Pneumothorax – Causes, Symptoms, Diagnosis, Treatment and Ongoing care
- Accumulation of air or gas between the parietal and visceral pleurae
- Spontaneous pneumothorax (SP) may be primary (PSP) or secondary (SSP).
- PSP occurs in healthy adults with no underlying lung disease (age 20s); rarely in patients >40 years of age.
- SSP is a complication of underlying lung disease [e.g., chronic obstructive pulmonary disease (COPD), cystic fibrosis, acquired immune-deficiency syndrome (AIDS), or tuberculosis (TB)].
- Traumatic pneumothorax, both closed and open, may exist in tandem with hemothorax.
- Tension pneumothorax (TP): Inspired air accumulates into the pleural space with no means of escape. More air increases lung compression and causes hypoxia and hemodynamic compromise.
- Occult pneumothorax (OP) is not suspected on the basis of clinical exam or plain radiography but is detected with thoracoabdominal CT scanning.
- System(s) affected: Pulmonary; Cardiovascular
- Synonym(s): Collapsed lung
- >20,000 new SP cases occur each year in the US at a cost of >$130 million.
- Predominant sex: Male > Female.
- Predominant age: PSP 10–40 years of age; SSP >60 years of age
- 25–50% recurrence rate of SSP within 1 year:
- PSP: 7.4-18/100,000 in men, 1.2-6/100,000 in women
- SSP: 6.3/100,000 in men, 2/100,000 in women
Higher rates of morbidity and mortality
Incidence is 1–2% of all neonates, associated with meconium aspiration and respiratory distress syndrome.
Rare complication of labor and delivery
- Traumatic pneumothorax:
- Trauma (penetrating injury, broken rib, ruptured bronchus, perforated esophagus)
- Iatrogenic/postprocedure: Intubation, central line placement, liver biopsy, mechanical ventilation, thoracentesis, cardiopulmonary resuscitation (CPR; seen in 3% of ICU patients)
- Self-inflicted in intravenous drug abusers (attempting to access internal jugular vein)
- Spontaneous pneumothorax:
- Cigarette smoking (increases risk 20×)
- Airway disease: COPD, asthma, cystic fibrosis
- Infection: Pneumocystis pneumonia, TB, necrotizing pneumonia
- Malignancy: Lung cancer, sarcoma
- Connective tissue disorder: Marfan or Ehlers-Danlos syndrome, scleroderma, rheumatoid arthritis, ankylosing spondylitis
- Interstitial lung disease: Sarcoidosis, idiopathic pulmonary fibrosis, histiocytosis X, lymphangioleiomyomatosis
- Bronchial obstruction or foreign body
- Scuba diving
- Loss of airplane cabin pressure
- Possible predisposition in tall, thin young men, especially those with marfanoid habitus
- Multiple modes of inheritance proposed/observed: Autosomal dominant, recessive, X-linked recessive pattern
- Birt-Hobb-Dube syndrome: Autosomal dominant, associated with lung cysts, benign skin tumor, renal cancer; the FLCN mutation has been mapped to chromosome 17p11.2.
- Smoking cessation
- Advise use of seatbelts while driving.
- With subclavian vein cannulation, use a supraclavicular rather than an infraclavicular approach.
Loss of negative intrapleural pressure, lung collapse
- Perforation of the visceral pleura and entry of gas from the lung
- Penetration of the chest wall, diaphragm, mediastinum, or esophagus
- Blunt thoracic trauma
- Gas generated by microorganisms in an empyema
Commonly Associated Conditions
See Risk Factors.
- Chest trauma
- Pleuritic chest pain
- Moderate to severe: Profound respiratory distress, shock, circulatory collapse
- Referred pain to shoulder or back
- Rapid, shallow breathing
- Asymmetry of respirations
- Diminished breath sounds on affected side
- Decreased fremitus
- Absent egophony and bronchophony on affected side
- Hyperresonance to percussion
- Crepitus over chest wall and neck
- Respiratory distress
- Tension pneumothorax: Weak, rapid pulse; pallor; neck vein distention; anxiety; tracheal deviation away from affected side; hypotension; altered mental status
- Consider TP with sudden onset of tachycardia and hypotension in patients on ventilator (especially asthmatic/COPD patients).
