II. Epidemiology: Incidence (United States)

  1. Medical Encounters: 20,000/year
  2. Men: Up to 28 per 100,000/year
  3. Women: Up to 6 per 100,000/year

III. Pathophysiology

  1. Pressure gradient from intraalveolar space to intrapleural space
    1. Intrapleural pressure is negative
      1. Chest wall springs outward and alveoli recoil inward
      2. Inspiration: -12 mmHg
      3. Expiration: -4 mmHg
    2. Alveolar pressures become positive on expiration (3 mmHg)
  2. Defect in alveolar wall and visceral pleura allows air to enter the pleural space
    1. Pleural air accumulates and decreases pressure gradient if defect does not close
    2. Eventually, if pleural pressure increases to alveolar pressure, lung collapses
    3. Tension Pneumothorax will arise if air enters pleural space during inspiration, but is trapped from exiting during expiration

IV. Types

  1. Primary Spontaneous Pneumothorax (66%)
    1. No underlying lung disease
    2. Typical patient is a tall, thin male
    3. Age typically 10 to 30 years old (uncommon after age 40 years)
    4. Subpleural blebs are responsible for most cases (forming at apices in tall, thin patients)
  2. Secondary Spontaneous Pneumothorax (33%)
    1. Chronic Obstructive Pulmonary Disease or COPD (70% of secondary causes)
      1. Related to pulmonary blebs
    2. Asthma
      1. Related to marked thoracic pressure changes
    3. Tuberculosis and abscess (most common cause world-wide)
    4. Cystic Fibrosis
      1. Lifetime risk of 8-20%
    5. AIDS
      1. Risk: 2-6%
      2. Typically associated with comorbid Pneumocystis jiroveci Pneumonia
    6. Menstruation (Catamenial Pneumothorax, thoracic endometrial syndrome)
      1. Occurs within first 3 days of Menses onset
      2. Endometrial implants on diaphragm or lung
      3. High risk of recurrence
    7. Pneumonia
    8. Bronchitis

V. Risk Factors

  1. See Primary Spontaneous Pneumothorax regarding body habitus
    1. Tall Stature
    2. Low BMI
  2. See Secondary causes above
  3. Tobacco Abuse
    1. Increases the risk of both primary and Secondary Spontaneous Pneumothorax
    2. May increase lifetime risk from 0.1% in non-smokers to 12% in smokers
  4. Prior Pneumothorax
    1. See recurrence rates below
  5. Other contributing factors
    1. Malnutrition
    2. Connective tissue disease
  6. Factors that appear unrelated
    1. Exercise does not appear to predispose to Pneumothorax
    2. Most Spontaneous Pneumothorax events take place at rest

VI. Symptoms

  1. Presentation within 24 hours of onset in 70% of cases
  2. Chest Pain
    1. Sudden sharp pain
    2. Radiates to back or Shoulders
    3. Pleuritic Chest Pain initially transitions into a steady ache-type Chest Pain
    4. Chest Pain improves after the first 24 hours despite persistence of Pneumothorax
  3. Dyspnea
    1. Variably present
    2. Typically not severe in Primary Spontaneous Pneumothorax
  4. Variable cardiopulmonary symptoms
    1. Symptoms severity is increased with Secondary Spontaneous Pneumothorax
    2. Severe Dyspnea with Hypoxia, Hypotension, Tachycardia is Tension Pneumothorax until proven otherwise

VII. Signs

  1. Examination may be unremarkable
    1. Tachycardia may be the only clinical finding (single most common finding)
  2. Keep high index of suspicion
    1. COPD patients
    2. Tall, thin males
  3. Changes on affected side
    1. Unilateral absent or decreased breath sounds
    2. Hyperresonance to percussion
    3. Decreased tactile fremitus
    4. Decreased chest wall movement
    5. Coin Test

VIII. Signs: Red Flags - Signs of Tension Pneumothorax

X. Precautions

  1. Secondary Spontaneous Pneumothorax is significantly higher risk than Primary Spontaneous Pneumothorax
    1. Secondary Spontaneous Pneumothorax has potential for life threatening presentation due to underlying lung disease
    2. Treat Secondary Spontaneous Pneumothorax aggressively
    3. Mortality approaches 10% even after reexpansion of Pneumothorax
  2. Delayed presentation in >50% of patients
    1. Higher risk of complication (e.g. reexpansion pulmonary edema)

