eMedicine Specialties > Emergency Medicine > Pulmonary

Pneumothorax, Iatrogenic, Spontaneous and Pneumomediastinum: Follow-up

Author: Andrew K Chang, MD, Associate Professor, Department of Emergency Medicine, Albert Einstein College of Medicine, Montefiore Medical Center
Coauthor(s): Pinaki Mukherji, MD, Assistant Professor, Attending Physician, Department of Emergency Medicine, Montefiore Medical Center
Contributor Information and Disclosures

Updated: Jul 7, 2009

Follow-up

Further Inpatient Care

  • Prophylactic antibiotics: Although no data support the use of prophylactic antibiotics, many physicians routinely treat patients with antibiotics until the chest tube is removed.
  • Analgesics: Patients may require analgesics for 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 analgesics.
  • Suction: Strong suction should not be used with a spontaneous pneumothorax because of the increased risk of reexpansion pulmonary edema.
  • Video-assisted thoracoscopic surgery  
    • Video-assisted thoracoscopic surgery (VATS) has been replacing thoracotomy in the treatment of chronic or persisting pneumothoraces. Particularly for pediatric patients, it has been shown to have better outcomes and shorter recovery.
    • 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).
  • Pleurodesis: This treatment decreases chance of pneumothorax recurrence. It 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). This procedure should be performed in consultation with the surgeon.
    • Talc (5-10 g in 250 mL sterile isotonic sodium chloride solution) usually is insufflated during video-assisted thoracoscopic surgery 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. Minocycline and doxycycline have been shown to be successful sclerosing agents. Bleomycin was found to be ineffective in rabbits and is expensive.
    • Sclerosis is painful, and the patient should be premedicated with benzodiazepine and intrapleural lidocaine.
    • Physical disruption and scraping of the pleura can also induce scarring in pleurodesis.
  • Follow-up for pneumomediastinum
    • 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.

Further Outpatient Care

  • Heimlich valve placement
    • The Heimlich valve is a one-way, rubber flutter valve. 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.
    • It can allow outpatient treatment of a pneumothorax.

Deterrence/Prevention

  • Smoking cessation is strongly advised for all patients. Whether primary or secondary pneumothorax, smoking increases the likelihood of bleb rupture and recurrence, and does so in a predicable, dose-related manner.
  • Ascent from deep-sea diving causes gases to expand and can lead to pneumothorax in patients with bullae and blebs. Patients with previous spontaneous pneumothoraces are at risk for recurrence and are advised not to dive unless thoracotomy or pleurodesis has been performed.2
  • Commercial air travel achieves minimal change in gas volumes due to pressurization of the cabin. However, spontaneous pneumothorax has been described during commercial travel, and patients with resolving pneumothorax are cautioned not to fly until intrapleural air has completely resolved.

Complications

  • Reexpansion pulmonary edema
    • This condition is a unilateral pulmonary edema that rarely occurs after reinflation of a collapsed lung.
    • Incidence, etiology, risks, and mortality rates 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 longer than 3 days 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.
    • For spontaneous pneumothoraces, suction should not be applied because of an often-delayed presentation and, thus, an increased risk of reexpansion pulmonary edema. In addition, one study revealed that the rate of lung reexpansion is independent of suction.
    • Reexpansion pulmonary edema can occur in the opposite lung.
  • Tension pneumothorax
    • A worsening pneumothorax, usually with a one-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 prior to confirmatory radiologic studies.
    • Needle decompression is performed prior to definitive treatment with tube thoracostomy. (See Procedures.)
    • 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.
  • Accidental disconnection and malpositioning of Heimlich valves can complicate an attempted outpatient treatment of pneumothorax via pigtail catheter.

Prognosis

  • The prognosis is generally good with appropriate therapy.

Miscellaneous

Special Concerns

  • HIV
    • While pneumonia is a possible cause of pneumothorax, in the patient with HIV, the pathogens include Pneumocystis carinii (PCP) pneumonia , toxoplasmosis , and Kaposi sarcoma . A patient with HIV can have spontaneous pneumothorax as the presenting symptom of the illness.
    • HIV carries a lifetime risk of 6% for pneumothorax; about 85% of that number is related to PCP pneumonia.
  • Catamenial
    • A rare cause of recurrent pneumothorax in women, catamenial is thought to arise from endometriosis reaching the chest wall across the diaphragm. Prior to recurrence, it may be initially diagnosed as primary spontaneous pneumothorax. 
    • Onset of symptoms within 48 hours of menstruation, right-sided pneumothorax, and recurrence raise suspicion for this disease. It is rarely treated surgically, and oral contraceptives carry a high success rate.
  • Familial
    • Folliculin gene disorders are being described in familial spontaneous pneumothorax.3  These patients may have pneumothorax as the presenting symptom of Birt-Hogg-Dube disease.4  Some authors recommend screening patients with a family history of pneumothorax for the benign skin tumors and renal cancers that arise from the disease. 
    • Since primary spontaneous pneumothorax patients will have apical emphysematous pulmonary disease on CT or thoracoscopy, they can be thought to have a congenital syndrome of mild acinar emphysema, whose expression is enhanced by environmental factors (eg, smoking) just as it is in patients with alpha-1-antitrypsin deficiency and "typical" emphysema.
 
Acknowledgments

The authors and editors of eMedicine gratefully acknowledge the contributions of previous author, Erik D Barton, MD, to the development and writing of this article.



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References
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Further Reading

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Keywords

pneumothorax, intrapleural air, perivascular alveolar rupture, primary spontaneous pneumothorax, secondary spontaneous pneumothorax, pneumomediastinum, iatrogenic pneumothorax, air in intrapleural space, lung disease, malignant pneumomediastinum, Boerhaave syndrome, cystic fibrosis

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Contributor Information and Disclosures

Author

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.

Coauthor(s)

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.

Medical Editor

Joseph A Salomone III, MD, EMS Medical Director, Kansas City, Missouri; Associate Professor and Staff Physician, Truman Medical Centers/UMKC School of Medicine
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.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Paul Blackburn, DO, FACOEP, FACEP, Program Director, Department of Emergency Medicine, Maricopa Medical Center; Assistant Professor, Department of Surgery, University of Arizona
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.

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

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.

 
 
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