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
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