Pneumothorax is defined as the presence of air in the pleural space, which can be classified into spontaneous, traumatic, and tension pneumothorax, each with distinct causes and management strategies. Clinical features include pleuritic chest pain, breathlessness, and signs of shock in severe cases; diagnosis primarily involves chest X-ray, CT, and ultrasound. Management includes observation, decompression for tension pneumothorax, intercostal drain insertion, and potential surgical intervention for persistent cases.

1. Pneumothorax
Dr. Irfat Mahjabeen
Clinical fellow (Respiratory Medicine)
Worcestershire Acute Hospitals NHS Trust

2. Definition
• Pneumothorax is the presence of air in
Pleural space
• Normally pleural space is closed latent sac
with no air
• Negative pressure exists in pleural space
throughout the respiratory cycle.
• If any communication develop between
pleural space and lung, pressure difference
is altered.

3. Classification
1. Spontaneous/ simple 2. Traumatic
Primary :
• no evidence of lung disease
• smoking, tall stature are
additional risk factors.
• usually seen in young age <30
years
• usually rupture of apical or sub
pleural blebs
Secondary :
• Occurs due to Underlying
diseases : COPD and Pulmonary
TB mostly
• Others : asthma, (ILD), necrotizing
pneumonia, cystic fibrosis (CF),
Marfan’s syndrome, lung cancer,
pulmonary infarction
• Usually seen in males above 55
years
• Mortality is 10%
Iatrogenic or traumatic chest injury :
• percutaneous biopsy
• endoscopic perforation of the
esophagus
• nasogastric tube placement
• esophageal rupture
• post CPR
• Can be associated with
haemothorax or
haemopneumothoraz

4. Tension Pneumothorax :
• Life threatening condition
• One way valve , air enters the pleural space on inspiration, but unable to escape on expiration
• The progressive increase in pleural pressure > atmospheric pressure
• Shifting of mediastinum compresses opposite lung and vessels result in impairment of venous
return & CVS compromise

5. Clinical features:
Symptoms :
• Pleuritic chest pain and/or
• Breathlessness , more severe in
2° pneumothorax
• In tension pneumothorax,
features of shock or cardiac
arrest or acute deterioration,
increasing inflation pressures in
mechanical ventilation
Signs:
• tachycardia, tachypnoea, hyoxia,
cyanosis, accessory muscles of
respiration, raised JVP,
• Lung : tracheal deviation,
reduced expansion, hyper-
resonant percussion note,
reduced air entry, diminished
breath sounds .

6. Investigation:
1. CXR :
• visceral pleural edge is seen as a very thin, sharp white line.
• Absent lung markings peripheral to the line
• Mediastinal shift +/-,
• lung collapse +/-
• Peripheral space is radiolucent compared to the adjacent lung

9. 2. Computed tomography (CT):
• More accurate in detrmining size of
pneumothorax
• Differentiate pneumothorax from bullous
disease/ associated underlying lung disease
3.Ultrasound (US) chest :
4. Arterial blood gases (ABGs) - hypoxia and
or hypercapnia in 2° pneumothorax

10. Management:
1. degree of breathlessness and hypoxia, haemodynamic compromise.
2. background lung disease/respiratory reserve :
3. size of the pneumothorax :
• Width of the rim of air, measured from chest wall to lung edge at the level of the
hilum , <2 cm: small & ≥2 cm: large (BTS guideline 2010)
• A 2 cm rim of air = to a 50% pneumothorax in volume (approx)

12. Management of Tension Pneumothorax
• Medical emergency
• Do not wait for a CXR if the diagnosis is clinically certain / patient
seriously compromised or cardiac arrest
• Immediate decompression - insert large-bore cannula (14- 16 G) into
second intercostal space in mid-clavicular line
• Cannula shoula be left in place untill ICD can be inserted.

13. Intercostal drain
• inserted in 4th, 5th. 6th intercostal space in midaxillary line
• should be removed 24 hrs after lung has fully reinflated and bubbling
stopped
• usually 10-14 F in most cases,
• never clamp a bubbling chest drain

14. Surgical management
Aim is to repair the apical hole or bleb and close the pleural space.
Indications for cardiothoracic surgical referral
• Bilateral spontaneous pneumothorax
• Persistent air leak or failure of lung to re-expand (3–5 days of drainage)
• Spontaneous haemothorax
• 1st contralateral and 2nd ipsilateral pneumothorax
• Professions at risk (e.g. pilots, divers) after first pneumothorax.
• pneumothorax in pregnancy

15. Plurodesis
• Talc commonly used, failure rate 10-20%
• via intercostal drain , placed between the pleural layers to decrease
pleural space and prevent fluid build up
• only as a last resort in older patients with recurrent pneumothorax in
whom surgery would be high risk ( severe COPD)
• in an incompletely re-expanded lung with a persistent air leak,
plurodesis may be attempted if surgery is not an option.

16. Advice during discharge
• Diving- never unless surgically corrected , normal lung function
testand a chest CT postoperatively
• Flying - 1 week from complete resolution
• smoking cessation
• F/up in 4 to 6 weeks time
• Risk of recurrence is around 30% after a 1st pneumothorax, 40% after
a 2nd, and > 50% after a 3rd incidence

17. Thank You