History
The presentation of patients with pneumothorax varies depending on the type of pneumothorax.
Spontaneous and iatrogenic pneumothorax
Until a bleb ruptures and causes pneumothorax, no clinical signs or symptoms are present in primary spontaneous pneumothorax (PSP). Young and otherwise healthy patients can tolerate the main physiologic consequences of a decrease in vital capacity and partial pressure of oxygen fairly well, with minimal changes in vital signs and symptoms, but those with underlying lung disease may have respiratory distress.
In one series, acute onset of chest pain and shortness of breath were present in all patients in one series; typically, both symptoms are present in 64-85% of patients. The chest pain is described as severe and/or stabbing, radiates to the ipsilateral shoulder and increases with inspiration (pleuritic).
In PSP, chest often improves over the first 24 hours, even without resolution of the underlying air accumulation. Well-tolerated primary pneumothorax can take 12 weeks to resolve. In secondary pneumothorax (SSP), the chest pain is more likely to persist with more significant clinical symptoms.
Shortness of breath/dyspnea in PSP is generally of sudden onset and tends to be more severe with SSPs because of decreased lung reserve. Anxiety, cough, and vague presenting symptoms (eg, general malaise, fatigue) are less commonly observed. The most common underlying abnormality in secondary spontaneous pneumothorax is chronic obstructive pulmonary disease (COPD), and cystic fibrosis carries one of the highest associations, with more than 20% reporting spontaneous pneumothorax.
Despite descriptions of Valsalva maneuvers and increased intrathoracic pressures as inciting factors, spontaneous pneumothorax usually develops at rest. By definition, spontaneous pneumothorax is not associated with trauma or stress. Symptoms of iatrogenic pneumothorax are similar to those of a spontaneous pneumothorax and depend on the age of the patient, the presence of underlying lung disease, and the extent of the pneumothorax.
A history of previous pneumothorax is important, as recurrence is common, with rates reported between 15% and 40%. Up to 15% of recurrences can be on the contralateral side. Secondary pneumothoraces are often more likely to recur, with cystic fibrosis carrying the highest recurrence rates at 68-90%. No study has shown that the number or size of blebs and bullae found in the lung can be used to predict recurrence.
Tension pneumothorax
Signs and symptoms of tension pneumothorax are usually more impressive than those seen with a simple pneumothorax, and clinical interpretation of these is crucial for diagnosing and treating the condition. Tension pneumothorax is classically characterized by hypotension and hypoxia. On examination, breath sounds are absent on the affected hemothorax and the trachea deviates away from the affected side. The thorax may also be hyperresonant; jugular venous distention and tachycardia may be present. If on mechanical ventilation, the airway pressure alarms are triggered.
Unlike the obvious patient presentations oftentimes used in medical training courses to describe a tension pneumothorax, actual case reports include descriptions of the diagnosis of the condition being missed or delayed because of subtle presentations that do not always present with the classically described clinical findings of this condition or the complexity of the patient with critical illness or injury. Nevertheless, tension pneumothorax should always be a consideration when acute compromise occurs.
Symptoms of tension pneumothorax may include chest pain (90%), dyspnea (80%), anxiety, fatigue, or acute epigastric pain (a rare finding).
Catamenial pneumothorax
Women aged 30-40 years who present with onset of symptoms within 48 hours of menstruation, right-sided pneumothorax, and recurrence raise suspicion for catamenial pneumothorax.
Pneumomediastinum
Pneumomediastinum must be differentiated from spontaneous pneumothorax. Patients may or may not have symptoms, as this is typically a well-tolerated disease, although mortality in cases of esophageal rupture is very high.
This condition usually occurs when intrathoracic pressures become elevated, such as with an exacerbation of asthma, coughing, vomiting, childbirth, seizures, and a Valsalva maneuver. In many patients who present with pneumomediastinum, it occurs as a result of endoscopy and small esophageal perforation.