Diagnostic Tests & Interpretation
Initial lab tests
- Arterial blood gases (ABGs; not diagnostic): Typically elevated A–a gradient and acute respiratory alkalosis
- Electrocardiogram (ECG): Not diagnostic but may show axis deviation, nonspecific ST-segment changes, T-wave inversion
- Chest X-rays (CXRs):
- Upright CXR usually is sufficient, but lateral, expiratory, or decubitus position is recommended in equivocal cases.
- White visceral pleural line separated by a space with no lung/vascular markings adjacent to chest wall
- Deep sulcus sign: Low lateral costophrenic angle on affected side
- TP: Mediastinal shift to contralateral side
- CT scan: Most useful for
- Trauma patients
- Small pneumothoraces (if diagnosis is necessary)
- Distinguishing emphysematous bullae from pneumothorax
- Ultrasound: Useful adjunct in major trauma patients
- Absence of lung sliding is virtually pathognomic, with a sensitivity of 92–100%. Accurate in identifying size and extension of occult pneumothorax (OP), but this accuracy is lost in 24 h (1)[B]
- Acute coronary syndrome
- Pulmonary embolism
- Pleural effusion
- Flail chest
- Airway obstruction/foreign body
- Esophageal perforation
- Diaphragmatic hernia
100% O2 accelerates rate of pleural air absorption.
See “Pleurodesis” under Surgery/Other Procedures
- Monitor vital signs.
- Treat any underlying condition.
- Open pneumothorax: Place dressing over wound. Secure only on 3 sides to avoid tension pneumothorax.
- For 1st time PSP:
- If small (<2–3 cm, <20%) and few symptoms: Patient may be observed in the emergency department for 3–6 h and discharged if repeat X-ray shows no progression (2)[C].
- If larger and/or patient is symptomatic:
- Randomized, controlled trial (RTC) has shown no difference between aspiration and chest tube in outcomes and fewer hospitalizations with aspiration (3)[A], but this should be accepted with caution owing to small sample size in study (4).
- Aspiration technique: (1) Position patient semisupine at 45°, (2) prep and anesthetize skin, (3) insert a 16-gauge over-the-needle catheter into 2nd anterior intercostal space and aspirate air, (4) extract needle and connect 3-way stopcock and 60-mL syringe, and (5) aspirate until no more air can be removed. There is disagreement as to whether a failed aspiration should be reattempted.
- Radiologists can place small-bore catheter or small-caliber chest tube over a guide wire and connect to a Heimlich valve or water seal. However, no RCTs compare their effectiveness.
- If pneumothorax is large, the patient is unstable, or prior treatment has failed:
- Insert thoracostomy tube (16–22 F) into 4th, 5th, or 6th intercostal space at the midaxillary line and connect to water seal device. Clamp after 12 h of no air leak.
- If tension pneumothorax:
- Needle decompression; Insert 19F or larger needle (14- to 16-gauge, 5-cm needle) into the 2nd intercostal space at the midclavicular line over the superior aspect of rib to avoid vessels, and attach a 3-way stopcock. (Failure rate is 10–35%; longer needles are needed for patients with increased chest wall thickness.) Use large syringe to withdraw air. Follow with a chest tube.
- For recurrent PSP:
- There is good consensus and clinical evidence that PSP recurrence prevention should be proposed only after a first recurrence (5)[B].
- Pleurodesis: Superior to simple drainage in reducing recurrence (6)[C]
- Intrapleural talc: 5 g in 250 mL of isotonic saline; more effective than tetracycline derivatives, but safety concerns still exist.
- Intrapleural doxycycline: 5 mg/kg or 500 mg in total of 50 mL
- Pleural abrasion or partial pleurectomy is also used.
- Sclerosing agents are contraindicated if patient is a possible candidate for future lung transplant because they increase the risk of bleeding during surgery.
- Side effects: Fever, pain, and acute lung injury
- Premedicate patients with a benzodiazepine and/or a narcotic for pain.
- Consider moderate or deep sedation with ketamine, propofol, or etomidate.
