6):1009-12. [Medline].

  31. Huang TW, Lee SC, Cheng YL, Tzao C, Hsu HH, Chang H. Contralateral recurrence of primary spontaneous pneumothorax. Chest. Oct 2007;132(4):1146-50. [Medline].

  32. Rezende-Neto JB, Hoffmann J, Al Mahroos M, et al. Occult pneumomediastinum in blunt chest trauma: clinical significance. Injury. Jan 2010;41(1):40-3. [Medline].

  33. [Guideline] British Thoracic Society guidelines on respiratory aspects of fitness for diving. Thorax. Jan 2003;58(1):3-13. [Medline]. [Full Text].

  34. Rodriguez RM, Hendey GW, Marek G, Dery RA, Bjoring A. A pilot study to derive clinical variables for selective chest radiography in blunt trauma patients. Ann Emerg Med. May 2006;47(5):415-8. [Medline].

  35. Lopes JA, Frankel HL, Bokhari SJ, Bank M, Tandon M, Rabinovici R. The trauma bay chest radiograph in stable blunt-trauma patients: do we really need it?. Am Surg. Jan 2006;72(1):31-4. [Medline].

  36. Shatz DV, de la Pedraja J, Erbella J, Hameed M, Vail SJ. Efficacy of follow-up evaluation in penetrating thoracic injuries: 3- vs. 6-hour radiographs of the chest. J Emerg Med. Apr 2001;20(3):281-4. [Medline].

  37. Henry M, Arnold T, Harvey J,. BTS guidelines for the management of spontaneous pneumothorax. Thorax. May 2003;58 Suppl 2:ii39-52. [Medline].

  38. Baumann MH, Strange C, Heffner JE, Light R, Kirby TJ, Klein J. Management of spontaneous pneumothorax: an American College of Chest Physicians Delphi consensus statement. Chest. Feb 2001;119(2):590-602. [Medline].

  39. Light RW, Courtney Broaddus V. Pneumothorax, chylothorax, hemothorax, and fibrothorax. In: Textbook of Pulmonary Medicine. 3rd ed. 2000:2043-66.

  40. Ball CG, Kirkpatrick AW, Feliciano DV. The occult pneumothorax: what have we learned?. Can J Surg. Oct 2009;52(5):E173-9. [Medline]. [Full Text].

  41. Barrios C, Tran T, Malinoski D, et al. Successful management of occult pneumothorax without tube thoracostomy despite positive pressure ventilation. Am Surg. Oct 2008;74(10):958-61. [Medline].

  42. Busch M. Portable ultrasound in pre-hospital emergencies: a feasibility study. Acta Anaesthesiol Scand. Jul 2006;50(6):754-8. [Medline].

  43. Zanobetti M, Poggioni C, Pini R. Can chest ultrasonography replace standard chest radiography for evaluation of acute dyspnea in the ED?. Chest. May 2011;139(5):1140-7. [Medline].

  44. Dente CJ, Ustin J, Feliciano DV, Rozycki GS, Wyrzykowski AD, Nicholas JM, et al. The accuracy of thoracic ultrasound for detection of pneumothorax is not sustained over time: a preliminary study. J Trauma. Jun 2007;62(6):1384-9. [Medline].

  45. Knudtson JL, Dort JM, Helmer SD, Smith RS. Surgeon-performed ultrasound for pneumothorax in the trauma suite. J Trauma. Mar 2004;56(3):527-30. [Medline].

  46. Dulchavsky SA, Schwarz KL, Kirkpatrick AW, Billica RD, Williams DR, Diebel LN, et al. Prospective evaluation of thoracic ultrasound in the detection of pneumothorax. J Trauma. Feb 2001;50(2):201-5. [Medline].

  47. Brook OR, Beck-Razi N, Abadi S, Filatov J, Ilivitzki A, Litmanovich D, et al. Sonographic detection of pneumothorax by radiology residents as part of extended focused assessment with sonography for trauma. J Ultrasound Med. Jun 2009;28(6):749-55. [Medline].

