Spontaneous Pneumothorax

1. Also See
   1. Pneumothorax
   2. Tension Pneumothorax
   3. Open Pneumothorax
2. Epidemiology
   1. Typical patient is a tall, thin male
   2. Age under 40 years (80%)
   3. Presentation within 24 hours (70%)
3. Pathophysiology
   1. Primary Spontaneous Pneumothorax
      1. No underlying lung disease
   2. Secondary Spontaneous Pneumothorax
      1. Underlying lung disease (esp. COPD)
      2. Conservative management is indicated
4. Risk Factors
   1. Chronic Obstructive Pulmonary Disease (COPD)
      1. Related to pulmonary blebs
   2. Asthma
      1. Related to marked thoracic pressure changes
   3. Bronchitis
   4. Tuberculosis
   5. HIV Infection
   6. Cystic Fibrosis
   7. Pneumonia
   8. Menstruation
5. Symptoms
   1. Chest Pain
      1. Sudden sharp pain
      2. Radiates to back or Shoulders
   2. Variable cardiopulmonary symptoms including Dyspnea
6. Signs
   1. Examination may be unremarkable
   2. Keep high index of suspicion
      1. COPD patients
      2. Tall, thin males
   3. Unilateral absent breath sounds
   4. Hyperresonant to percussion
   5. Coin Test
7. Signs: Red Flags - Signs of Tension Pneumothorax
   1. Tracheal deviation
   2. Hypotension
   3. Jugular Venous Distention
8. Imaging
   1. See Pneumothorax Imaging
9. Management: Small Pneumothorax options
   1. Observation for small Pneumothorax
      1. Volume: <20%
      2. Apical depth: <1-3 cm (from apex to lung cupola)
   2. Needle aspiration
      1. Successful in 70% of cases
      2. However very slow resolution
         1. Room air: 1.25% per day (25% Pneumothorax would resolve in 20 days)
         2. Oxygen: 5% per day (25% Pneumothorax would resolve in 5 days)
   3. Cook catheter (small catheter with heimlich valve)
      1. Allows patient to go home with this
   4. Chest Tube
      1. See Indications below
10. Management: Chest Tube
    1. Chest Tube Indications
       1. Large Pneumothorax
       2. Decompensating patient status
       3. Positive Pressure Ventilations used
       4. Hemothorax
       5. Persistent air leak despite cook catheter (Heimlich valve) described above
       6. Signs of infection
       7. Failure to reexpand lung
11. Complications
    1. Hemothorax accompanies penumothorax in up to 2-7% of cases
       1. Significant blood loss may occur
    2. Re-Expansion pulmonary edema
       1. Massive pulmonary edema onset following re-expansion of Pneumothorax
          1. Severe, life threatening event
       2. Risk Factors
          1. Young patients
          2. Large Pneumothorax
          3. Pneumothorax present longer than 72 hours
          4. Hemothorax (or pus)
          5. Rapid re-expansion with suction
       3. Management
          1. Admit to intensive care unit
          2. Intubation
          3. IV Fluids
          4. Supportive care
12. Prognosis
    1. Recurrent up to every 2 years in as many as 30% of patients
    2. Higher risk in smokers
13. References
    1. Majoewsky (2012) EM:RAPC3 2(2): 3-4