XI. Management: Small Pneumothorax options

  1. Observation for small Pneumothorax
    1. Volume: <20%
    2. Apical depth: <1-3 cm (from apex to lung cupola)
    3. Observe for 3-6 hours in emergency department
  2. Supplemental Oxygen
    1. Successful in 70% of cases
    2. However slow resolution
      1. Room air: 1.25% per day (25% Pneumothorax would resolve in 20 days)
      2. High Flow Oxygen (10 L/min): 5% per day (25% Pneumothorax would resolve in 5 days)
    3. Kelly (2008) Chest 134(5): 1033-6 [PubMed]
  3. Simple Needle aspiration
    1. See Simple Needle Aspiration of Pneumothorax
    2. Similar technique as with Small Calibre Chest Tube (Heimlich Valve, Pigtail Chest Catheter)
    3. Insert 16 to 18 gauge catheter with 3-way stop cock into the second intercostal space mid-clavicular line
    4. Remove catheter after full evacuation of air
  4. Small Calibre Chest Tube (Heimlich Valve, Pigtail Chest Catheter)
    1. Allows patient to go home with catheter
  5. Chest Tube
    1. See Indications below

XII. Management: Large or complicated Pneumothorax (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
  2. Technique
    1. See Chest Tube
    2. Chest Tube size
      1. Uncomplicated Spontaneous Pneumothorax: 16F to 22 F (small bore)
      2. Unstable, Bronchopleural Fistula or Mechanical Ventilation: 24-28 F
      3. Hemothorax: 32 F (large bore)
        1. Some Trauma surgeons recommend 36 or 40 F
    3. Suction
      1. Start with water seal or Heimlich Valve
      2. Low intermittent suction (-10 to -20 cm H2O) indicated in persistent air leak despite Chest Tube >24 hours
    4. Prophylactic Antibiotics
      1. Not indicated in non-Traumatic Pneumothorax with Chest Tube

XIII. Management: Refractory Pneumothorax (Surgery)

  1. Surgical Indications
    1. Recurrent ipsilateral Pneumothorax (after second event)
    2. Bilateral Spontaneous Pneumothorax
    3. Persistent air leak or failed re-expansion (>5-7 days)
      1. Despite well placed large Chest Tube to low intermittent suction
    4. Spontaneous Hemothorax
    5. Tension Pneumothorax
    6. High risk profession (e.g. pilot, scuba diver)
  2. Methods
    1. Pleurodesis with talc or other sclerosing agent
      1. Decreases Spontaneous Pneumothorax recurrence rate from 20-60% to less than 5-8%
      2. Talc appears more effective than Tetracycline
      3. Guo (2005) Respirology 10(3): 378-84 [PubMed]
    2. Cautery to visceral pleura
    3. Application of mesh to pleura
    4. Bleb resection
    5. Thoracotomy with bullectomy and pleurectomy
  3. References
    1. Kurihara (2010) Gen Thorac Cardiovasc Surg 58(3): 113-9 [PubMed]

XIV. Management: Disposition

  1. Hospitalization indications
    1. Moderate to large Spontaneous Pneumothorax
    2. Secondary Spontaneous Pneumothorax
    3. Delayed presentation of large Spontaneous Pneumothorax (risk of reexpansion pulmonary edema)
    4. Unreliable or difficult follow-up (e.g. patient lives far from emergency department)
    5. Air transport anticipated
  2. Discharge indications
    1. No hospitalization indications above AND
    2. Observation for 3-6 hours without Pneumothorax reexpansion (see protocol below)
  3. Protocol: Observation prior to discharge
    1. Admit all patients with Secondary Spontaneous Pneumothorax
      1. Observe for at least 24 hours
    2. Hgh flow oxygen (10 Liters) is typical (see above for details)
    3. Observation for small to moderate Primary Spontaneous Pneumothorax following air evacuation or Chest Tube placement
      1. British Thoracic Society: 6 hours
      2. American College of Chest Physicians: 3-6 hours
    4. Repeat imaging
      1. Prior to discharge at 3-6 hours
      2. Follow-up: 24 to 48 hours

XV. Management: Restrictions

  1. Exercise
    1. Exertion or Exercise is not a risk for recurrence of Pneumothorax
    2. No restriction of activity after Pneumothorax has resolved
  2. Scuba Diving Contraindications
    1. History of Spontaneous Pneumothorax
      1. In some cases, may be permitted following definitive surgical management
    2. History of pulmonary blebs or bullae
    3. Emphysema
  3. Air travel
    1. Air transport to a medical facility for Pneumothorax management
      1. Risk of Tension Pneumothorax
      2. Requires Chest Tube placement and drain to water seal or Heimlich Valve prior to transport
    2. Commercial aircraft travel following Pneumothorax resolution
      1. Commerical air travel does not increase Pneumothorax recurrence risk
      2. Commercial regulations following Pneumothorax resolution (by Chest XRay) varies by guideline
        1. U.S. safety regulations: 3 week waiting period prior to air travel
        2. British Thoracic society: 6 week waiting period prior to air travel

