34 YOM with no chronic medical
problems presents with the
complaint of 2 days of right-
sided chest pain that began while
walking. The pain is worse with
deep inspiration and radiates
into the right aspect of his neck
and into his “shoulderblade”. He
denies previous similar episodes;
no associated nausea/vomiting,
no diaphoresis/dyspnea. He has
been otherwise well free of
illness or injury. At presenation
he is awake/alert and in no
distress. He has a 20 pk/yr hx of
T 98.7 P 80 BP 126/84 O2 99%
Gen: WDWN, NAD
CV: RRR, no m/r/g
Pulm: Lungs CTA , chest wall is
free of injury with no
Ext: No cy/cl/ed – pain is not
worsened with manipulation of
The visceral pleura at the edge of the
collapsed lung is barely visible. It can be
identified by looking for a fine line that
parallels the curve of the lateral chest
Treatment decisions are based on the clinical status of the patient, the size
of the pneumothorax (large or small), and the presence of underlying lung
Patients with no underlying lung disease who have only mild symptoms
and normal vital signs in the setting of a first/small primary
spontaneous pneumothorax can be managed with observation alone
If this is the patient's first primary spontaneous pneumothorax and the
patient is reliable and able to return promptly to the ED if symptoms
worsen, the patient may be discharged home and scheduled for a
return visit with repeat radiography in 12–48 hours. Prior to discharge,
it is recommended that the patient be observed in the ED for 3–6 hours
and a repeat chest film be obtained to assure that the pneumothorax
size has not increased.
Patients with a large pneumothorax require catheter or chest tube
placement to re-expand the lung.
Patients with a second spontaneous pneumothorax should be
hospitalized and referred to a surgeon.
Whenever tension pneumothorax is suspected, catheter aspiration
should be performed immediately
Patients with a traumatic pneumothorax will require admission for
observation and evaluation/management of associated injuries .
Three approximations of the size of pneumothorax can be distinguished:
small, medium, and large . A small pneumothorax is confined to the apex
of the thorax and a thin rim around the lung (less than 1 or 2 cm) . A
medium pneumothorax occupies up to one-half of the thoracic diameter.
With a large pneumothorax, the lung is completely or nearly completely
A primary spontaneous pneumothorax occurs in patients without
underlying lung disease
A secondary spontaneous pneumothorax is associated with an
underlying pulmonary disorder. Such disorders include chronic obstructive
pulmonary disease (COPD), cysts or cavities due to necrotizing pneumonia
(staphylococcus aureus), malignancies, tuberculosis, or pneumocystis
pneumonia, and interstitial lung diseases such as sarcoidosis, collagen
vascular diseases, pneumoconiosis, or idiopathic pulmonary fibrosis.
A traumatic pneumothorax is associated with blunt or penetrating
trauma to the thoracic cavity.
Chest pain is the primary symptom, occurring in 90% of cases.
Dyspnea is present in 80% of patients.
Severe dyspnea can also occur with a relatively small pneumothorax in
patients who have significant underlying lung disease such as COPD or in
the setting of tension pneumothorax.
Bedside ultrasonography can be used to rapidly detect a pneumothorax and
can be incorporated into the FAST exam .
The radiograph should be taken with the patient in an upright position.
When the patient is supine, a pneumothorax collects anteriorly and may be
impossible to detect
In patients whose radiographic findings are equivocal, an expiratory
radiograph can make a small pneumothorax more conspicuous. Expiration
compresses the lung and increases the relative size of the pneumothorax