In a retrospective review of cases presenting to an academic medical center, 67% of identified patients had chest pain; 42% had persistent cough; 25% had sore throat; and 8% had dysphagia, shortness of breath, or nausea/vomiting.
Other symptoms may include substernal chest pain, usually radiating to the neck, back, or shoulders and exacerbated by deep inspiration, coughing, or supine positioning; dyspnea; neck or jaw pain; dysphagia, dysphonia, and/or abdominal pain (unusual symptoms).
Traumatic mediastinum, although present in up to 6% of patients, does not portend serious injury. [33]
Physical Examination
The presentation of a patient with pneumothorax may range from completely asymptomatic to life-threatening respiratory distress. Symptoms may include diaphoresis, splinting chest wall to relieve pleuritic pain, and cyanosis (in the case of tension pneumothorax). Findings on lung auscultation also vary depending on the extent of the pneumothorax. Affected patients may also reveal altered mental status changes, including decreased alertness and/or consciousness (a rare finding).
Respiratory findings may include the following:
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Respiratory distress (considered a universal finding) or respiratory arrest
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Tachypnea (or bradypnea as a preterminal event)
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Asymmetric lung expansion - A mediastinal and tracheal shift to the contralateral side can occur with a large tension pneumothorax
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Distant or absent breath sounds - Unilaterally decreased or absent lung sounds is a common finding, but decreased air entry may be absent even in an advanced state of the disease
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Lung sounds transmitted from the unaffected hemithorax are minimal with auscultation at the midaxillary line
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Hyperresonance on percussion - This is a rare finding and may be absent even in an advanced state of the disease
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Decreased tactile fremitus
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Adventitious lung sounds (crackles, wheeze; an ipsilateral finding)
Cardiovascular findings may include the following:
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Tachycardia - This is the most common finding. If the heart rate is faster than 135 beats/min, tension pneumothorax is likely
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Pulsus paradoxus
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Hypotension - This should be considered as an inconsistently present finding; although hypotension is typically considered a key sign of a tension pneumothorax, studies suggest that hypotension can be delayed until its appearance immediately precedes cardiovascular collapse
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Jugular venous distention - This is generally seen in tension pneumothorax, although it may be absent if hypotension is severe
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Cardiac apical displacement - This is a rare finding
Spontaneous and iatrogenic pneumothorax
Signs of spontaneous and iatrogenic pneumothorax are similar and depend on the underlying lung disease and extent of the pneumothorax. Tachycardia is the most common finding, and tachypnea and hypoxia may be present.
Tension pneumothorax
Although tension pneumothorax may be a difficult diagnosis to make and may present with considerable variability in signs, respiratory distress and chest pain are generally accepted as being universally present, and tachycardia and ipsilateral air entry on auscultation are also common findings. Sometimes, reliance on history alone may be warranted.
Findings may be affected by the volume status of the patient. In hypovolemic trauma patients with ongoing hemorrhage, the physical findings may lag behind the presentation of shock and cardiopulmonary collapse. Increased pulmonary artery pressures and decreased cardiac output or cardiac index are evidence of tension pneumothorax in patients with Swan-Ganz catheters.
When examining a patient for suspected tension pneumothorax, any clue may be helpful, as subtle thoracic size and thoracic mobility differences may be elicited by performing careful visual inspection along the line of the thorax. In a supine patient, the examiner should lower themselves to be on a level with the patient.
Tracheal deviation is an inconsistent finding. Although historic emphasis has been placed on tracheal deviation in the setting of tension pneumothorax, tracheal deviation is a relatively late finding caused by midline shift.
Abdominal distention may occur from increased pressure in the thoracic cavity producing caudal deviation of the diaphragm and from secondary pneumoperitoneum produced as air dissects across the diaphragm through the pores of Kohn.