  48. Hernandez C, Shuler K, Hannan H, Sonyika C, Likourezos A, Marshall J. C.A.U.S.E.: Cardiac arrest ultra-sound exam--a better approach to managing patients in primary non-arrhythmogenic cardiac arrest. Resuscitation. Feb 2008;76(2):198-206. [Medline].

  49. Sartori S, Tombesi P, Trevisani L, Nielsen I, Tassinari D, Abbasciano V. Accuracy of transthoracic sonography in detection of pneumothorax after sonographically guided lung biopsy: prospective comparison with chest radiography. AJR Am J Roentgenol. Jan 2007;188(1):37-41. [Medline].

  50. Zhang M, Liu ZH, Yang JX, Gan JX, Xu SW, You XD, et al. Rapid detection of pneumothorax by ultrasonography in patients with multiple trauma. Crit Care. 2006;10(4):R112. [Medline]. [Full Text].

  51. Slater A, Goodwin M, Anderson KE, Gleeson FV. COPD can mimic the appearance of pneumothorax on thoracic ultrasound. Chest. Mar 2006;129(3):545-50. [Medline].

  52. Lichtenstein D, Meziere G, Biderman P, Gepner A. The "lung point": an ultrasound sign specific to pneumothorax. Intensive Care Med. Oct 2000;26(10):1434-40. [Medline].

  53. Miller AC, Harvey JE. Guidelines for the management of spontaneous pneumothorax. Standards of Care Committee, British Thoracic Society [published erratum appears in BMJ 1993 Jul 31;307(6899):308]. BMJ. Jul 10 1993;307(6896):114-6. [Medline].

  54. Tschopp JM, Rami-Porta R, Noppen M, Astoul P. Management of spontaneous pneumothorax: state of the art. Eur Respir J. Sep 2006;28(3):637-50. [Medline].

  55. Contou D, Razazi K, Katsahian S, Maitre B, Mekontso-Dessap A, Brun-Buisson C, et al. Small-bore catheter versus chest tube drainage for pneumothorax. Am J Emerg Med. Jan 2 2012;[Medline].

  56. Bense L, Lewander R, Eklund G, et al. Nonsmoking, non-alpha 1-antitrypsin deficiency-induced emphysema in nonsmokers with healed spontaneous pneumothorax, identified by computed tomography of the lungs. Chest. Feb 1993;103(2):433-8. [Medline].

  57. Moore FO, Goslar PW, Coimbra R, et al. Blunt Traumatic Occult Pneumothorax: Is Observation Safe?-Results of a Prospective, AAST Multicenter Study. J Trauma. May 2011;70(5):1019-1025. [Medline].

  58. Delius RE, Obeid FN, Horst HM, Sorensen VJ, Fath JJ, Bivins BA. Catheter aspiration for simple pneumothorax. Experience with 114 patients. Arch Surg. Jul 1989;124(7):833-6. [Medline].

  59. Noppen M, Baumann MH. Pathogenesis and treatment of primary spontaneous pneumothorax: an overview. Respiration. Jul-Aug 2003;70(4):431-8. [Medline].

  60. [Best Evidence] Zehtabchi S, Rios CL. Management of emergency department patients with primary spontaneous pneumothorax: needle aspiration or tube thoracostomy?. Ann Emerg Med. Jan 2008;51(1):91-100, 100.e1. [Medline].

  61. Marquette CH, Marx A, Leroy S, Vaniet F, Ramon P, Caussade S. Simplified stepwise management of primary spontaneous pneumothorax: a pilot study. Eur Respir J. Mar 2006;27(3):470-6. [Medline].

  62. Ferrie EP, Collum N, McGovern S. The right place in the right space? Awareness of site for needle thoracocentesis. Emerg Med J. Nov 2005;22(11):788-9. [Medline]. [Full Text].

