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

• Smoking
• COPD
• Asthma
• Cystic fibrosis
• Necrotizing pneumonia
• Lung abscess
• PCP PNA
• TB
• Neoplasm
• Interstitial lung disease
• Connective tissue disease
• Pulmonary infarct

Clinical Features

• Sudden onset pleuritic chest pain evolving to dull constant ache over days
• Most often occurs at rest, not during exertion
• Tachypnea, hypoxemia, increased work of breathing
• Reduced ipsilateral lung excursion
• Hypotension -> tension pneumothorax

Differential Diagnosis

Pneumothorax Types

The pleural cavity is normally a potential space, in which air collects in a pneumothorax.

• Tension pneumothorax
• Spontaneous pneumothorax
  • Catamenial pneumothorax
• Traumatic pneumothorax
  • Iatrogenic pneumothorax

Acute dyspnea

Emergent

• Pulmonary
  • Airway obstruction
  • Anaphylaxis
  • Angioedema
  • Aspiration
  • Asthma
  • Cor pulmonale
  • Inhalation exposure
  • Noncardiogenic pulmonary edema
  • Pneumonia
  • Pneumocystis Pneumonia (PCP)
  • Pulmonary embolism
  • Pulmonary hypertension
  • Tension pneumothorax
  • Idiopathic pulmonary fibrosis acute exacerbation
  • Cystic fibrosis exacerbation
• Cardiac
  • Cardiac tamponade
  • Cardiogenic pulmonary edema (CHF)
  • Myocardial Infarction
  • Pericarditis
  • Myocarditis
• Other Associated with Normal/↑ Respiratory Effort
  • Abdominal distension
  • Anemia
  • CO Poisoning
  • Salicylate toxicity
  • Diabetic ketoacidosis (DKA)
  • Diaphragm injury
  • Electrolyte abnormalities
  • Epiglottitis
  • Flail chest
  • Hypotension
  • Metabolic acidosis
  • Pneumonia
  • Pneumothorax/hemothorax
  • Renal Failure
  • Sepsis
  • Toxic ingestion
• Other Associated with ↓ Respiratory Effort
  • Guillain-Barre syndrome
  • Multiple sclerosis
  • Myasthenia Gravis
  • Lambert-Eaton Syndrome
  • Organophosphate toxicity
  • Stroke (Main)
  • Tick paralysis

Non-Emergent

• ALS
• Ascites
• Uncorrected ASD
• Congenital heart disease
• COPD exacerbation
• Fever
• Hyperventilation
• Interstitial lung disease
• Neoplasm
• Obesity
• Panic attack
• Pleural effusion
• Polymyositis
• Porphyria
• Pregnancy
• Rib fracture
• Spontaneous pneumothorax
• Thyroid Disease
• URI

Diagnosis

• CXR
  • Displaced visceral pleural line w/o lung markings between pleural line and chest wall
  • Air fluid level with Pleural Effusion = ptx
  • Supine CXR view shows deep sulcus sign
• CT Chest
  • Very sensitive and specific
• Ultrasound: Lungs
  • NO comet tail artifact
  • No sliding lung sign
  • Bar Code (instead of waves on the beach) appearance on M-mode

Size

• Small: <3cm apex to cupola (chest wall)
• Large: >3cm lung apex to cupola (chest wall)

Management

Unstable

• Needle decompresion followed by chest tube insertion

Stable, First Episode

• Asymptomatic AND small (≤3 cm between the lung and chest wall on a chest radiograph)
  • Supplemental oxygen and observe
• Symptomatic OR large (>3 cm rim of air on chest radiograph)
  • Aspiration
    • If fail aspiration, chest tube and thoracoscopy (VATS)^

Stable, Recurrent OR Hemopneumothorax

• Chest tube + thoracoscopy (VATS)^

^if thoracoscopy (VATS) is not readily available, chemical pleurodesis through the chest tube

Primary Spontaneous Pneumothorax

• Small size, clinically stable
  • Option 1: Observe for 6hr; d/c if no sx and have pt return in 24hr for recheck
  • Option 2: Small-size catheter (<14F) or needle aspiration with immediate catheter removal
    • Then observe for 6h; d/c if no sx and have pt return in 24hr for recheck
  • Option 3: Small-size catheter or chest tube (10-14F), Heimlich valve or water-seal, admit
• Large size or bilateral
  • Mod-size chest tube (16-22) and admit; large-size chest tube (24-36) if hemothorax

Secondary Pneumothorax

• Small size, clinically stable
  • Small-size catheter or chest tube, Heimlich valve or water-seal drainage, and admit
  • Observation alone associated with some mortality
• Large size or bilateral
  • Mod-size chest tube (16-22) and admission; large-size chest tube (24-36) if hemothorax

Adult Chest Tube Sizes

Chest Tube Size	Type of Patient	Underlying Causes
Small (8-14 Fr)	Most spontaneous pneumothorax (primary and secondary) Most iatrogenic pneumothorax	Alveolar-pleural fistulae (small air leak) Iatrogenic air
Medium (20-28 Fr)	Traumatic pneumothorax Traumatic hemothorax ("any acute hemothorax visible on chest radiograph") Pneumothorax on mechanical ventilation Non-traumatic tension pneumothorax Malignant effusion	Trauma/bleeding (hemothorax/hemopneumothorax) Bronchial-pleural fistulae (large air leak) Malignant fluid
Large (36-40 Fr)	Empyema	Thick pus

Management Options

• Observation alone
• Observation + oxygen,
  • Oxygen (3L/min nasal cannula to 10L/min mask) increases pleural air resorption by 3-4x
• Needle or catheter aspiration
  • Needle/catheter aspiration is as effective as chest tube for small ptxs
    • Place in 2nd IC space in midclavicular line or 4th/5th IC space in ant axillary line
    • If lung fails to expand can try 2nd aspiration attempt, Heimlich valve, or chest tube
• Tube thoracostomy
  • Use for large, recurrent, or b/l ptxs, abnormal vitals, or large air leak anticipated
  • Underwater seal drainage is adequate (suction only necessary if persistent air leak)

Disposition

Special Instructions

Flying

• Patients can consider flying 1 week after resolution of pneumothorax

See Also

• Pneumothorax
• Chest Tube
• Thoracentesis