If patients who are mechanically ventilated are difficult to ventilate during resuscitation, high peak airway pressures are clues to pneumothorax. A tension pneumothorax causes progressive difficulty with ventilation as the normal lung is compressed. On volume-control ventilation, this is indicated by marked increase in both peak and plateau pressures, with relatively preserved peak and plateau pressure difference. On pressure control ventilation, tension pneumothorax causes sudden drop in tidal volume. However, these observations are neither sensitive nor specific for making the diagnosis of pneumothorax or ruling out the possibility of pneumothorax.
The development of tension pneumothorax in patients who are ventilated will generally be of faster onset with immediate, progressive arterial and mixed venous oxyhemoglobin saturation decline and immediate decline in cardiac output. Cardiac arrest associated with asystole or pulseless electrical activity (PEA) may ultimately result. Occasionally, the tension pneumothorax may be tolerated and its diagnosis delayed for hours to days after the initial insult. The diagnosis may become evident only if the patient is receiving positive-pressure ventilation. Tension pneumothorax has been reported during surgery with both single- and double-lumen tubes.
Pneumomediastinum
As with pneumothorax, physical findings of pneumomediastinum may be variable, including absent signs in some patients. However, subcutaneous emphysema is the most consistent sign. Another sign, the Hamman sign—a precordial crunching noise synchronous with the heartbeat and often accentuated during expiration—has a variable rate of occurrence, with one series reporting 10%.
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Radiograph of a patient with a small spontaneous primary pneumothorax
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Close radiographic view of patient with a small spontaneous primary pneumothorax (same patient as from the previous image).
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Expiratory radiograph of a patient with a small spontaneous primary pneumothorax (same patient as in the previous images).
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Radiograph of a patient with spontaneous primary pneumothorax due to a left upper lobe bleb.
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Close radiographic view of a patient with spontaneous primary pneumothorax due to a left upper lobe bleb (same patient as in the previous image).
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Radiograph of a patient with a large spontaneous tension pneumothorax.
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Radiograph showing subcutaneous emphysema and pneumothorax.
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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.
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Radiograph of a new left-sided pneumothorax in a patient on mechanical ventilation, requiring high inflation pressures.
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Radiograph of a patient with a complete right-sided pneumothorax due to a stab wound.
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Radiograph of a patient with idiopathic pulmonary fibrosis and a small pneumothorax, following video-assisted thoracoscopic surgery (VATS) lung biopsy.
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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.
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Radiograph depicting a right-sided iatrogenic pneumothorax after transbronchial biopsy.
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Pneumomediastinum from barotrauma may result in tension pneumothorax and obstructive shock.
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Radiograph of a patient in the intensive care unit (ICU) who developed pneumopericardium as a manifestation of barotrauma.
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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.
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Radiograph depicting right main stem intubation that resulted in left-sided tension pneumothorax, right mediastinal shift, deep sulcus sign, and subpulmonic pneumothorax.
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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.
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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.
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Radiograph demonstrating tension and traumatic pneumothorax.
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Radiograph demonstrating tension and traumatic pneumothorax.
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Lateral radiograph demonstrating tension and traumatic pneumothorax.
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Lateral radiograph demonstrating tension and traumatic pneumothorax.
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Chest radiograph depicting tension and traumatic pneumothorax.
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Lateral radiograph depicting tension and traumatic pneumothorax.
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Computed tomography scan demonstrating blebs in a patient with chronic obstructive pulmonary disease (COPD).
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Computed tomography scan demonstrating a bulla in an asymptomatic patient.
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Computed tomography scan demonstrating secondary spontaneous pneumothorax (SSP) from radiation/chemotherapy for lymphoma.
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Computed tomography scan demonstrating emphysematouslike changes (ELCs) in a patient with chronic obstructive pulmonary disease (COPD).
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Computed tomography scan in a patient with a history of bilateral pleurodesis and a strong family history of spontaneous pneumothorax.
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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.
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Insertion of chest tube. Video courtesy of Therese Canares, MD, and Jonathan Valente, MD, Rhode Island Hospital, Brown University.
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