Pneumothorax is the presence of air in the pleural cavity between the lungs and chest wall. It can range from asymptomatic to life-threatening depending on severity. It is caused by trauma, lung punctures, or spontaneous bleb ruptures. Symptoms include chest pain, shortness of breath, and respiratory distress. Diagnosis involves physical exam, chest x-rays, and blood gases. Treatment ranges from oxygen, needle aspiration, chest tube placement, to surgery depending on severity and recurrence risk.

2.  Pneumothorax is defined as the presence of air or gas
in the pleural cavity (ie, the potential space between
the visceral and parietal pleura of the lung), which can
impair oxygenation and/or ventilation. The clinical
results are dependent on the degree of collapse of the
lung on the affected side. If the pneumothorax is
significant, it can cause a shift of the mediastinum and
compromise hemodynamic stability. Air can enter the
intrapleural space through a communication from the
chest wall (ie, trauma) or through the lung
parenchyma across the visceral pleura.

3.  The presentation of patients with pneumothorax
varies depending on the following types of
pneumothorax and ranges from completely
asymptomatic to life-threatening respiratory distress:
 1-Spontaneous pneumothorax: No clinical signs or
symptoms in primary spontaneous pneumothorax
until a bleb ruptures and causes pneumothorax;
typically, the result is acute onset of chest pain and
shortness of breath,

4.  Iatrogenic pneumothorax: Symptoms similar to those
of spontaneous pneumothorax, depending on patient’s
age, presence of underlying lung disease, and extent of
pneumothorax
 Tension pneumothorax: Hypotension, hypoxia, chest
pain, dyspnea
 Catamenial pneumothorax: Women aged 30-40 years
with onset of symptoms within 48 hours of
menstruation, right-sided pneumothorax, and
recurrence

5. Pneumomediastinum: Must be differentiated from
spontaneous pneumothorax; patients may or may not
have symptoms of chest pain, persistent cough, sore
throat, dysphagia, shortness of breath, or
nausea/vomiting

6. A large, right-sided pneumothorax has occurred
from a rupture of a subpleural bleb.

7. A true pneumothorax line. Note that the visceral pleural line is observed clearly,
with the absence of vascular marking beyond the pleural line.

8. Complications of pneumothorax
 In most reported series, the rate of recurrence of
spontaneous pneumothorax on the same side is as
much as 30%; on the contralateral side, the rate of
recurrence is approximately 10%.

9.  Other complications include the following:
 Reexpansion pulmonary edema
 Bronchopleural fistula - Occurs in 3-5% of patients
 Pneumomediastinum and pneumopericardium
 Tension pneumothorax may occur after spontaneous
pneumothorax, although it is more common after
traumatic pneumothorax or with mechanical ventilation.

10. Diagnosis
 History and physical examination remain the keys to
making the diagnosis of pneumothorax. Examination
of patients with this condition may reveal diaphoresis
and cyanosis (in the case of tension pneumothorax).
Affected patients may also reveal altered mental
status changes, including decreased alertness
and/or consciousness (a rare finding).

11. Findings on lung auscultation vary depending on the
extent of the pneumothorax. Respiratory findings may
include the following:
 Respiratory distress (considered a universal finding) or
respiratory arrest
 Tachypnea (or bradypnea as a preterminal event)
 Asymmetric lung expansion: Mediastinal and tracheal
shift to contralateral side (large tension
pneumothorax)
 Distant or absent breath sounds: Unilaterally
decreased/absent lung sounds common, but decreased
air entry may be absent even in advanced state of
pneumothorax

12.  Hyperresonance on percussion: Rare finding; may be
absent even in an advanced state
 Decreased tactile fremitus
 Adventitious lung sounds: Ipsilateral crackles,
wheezes

13. Cardiovascular findings may
include the following:
 Tachycardia: Most common finding; if heart rate is faster
than 135 beats/min, tension pneumothorax likely
 Pulsus paradoxus
 Hypotension: Inconsistently present finding; although
typically considered a key sign of tension pneumothorax,
hypotension can be delayed until its appearance
immediately precedes cardiovascular collapse
 Jugular venous distention: Generally seen in tension
pneumothorax; may be absent if hypotension is severe
 Cardiac apical displacement: Rare finding

14. Common findings among the types of
pneumothoraces include the following:
 Spontaneous and iatrogenic pneumothorax:
Tachycardia most common finding; tachypnea and
hypoxia may be present
 Tension pneumothorax: Variable findings; respiratory
distress and chest pain; tachycardia; ipsilateral air
entry on auscultation; breath sounds absent on
affected hemithorax; trachea may deviate from
affected side; thorax may be hyperresonant; jugular
venous distention and/or abdominal distention may
be present

15.  Pneumomediastinum: Variable or absent findings;
subcutaneous emphysema is the most consistent sign;
Hamman sign—a precordial crunching noise
synchronous with the heartbeat and often accentuated
during expiration—has a variable rate of occurrence,
with one series reporting 10%

16. Lab and imaging studies
 Although laboratory and imaging studies help
determine a diagnosis, tension pneumothorax
primarily is a clinical diagnosis based on patient
presentation. Suspicion of tension pneumothorax,
especially in late stages, mandates immediate
treatment and does not require potentially prolonged
diagnostic studies.

17.  Arterial blood gas (ABG) studies measure the degrees
of acidemia, hypercarbia, and hypoxemia, the
occurrence of which depends on the extent of
cardiopulmonary compromise at the time of
collection. ABG analysis does not replace physical
diagnosis, nor should treatment be delayed while
awaiting results if symptomatic pneumothorax is
suspected. However, ABG analysis may be useful in
evaluating hypoxia and hypercarbia and respiratory
acidosis.

18. The following radiologic studies may be used to
evaluate suspected pneumothorax:
 Chest radiography: Anteroposterior and/or lateral
decubitus films
 Chest computed tomography scanning: Most reliable
imaging study for diagnosis of pneumothorax but not
recommended for routine use in pneumothorax
 Chest ultrasonography

19. Management
 Although there is general agreement on the
management of pneumothorax, a full consensus about
management of initial or recurrent pneumothorax
does not exist.

20. The range of medical therapeutic options for
pneumothorax includes the following:
 Watchful waiting, with or without supplemental
oxygen
 Simple aspiration
 Tube drainage, with or without medical pleurodesis

21. Surgery
 If the patient has had repeated episodes of
pneumothorax or if the lung remains unexpanded
after 5 days with a chest tube in place, operative
therapy such as the following may be necessary:
 Thoracoscopy: Video-assisted thoracoscopic surgery
(VATS)
 Electrocautery: Pleurodesis or sclerotherapy
 Laser treatment
 Resection of blebs or pleura
 Open thoracotomy

22. Pharmacotherapy
 The following medications may be used to aid in the
management of patients with pneumothorax:
 Local anesthetics (lidocaine ,hydrochloride)
 Opioid anesthetics (fentanyl citrate, morphine)
 Benzodiazepines (midazolam, lorazepam)
 Antibiotics (doxycycline, cefazolin)

23. An older man admitted to ICU postoperatively. Note the right-sided pneumothorax
induced by the incorrectly positioned small-bowel feeding tube in the right-sided
bronchial tree. Marked depression of the right hemidiaphragm is noted, and mediastinal
shift is to the left side, suggestive of tension pneumothorax. The endotracheal tube is in
a good position.

24. Right main stem intubation resulting in left-sided tension
pneumothorax, right mediastinal shift, and subpulmonic
pneumothorax