XVI. Complications

  1. Tension Pneumothorax
  2. Spontaneous hemopneumothorax
    1. Hemothorax accompanies penumothorax in up to 2.6% of cases
    2. Hemopneumothorax is >400 ml of air and blood within the pleural cavity
    3. Significant blood loss may occur
  3. Pneumomediastinum and subcutaneous Emphysema
    1. May occur with Valsalva Maneuver or other similar exertional activity
  4. 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

XVII. Prognosis: Recurrence

  1. Recurrent Spontaneous Pneumothorax will typically occur within 2 years of prior episode
  2. Overall recurrence rate: 20-60% (with similar rates on the contralateral side)
  3. Secondary Spontaneous Pneumothorax recurrence rate: 40-80%
  4. Third Spontaneous Pneumothorax recurrence rate: >80%
  5. Recurrence rate after definitive surgical management (e.g. pleurodesis): <5%

XVIII. References

  1. Noppen (2003) Respiration 70(4): 431-8 [PubMed]
  2. Majoewsky (2012) EM:RAPC3 2(2): 3-4
  3. Tranchell (2013) Crit Dec Emerg Med 27(7): 11-8

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Ontology: Spontaneous pneumothorax (C0149781)

Concepts Disease or Syndrome (T047)
MSH D011030
ICD10 J93.83
SnomedCT 196105001, 155610003, 233644000, 80423007
English Spontaneous pneumothorax, spontaneous pneumothorax, spontaneous pneumothorax (diagnosis), pneumothorax spontaneous, Spontaneous pneumothorax NOS, Spontaneous Pneumothoraxs, Pneumothoraxs, Spontaneous, Pneumothorax, Spontaneous, Primary Spontaneous Pneumothorax, Spontaneous Pneumothoraxs, Primary, Spontaneous Pneumothorax, Spontaneous Pneumothorax, Primary, Pneumothoraxs, Primary Spontaneous, Primary Spontaneous Pneumothoraxs, Spontaneous pneumothorax NOS (disorder), Pneumothorax spontaneous, Spontaneous pneumothorax (disorder), pneumothorax; spontaneous, spontaneous; pneumothorax
Spanish neumotórax espontáneo, SAI (trastorno), neumotórax espontáneo, SAI, Neumotórax espontáneo, neumotórax espontáneo (trastorno), neumotórax espontáneo
Czech Pneumotorax spontánní
Dutch spontane pneumothorax, pneumothorax; spontaan, spontaan; pneumothorax
French Pneumothorax spontané
German Pneumothorax spontan
Hungarian Spontán pneumothorax
Italian Pneumotorace spontaneo
Japanese シゼンキキョウ, 自然気胸
Portuguese Pneumotórax espontâneo

Ontology: PNEUMOTHORAX, PRIMARY SPONTANEOUS (C1868193)

Concepts Disease or Syndrome (T047)
MSH C566795
ICD9 512.81
ICD10 J93.11
SnomedCT 328561000119107
English PSP, PNEUMOTHORAX, PRIMARY SPONTANEOUS, Prim spont pneumothorax, pneumothorax spontaneous primary, pneumothorax spontaneous primary (diagnosis), Pneumothorax, Primary Spontaneous, Primary spontaneous pneumothorax, Primary spontaneous pneumothorax (disorder)
Czech Primární spontánní pneumotorax
Dutch primaire spontane pneumothorax
French Pneumothorax primitif spontané
German Primaerer Spontanpneumothorax
Hungarian Elsődleges spontán pneumothorax
Italian Pneumotorace spontaneo primario
Japanese 原発性自然気胸, ゲンパツセイシゼンキキョウ
Portuguese Pneumotórax espontâneo primário
Spanish Neumotórax espontáneo primario

Ontology: Secondary spontaneous pneumothorax (C3161098)

Concepts Disease or Syndrome (T047)
ICD9 512.82
ICD10 J93.12
SnomedCT 328571000119101
English Sec spont pneumothorax, pneumothorax spontaneous secondary, pneumothorax spontaneous secondary (diagnosis), Secondary spontaneous pneumothorax (disorder), Secondary spontaneous pneumothorax
Czech Sekundární spontánní pneumotorax
Dutch secundaire spontane pneumothorax
French Pneumothorax secondaire spontané
German Sekundaerer Spontanpneumothorax
Hungarian Másodlagos spontán pneumothorax
Italian Pneumotorace spontaneo secondario
Japanese ゾクハツセイシゼンキキョウ, 続発性自然気胸
Portuguese Pneumotórax espontâneo secundário
Spanish Neumotórax espontáneo secundario