  63. Wax DB, Leibowitz AB. Radiologic assessment of potential sites for needle decompression of a tension pneumothorax. Anesth Analg. Nov 2007;105(5):1385-8, table of contents. [Medline]. [Full Text].

  64. Harcke HT, Pearse LA, Levy AD, Getz JM, Robinson SR. Chest wall thickness in military personnel: implications for needle thoracentesis in tension pneumothorax. Mil Med. Dec 2007;172(12):1260-3. [Medline].

  65. Sanchez LD, Straszewski S, Saghir A, et al. Anterior versus lateral needle decompression of tension pneumothorax: comparison by computed tomography chest wall measurement. Acad Emerg Med. Oct 2011;18(10):1022-6. [Medline].

  66. Givens ML, Ayotte K, Manifold C. Needle thoracostomy: implications of computed tomography chest wall thickness. Acad Emerg Med. Feb 2004;11(2):211-3. [Medline].

  67. Zengerink I, Brink PR, Laupland KB, Raber EL, Zygun D, Kortbeek JB. Needle thoracostomy in the treatment of a tension pneumothorax in trauma patients: what size needle?. J Trauma. Jan 2008;64(1):111-4. [Medline].

  68. Almoosa KF, Ryu JH, Mendez J, Huggins JT, Young LR, Sullivan EJ. Management of pneumothorax in lymphangioleiomyomatosis: effects on recurrence and lung transplantation complications. Chest. May 2006;129(5):1274-81. [Medline].

  69. Sedrakyan A, van der Meulen J, Lewsey J, Treasure T. Video assisted thoracic surgery for treatment of pneumothorax and lung resections: systematic review of randomised clinical trials. BMJ. Oct 30 2004;329(7473):1008. [Medline].

  70. Schramel FM, Postmus PE, Vanderschueren RG. Current aspects of spontaneous pneumothorax. Eur Respir J. Jun 1997;10(6):1372-9. [Medline].

  71. Chen JS, Hsu HH, Huang PM, Kuo SW, Lin MW, Chang CC, et al. Thoracoscopic Pleurodesis for Primary Spontaneous Pneumothorax With High Recurrence Risk: A Prospective Randomized Trial. Ann Surg. Feb 8 2012;[Medline].

  72. Gonfiotti A, Santini PF, Jaus M, et al. Safety and effectiveness of a new fibrin pleural air leak sealant: a multicenter, controlled, prospective, parallel-group, randomized clinical trial. Ann Thorac Surg. Oct 2011;92(4):1217-25. [Medline].

  73. O'Rourke JP, Yee ES. Civilian spontaneous pneumothorax. Treatment options and long-term results. Chest. Dec 1989;96(6):1302-6. [Medline].

  74. Devanand A, Koh MS, Ong TH, et al. Simple aspiration versus chest-tube insertion in the management of primary spontaneous pneumothorax: a systematic review. Respir Med. Jul 2004;98(7):579-90. [Medline].

  75. Loddenkemper R, Schonfeld N. Medical thoracoscopy. Curr Opin Pulm Med. Jul 1998;4(4):235-8. [Medline].

  76. Almind M, Lange P, Viskum K. Spontaneous pneumothorax: comparison of simple drainage, talc pleurodesis, and tetracycline pleurodesis. Thorax. Aug 1989;44(8):627-30. [Medline].

  77. Baumann MH, Strange C. Treatment of spontaneous pneumothorax: a more aggressive approach?. Chest. Sep 1997;112(3):789-804. [Medline].

  78. van den Brande P, Staelens I. Chemical pleurodesis in primary spontaneous pneumothorax. Thorac Cardiovasc Surg. Jun 1989;37(3):180-2. [Medline].

