Pneumothorax
Pneumothorax Defined

Definition – “What?”



“Pneumo”- gas
“Thorax” – chest cavity
Analagous to Pleural Effusion
Pathophysiology – “How?

Pleural space
Baseline (-) pressure space
 Parietal Pleura
 Visceral Pleura


Normal inspiration
Diaphragm
 Transmit (-) Pressure


Pathologic inspiration

XS gas disrupts transmission of () pressure
Types of Pneumothorax

Spontaneous Pneumothorax
 Primary
- rupture of subpleural bleb
 “Jimmy
is a tall, wiry, 21-year old male, who plays trombone in the
marching band….”
 Secondary
-
underlying lung/pleural disease
– emphysema
 Chronic bronchitis, asthma, TB, …
 #1

Traumatic Pneumothorax
 Open
 Chest
wall is penetrated : outside air enters pleural space
 Closed
 Chest
wall is intact
Ex. Fractured rib
Types of Pneumothorax 2

Tension Pneumothorax




“Ball-valve mechanism”
Injury to pleura creates a tissue flap
that opens on inspiration and closes
on expiration
One of our own patients
Variations


Hemo-thorax
Chylo-thorax


Injury to thoracic duct
Empyema

Parapneumonic effusions in communityacquired pneumonia
Symptoms
Dyspnea
 Pleuritic chest pain

 Nerve
endings at pleural capsule
Sense of impending doom
 Sudden onset

 Tension
pneumothorax
 Spontaneous pneumothorax
Physical Exam - Signs

Unstable patients vs. Stable patients
 Vital
Signs
Asymmetric chest expansion
 Deviated trachea
 Diminished breath sounds unilaterally
 Hyper-resonance unilaterally
 Decreased tactile fremitus

Diagnosis

Unstable patient

Thoracentesis
Rapid release of air
 Vital signs stabilize rapidly


Stable patient

CXR
Monitor size by measuring
distance from lateral lung
margin to chest wall
 Be sure that
pneumothorax is not
expanding

Imaging

Plain Radiographs

Upright PA on inspiration



Detect other pathologies:
pneumonia, cardiac, etc.
Partially collapsed lung
Tension Pneumothorax
Trachea and mediastinum
deviate contralaterally
 Ipsilateral depressed hemidiaphragm


Chest CT


Not routine
Only to assess the need for
surgery (thoracotomy)
Treatment

Small pneumothorax
 Resolve
over days to weeks
 Supplemental oxygen and observation

Tension pneumothorax
 Immediate
decompression via chest tube or needle
thoracostomy

Spontaneous pneumothorax
– outpatient, f/u with serial CXR
 Symptomatic – inpatient, chest tube
 Recurrent pneumothorax – CT to evaluate need for
thoracotomy
 Asymptomatic
Tube
Thoracostomy

a.k.a. Chest tube