Pneumothorax is the presence of air in the pleural space between the lung and chest wall. It can be spontaneous, caused by trauma or medical procedures. Spontaneous pneumothorax is classified as primary, occurring without lung disease usually in young males, or secondary, occurring in older males with underlying lung conditions like COPD. Symptoms include shortness of breath and chest pain. Treatment depends on type and severity but may include needle aspiration, tube drainage, or surgery. Tension pneumothorax is a medical emergency where air builds up in the pleural space, compressing the heart and blood vessels and requiring immediate needle decompression.

1. Pneumothorax
By: Dr. Noshirwan P. Gazder

2. • Presence of air in the pleural space.
• Can be:
a) Spontaneous.
b) Result of iatrogenic injury.
c) Trauma to the lung or chest wall.

3. Classification
1. Spontaneous
Primary:
• No evidence of overt lung disease.
• Occurs mostly in males aged 15-30.
• Air escapes from the lung into the pleural space through rupture of a
small emphysematous bulla or pleural bleb.
• Smoking, tall stature & the presence of apical subpleural blebs are
additional risk factors.

4. Secondary:
• Underlying lung disease.
• Occurs mainly in males above 55 yrs.
• Most commonly COPD or TB patients
• Also seen in asthma, lung abscess, bronchogenic carcinoma etc.

5. 2. Traumatic
• Iatrogenic ( Thoracic Surgery or Biopsy)
• Chest Wall Injury.

6. Types
• Closed spontaneous pneumothorax.
• Open spontaneous pneumothorax.
• Tension pneumothorax.

7. Closed Type
• Closed pneumothorax is when air or gas gets in the pleural space
without any outside wound.
• Communication between airway and the pleural space seals off as the
lung deflates.
• Spontaneous reabsorption of air & re-expansion of lung occur over a
few days or weeks.
• Infection uncommon.

8. Open Type
• Open pneumothorax. Open pneumothorax is when air gets into the
pleural space from an injury to the chest. This can happen with stab
wounds, like from a knife. It can also happen after a gunshot injury.
• Communication fails to seal and air continues to transfer freely
between the lung and pleural space, a bronchopleural fistula.
• Infection can be transmitted leading to empyema.

9. Tension Type
• Tension pneumothorax is the progressive build-up of air within the
pleural space, usually due to a lung laceration which allows air to
escape into the pleural space but not to return.
• Communication between the airway & the pleural space acts as a
one-way valve, Allowing air to enter the pleural space during
inspiration but not to escape on expiration.
• Which leads to a large amount of air accumulating progressively in
the pleural space. Pressure causes mediastinal shift towards the
opposite side with compression of the opposite lung & impairment of
systemic venous return, causing cardiovascular compromise.

10. Symptoms
• Shortness of breath.
• Chest pain, which may be more severe on one side of the chest.
• Sharp pain when inhaling.
• Pressure in the chest that gets worse over time.
• Blue discoloration of the skin or lips.
• Rapid breathing.
• Confusion or dizziness.
• Loss of consciousness or coma.

11. General Examination
• Cyanosis.
• Rapid thready pulse.
• Signs of peripheral circulatory failure in severe cases.

12. Inspection & Palpation
• Dyspnoea.
• Use of accessory muscles of respiration.
• Shift of mediastinum to opposite side.
• Fullness of chest on the affected side.
• Diminished chest movements.
• Marked diminished vocal fremitus on affected side.
• Diminished expansion of the affected hemithorax.

13. Percussion
• Hyper resonant on affected hemithorax.
• Right sided pneumothorax-liver dullness is obliterated and cardiac
dullness is shifted to the opposite side.

14. Auscultation
• Diminished to absent breath sounds.
• Absence of adventitious sounds.
• Diminished vocal resonance.

15. CXR
• Increased radiolucency, with absence of bronchovascular markings
• Extend of mediastinal shift.
• Pleural fluid ,if present.

17. Treatment

18. Primary Pneumothorax
• If the lung edge is < 2cm from the chest wall and the patient is not
breathless, then it resolves normally with out intervention.
• If the patient is having severe symptoms then percutaneous needle
aspiration can be carried out.
• If it fails then intercostal tube drainage is done.

19. Secondary Pneumothorax
• Even a small secondary pneumothorax may cause respiratory failure,
so all such patients require, Intercostal tube drainage [Intercostal
drains are inserted in the 4th ,5th or 6th intercostal space in the
midaxillary line ,connected to an under waterseal].
• If intercostal tube drainage fails then thoracotomy with stapling of
blebs and pleural abrasion is indicated.
• If surgery is contraindicated then pleurodesis should be
done(Intrapleural injection of sclerosing agent)

20. Tension Pneumothorax
• It is a medical emergency.
• A large bore needle is inserted into pleural space through 2nd
intercostal space.
• The needle should be left in place until a thoracostomy tube can be
inserted.

21. Thank You