 
Previous
Next
 
Radiograph of a patient with a small spontaneous primary pneumothorax
Close radiographic view of patient with a small spontaneous primary pneumothorax (same patient as from the previous image).
Expiratory radiograph of a patient with a small spontaneous primary pneumothorax (same patient as in the previous images).
Radiograph of a patient with spontaneous primary pneumothorax due to a left upper lobe bleb.
Close radiographic view of a patient with spontaneous primary pneumothorax due to a left upper lobe bleb (Same patient as in the previous image).
Radiograph of a patient with a large spontaneous tension pneumothorax.
Radiograph showing subcutaneous emphysema and pneumothorax.
This chest radiograph has 2 abnormalities: (1) tension pneumothorax and (2) potentially life-saving intervention delayed while waiting for x-ray results. Tension pneumothorax is a clinical diagnosis requiring emergent needle decompression, and therapy should never be delayed for x-ray confirmation.
Radiograph of a new left-sided pneumothorax in a patient on mechanical ventilation, requiring high inflation pressures.
Radiograph of a patient with a complete right-sided pneumothorax due to a stab wound.
Radiograph of a patient with idiopathic pulmonary fibrosis and a small pneumothorax, following video-assisted thoracoscopic surgery (VATS) lung biopsy.
Close radiographic view of a small pneumothorax in a patient with idiopathic pulmonary fibrosis, following video-assisted thoracoscopic surgery (VATS) lung biopsy (same patient as in the previous image). Note that the hole on a chest tube is outside the pleural space.
Radiograph depicting a right-sided iatrogenic pneumothorax after transbronchial biopsy.
Pneumomediastinum from barotrauma may result in tension pneumothorax and obstructive shock.
Radiograph of a patient in the intensive care unit (ICU) who developed pneumopericardium as a manifestation of barotrauma.
Radiograph of an older man who was admitted to the intensive care unit (ICU) postoperatively. Note the right-sided pneumothorax induced by the incorrectly positioned small-bowel feeding tube in the right-sided bronchial tree. Marked depression of the right hemidiaphragm is noted, and mediastinal shift is to the left side, suggestive of tension pneumothorax. The endotracheal tube is in a good position.
Radiograph depicting right main stem intubation that resulted in left-sided tension pneumothorax, right mediastinal shift, deep sulcus sign, and subpulmonic pneumothorax.
This is a chest radiograph of an elderly male with chronic obstructive pulmonary disease who presented with a second left-sided spontaneous pneumothorax in 2 months. Chest thoracostomy was performed, the patient was admitted, and talc pleurodesis was performed the next day.
This chest radiograph shows pneumomediastinum (radiolucency noted around the left heart border) in this patient who had a respiratory and circulatory arrest in the emergency department after experiencing multiple episodes of vomiting and a rigid abdomen. The patient was taken immediately to the operating room, where a large rupture of the esophagus was repaired.
Radiograph demonstrating tension and traumatic pneumothorax.
Radiograph demonstrating tension and traumatic pneumothorax.
Lateral radiograph demonstrating tension and traumatic pneumothorax.
Lateral radiograph demonstrating tension and traumatic pneumothorax.
Chest radiograph depicting tension and traumatic pneumothorax.
Lateral radiograph depicting tension and traumatic pneumothorax.
Computed tomography scan demonstrating blebs in a patient with chronic obstructive pulmonary disease (COPD).
Computed tomography scan demonstrating a bulla in an asymptomatic patient.
Computed tomography scan demonstrating secondary spontaneous pneumothorax (SSP) from radiation/chemotherapy for lymphoma.
Computed tomography scan demonstrating emphysematouslike changes (ELCs) in a patient with chronic obstructive pulmonary disease (COPD).
Computed tomography scan in a patient with a history of bilateral pleurodesis and a strong family history of spontaneous pneumothorax.
Illustration depicting multiple fractures of the left upper chest wall. The first rib is often fractured posteriorly (black arrows). If multiple rib fractures occur along the midlateral (red arrows) or anterior chest wall (blue arrows), a flail chest (dotted black lines) may result, which may result in pneumothorax.
 
 
 
All material on this website is protected by copyright, Copyright © 1994-2012 by WebMD LLC.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.