Pneumothorax (main)
Spontaneous Pneumothorax
Background
- Primary Pneumothorax
- Spontaneous ptx in pt w/o underlying pulm disease
- Secondary Pneumothorax
- Spontaneous ptx in pt w/ underlying pulm disease
- Worse prognosis
Causes
- COPD/Asthma
- Cystic fibrosis
- Necrotizing pneumonia
- Lung abscess
- PCP
- TB
- Neoplasm
- Interstitial lung disease
- Connective tissue disease
- Pulmonary infarct
Diagnosis
Presentation
- Sudden onset of pleuritic chest pain evolving to dull constant ache over days
- Most often occurs at rest, not during exertion
Physical Exam
- Reduced ipsilateral lung excursion
- Hyperresonance
- Tachypnea
- Hypoxia
- Increased work of breathing
- Hypotension -> tension pneumothorax
Imaging
- Ultrasound
- NO comet tail artifact
- No sliding lung sign
- Bar Code (instead of waves on the beach) appearance on M-mode
- CXR*
- Displaced visceral pleural line
- Size
- Large >3cm apex to cupola
- Small <3cm apex to cupola
- Air fluid level with pleural effusion = ptx
- Deep sulcus sign
- CT Chest
- Very sensitive and specific
Treatment
Important features are:
- Stability of the patient
- 2001 ACP Guidelines for stability:
- RR<24, O2 Sat >90%, HR between 60-120, nl BP
- Can speak in full sentences
- Age <50yo
- 2001 ACP Guidelines for stability:
- Size of pneumothorax
- Primary or secondary pneumothorax
- Time course unimportant
Primary Spontaneous Pneumothorax
- Clinically stable and small pneumothorax
- Observe in ED at least 6hr
- Repeat CXR shows stable or smaller pneumothorax then no chest tube required
- May DC home with f/u in 12-24 hr
- If no f/u or unreliable admit, high-flow O2
- If ptx enlarges then place chest tube
- Clincally stable & large pneumothorax
- Place Chest Tube and admit
- If pt refuses admission:
- 14Fr catheter to Heimlich valve
- 12 hour f/u
Secondary Spontaneous Pneumothorax
- Clincally stable and small pneumothorax
- Chest Tube
- Observation alone associated with some mortality
- Admit
- Do not simply aspirate or ED observe
- Clincically stable and large pneumothorax
- Chest Tube
- Admit
Tension Pneumothorax
Diagnosis
- Diminished or absent breath sounds
- Hypotension or e/o hypoperfusion
- Distended neck veins
- May not occur if pt is hypovolemic
- Tracheal deviation
- Late sign
Treatment
- Immediate needle decompression if unstable (clinical = decreased BS or US findings)
- Wait for CXR confirmation if stable
- 14ga IV in midclavicular line just above the rib at the second intercostal space
- Followed by Chest Tube
Traumatic Pneumothorax
Background
- Present in 25% of pts w/ chest trauma
- Rib fx and penetrating trauma most common causes
- Isolated ptx does not cause severe symptoms until >40% of hemithorax is occupied
Types
- Can be open, closed, or occult
- Open
- Communication between pleural space and atmospheric pressure (sucking chest wound)
- Occult
- PPV can convert an occult ptx to a tension ptx
- Open
Diagnosis
- Ptx after a stab wound may be delayed for up to 6 hr
- If pt decompensates obtain repeat imaging
- CXR
- Upright is best (esp expiratory film)
- Thin white line (pleura) between 2 areas of lucency (lung parenchyma and air)
- No lung markings distal to white line
- Supine
- Look for deep sulcus sign
- Upright is best (esp expiratory film)
- US
- Absence of lung sliding; absence of seashore (M-mode)
Treatment
- Tension ptx
- Immediate needle thoracostomy
- Open ptx
- Cover wound with three-sided dressing
- Make sure to avoid complete occlusion (may convert injury to a tension ptx)
- Cover wound with three-sided dressing
- Tube thoracostomy indicated if:
- Pt cannot be observed closely
- Pt requires intubation
- Pt will be transported by air or over a long distance
- Observation alone ok if:
- Small ptx (<1cm wide, confined to upper 1/3 of chest) is unchanged on two CXR 6hr apart
- Occult ptx (seen only on CT) unless pt requires mechanical ventilation
See Also
Source
Tintinalli