Diagnostic Considerations
This section reviews some important points to consider in the diagnosis of pneumothoraces.
Spontaneous pneumothorax
Because patients with primary spontaneous pneumothorax (PSP) will have apical emphysematous pulmonary disease on computed tomography (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.
Folliculin gene disorders have been described in familial spontaneous pneumothorax. [4] These patients may have pneumothorax as the presenting symptom of Birt-Hogg-Dube disease. [5] Some authors recommend screening patients with a family history of pneumothorax for the benign skin tumors and renal cancers that arise from the disease.
Catamenial pneumothorax is a rare cause of recurrent pneumothorax in women. Prior to recurrence, this condition may initially be diagnosed as PSP.
Pneumonia is a possible cause of pneumothorax; in the patient with human immunodeficiency virus infection (HIV), Pneumocystis jiroveci pneumonia (PCP) , toxoplasmosis, and Kaposi sarcoma need to be considered . A patient with HIV can have spontaneous pneumothorax as the presenting symptom of their illness: HIV carries a lifetime risk of 6% for pneumothorax, and about 85% of that number is related to PCP pneumonia.
The rare event of spontaneous pneumothorax leading to tension pneumothorax may be misdiagnosed as an asthma crisis or exacerbation of chronic obstructive pulmonary disease (COPD) in the patient presenting with tachycardia, subcutaneous emphysema, dyspnea, and shock.
Traumatic pneumothorax
Always consider pneumothorax in the differential diagnosis of major trauma. In the patient with blunt trauma and mental status changes, hypoxia, and acidosis, symptoms of a tension pneumothorax may be masked by associated and similarly potentially lethal injuries.
When assessing the trauma patient, be aware that clinical presentations of tension pneumothorax and cardiac tamponade may be similar.
Tension pneumothorax
The diagnosis of a tension pneumothorax should largely be based on the history and physical examination findings. Ultrasonography in the emergency setting is being increasingly used as an adjunct to the physical examination when there is doubt regarding the diagnosis. Chest radiography or CT should be used only in those instances when the clinician is in doubt regarding the diagnosis and when the patient's clinical condition is hemodynamically stable. Obtaining such imaging studies when the diagnosis of tension pneumothorax is not in question causes an unnecessary and potentially lethal delay in treatment.
A tension pneumothorax is a life-threatening condition and requires immediate action (eg, needle thoracostomy or chest tube insertion). However, the clinician should be wary of prematurely diagnosing a tension pneumothorax in a patient without respiratory distress, hypoxia, hypotension, or cardiopulmonary compromise. If the patient's clinical presentation is questionable and if the patient appears stable, the clinician should reexamine the patient and use bedside ultrasonography or request immediate portable chest radiography (or reexamine the chest radiographs if they have already been obtained) to confirm the diagnosis.
A high index of suspicion for tension pneumothorax is recommended in patients on mechanical ventilation with acute onset of hemodynamic instability, difficult ventilation with high inspiratory pressures, and worsening hypoxemia and/or hypercapnia, even with a functioning chest tube in place. Patients at greatest risk of a pneumothorax and/or tension pneumothorax include those with COPD who are using ventilators; those with acute respiratory distress syndrome (ARDS); and those receiving a tidal volume greater than 12 mL/kg, a peak airway pressure greater than 60 cm H2O, or a positive end-expiratory pressure greater than 15 cm H2O. Portable chest radiograph may fail to show the pneumothorax; CT may be required for diagnosis.
Avoid assuming that a patient with a chest tube does not have a tension pneumothorax if he or she has respiratory or hemodynamic instability. Chest tubes can become plugged or malpositioned and cease to function. In addition, improper attachment of a one-way valve to the chest tube may produce tension pneumothorax.
Additional considerations
Other conditions to consider include the following:
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Aspiration, bacterial, mycoplasmal, and viral pneumonia
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Asthma
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Costochondritis
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Diaphragmatic injuries
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Esophageal spasm
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Foreign bodies, trachea
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Mediastinitis
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Myocardial ischemia
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Myocarditis
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Pericarditis
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Pleurodynia
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Pulmonary empyema and abscess
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Tuberculosis
Differential Diagnoses
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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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