- Decreased effectiveness if concurrent glucocorticoid use or if lung is not fully reexpanded prior to pleurodesis
- Video-assisted thoracoscopy (VAT) with pleurodesis is recommended for
- Recurrent PSP, initial SSP
- Persistent air leak after 3 days
- Persistent bronchopleural fistula
- Patient preference or high-risk occupation (e.g., pilot, diver)
- Open thoracotomy if failed or unavailable VAT
- For SSP: Patients should be hospitalized; most authors and guidelines recommend immediate chest tube insertion along with recurrence prevention (5)[C].
- For catamenial pneumothorax: Recurrence prevention after 1st episode and possible hormonal suppression (5)[C]
- For traumatic/OP:
- Usually both overt and occult pneumothorax patients get chest tubes.
- It appears that small to moderate OP can be treated conservatively.
- Chest tube insertion for OP needing mechanical ventilation is unclear. Retrospective studies indicate that tube thoracostomy may not be required, but two RCTs arrived at opposite conclusions (1)[B].
- Stabilize, oxygenation
- TP is a medical emergency. Do not wait for CXR; decompress as soon as possible.
Admit all patients with either a large PSP that does not resolve completely with simple aspiration, recurrent pneumothorax, SSP, or traumatic pneumothorax
- No air travel until radiographs are normal.
- Athletes with pneumothorax may return to sports activity after 2–3 weeks of rest as symptoms permit; athletes who require inpatient care should have a follow-up CXR before resuming sports activity.
- Bed rest while chest tube is in place
- Serial radiographs to document improvement
- After simple aspiration/tube thoracostomy: Clamp for 24 h, and then remove if no recurrence is seen on radiograph. If lung is not fully reexpanded after 7 days, consider persistent bronchopleural fistula.
- Outpatient management should include follow-up CXR to document resolution of pneumothorax, typically in several days.
- Air is reabsorbed in days to weeks.
- Risk of recurrence: For PSP, mean of 30% with range of 16–52%; for SSP, 39–47%.
- Prognosis is worse depending on comorbidities.
- Reexpansion pulmonary edema
- Bronchopleural fistulas requiring repair
1. Ball CG, Kirkpatrick AW, Feliciano DV et al. The occult pneumothorax: what have we learned? Can J Surg. 2009;52:E173–9.
2. Zehtabchi S, Rios CL et al. Management of emergency department patients with primary spontaneous pneumothorax: needle aspiration or tube thoracostomy? Ann Emerg Med. 2008;51:91–100, 100.e1.
3. Wakai A, O’Sullivan RG, McCabe G et al. Simple aspiration versus intercostal tube drainage for primary spontaneous pneumothorax in adults. Cochrane Database Syst Rev. 2007;CD004479.
4. Gaudio M, Hafner JW et al. Evidence-based emergency medicine/systematic review abstract: Simple aspiration compared to chest tube insertion in the management of primary spontaneous pneumothorax. Ann Emerg Med. 2009;54:458–60.
5. Noppen M, De Keukeleire T et al. Pneumothorax. Respiration. 2008;76:121–7.
6. Gyorik S, et al. Long-term follow up of thoracoscopic talc pleurodesis for primary spontaneous pneumothorax. Eur Resp J. 2007;29(4):757–760.
- 512.0 Spontaneous tension pneumothorax
- 512.1 Iatrogenic pneumothorax
- 512.8 Other spontaneous pneumothorax
- 860.0 Traumatic pneumothorax without mention of open wound into thorax
- 860.1 Traumatic pneumothorax with open wound into thorax
- 36118008 Pneumothorax (disorder)
- 196102003 Spontaneous tension pneumothorax (disorder)
- 80423007 Spontaneous pneumothorax (disorder)
- 90070003 Traumatic pneumothorax (disorder)
- 22897006 traumatic pneumothorax with open wound into thorax (disorder)
- Primary pneumothorax is unusual in patients over the age of 40. Consider other etiologies in this population.
- Emergency needle decompression is accomplished in the 2nd intercostal space in the midclavicular line, tracking over the superior margin of the rib if possible.