What Is a Pneumothorax And How Can It Be Caused?

What Is a Pneumothorax And How Can It Be Caused?
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What Is a Pneumothorax And How Can It Be Caused?/Pneumothorax is defined as the presence of air between the parietal and visceral pleural cavity. Tension pneumothorax is the accumulation of air under pressure in the pleural space. This condition develops when injured tissue forms a 1-way valve, allowing air to enter the pleural space and preventing the air from escaping naturally. This condition rapidly progresses to respiratory insufficiency, cardiovascular collapse, and ultimately death if, unrecognized and untreated.[]

Pneumothorax is a collection of air outside the lung but within the pleural cavity. It occurs when air accumulates between the parietal and visceral pleura inside the chest. The air accumulation can apply pressure on the lung and make it collapse. That is why a pneumothorax is commonly referred to as a “collapsed lung.”

pneumothorax is an abnormal collection of air in the pleural space between the lung and the chest wall.[rx] Symptoms typically include sudden onset of sharp, one-sided chest pain and shortness of breath.[rx] In a minority of cases, the amount of air in the chest increases when a one-way valve is formed by an area of damaged tissue, leading to a tension pneumothorax.[rx] This condition can cause a steadily worsening oxygen shortage and low blood pressure.[rx] Unless reversed by effective treatment, it can result in death.[rx] Very rarely both lungs may be affected by a pneumothorax.[rx] It is often called a collapsed lung, although that term may also refer to atelectasis.[rx]

Types of Pneumothorax

Pneumothorax can subdivide into three broad categories according to the etiology:

  • Traumatic – resulting from blunt or penetrating chest trauma. Majority of all pneumothoraces are traumatic in origin. (a) Penetrating trauma – (e.g., stab wounds, gunshot wounds, and impalement on a foreign body) primarily injure the peripheral lung, producing both a hemothorax and pneumothorax in more than 80% of all penetrating chest wounds. (b) Blunt trauma – can lead to rib fracture, causes increased intrathoracic pressure and bronchial rupture. Manifested either by “Fallen lung sign” (ptotic lung sign), hilum of lung is below expected level within the chest cavity or persistent pneumothorax with a functioning chest tube.
  • Iatrogenic – caused by manipulation by a healthcare provider, such as the insertion of central lines, etc
  • Spontaneous – a pneumothorax without any apparent cause or inciting event.
  • Catamenial pneumothorax – This is an extremely rare condition that occurs only in menstruating women. The onset of the pneumothorax is usually within 72 hours before or after the menstrual cycle begins. Endometrial tissue becomes attached to the thorax, where it forms cysts. The cysts can release blood similar to the way that the lining of the uterus is shed during menstrual periods. Blood and air that enter the pleural space can cause the lung to collapse.

According To The Size

The definition of large vs. small pneumothorax is by the distance between the lung margin and chest wall

  • Small pneumothorax – the presence of a visible rim of less than 2 cm between the lung margin and the chest wall
  • Large pneumothorax – the presence of a visible rim of greater than 2 cm between the lung margin and the chest wall.

Pneumothorax can also be classified based on their physiology into the following types

  • Simple – when the air in the pleural space does not communicate with an outside atmosphere, and there is no shift in mediastinum or hemidiaphragm. An example is a pleural laceration from a fractured rib.
  • Communicating – when there is a defect in a chest wall, such as from a gunshot wound, that causes open communication with an outside atmosphere. This loss of the chest wall integrity can create an air sucking and a paradoxical lung collapse, thus causing significant ventilatory problems.
  • Tension – progressive accumulation of air in the pleural cavity causing the shift of the mediastinum to the opposite side, resulting in compression of vena cava and other great vessels, decreased diastolic filling, and ultimately compromised cardiac output. It occurs when a chest injury causes a one-valve situation when the air gets into the pleural cavity but is unable to escape freely and thus gets trapped.

According to Etiology

Pneumothorax can be categorized as

  • Primary
  • Secondary
  • Iatrogenic
  • Traumatic
  • Occasionally, individuals may develop a concomitant haemothorax due to bleeding caused by shearing of adjacent subpleural vessels when the lung collapses.

Conditions predisposing to the development of a secondary pneumothorax

Obstructive airway disease

Suppurative lung disease

Malignant disease

Interstitial lung disease

  • Pulmonary fibrosis
  • Extrinsic allergic alveolitis
  • Sarcoidosis
  • Lymphangioleiomyomatosis
  • Histiocytosis X


  • Pneumonia (for example, due to Staphylococcus aureus or Pneumocystis jiroveci)
  • Tuberculosis


  • Adult respiratory distress syndrome
  • Marfan syndrome
  • Ehlers Danlos syndrome
  • Catamenial
  • Rheumatoid arthritis and other connective tissue diseases

Further More

A primary spontaneous pneumothorax is one which occurs in a patient with no known underlying lung disease. Tall and thin people are more likely to develop a primary spontaneous pneumothorax. There may be a familial component, and there are well-known associations:

  • Marfan syndrome
  • Ehlers-Danlos syndrome
  • Alpha-1-antitrypsin deficiency
  • Homocystinuria

When the underlying lung is abnormal, a pneumothorax is referred to as secondary spontaneous. There are many pulmonary diseases which predispose to pneumothorax including:

Cystic lung disease

  • Bullae, blebs
  • Emphysema, asthma
  • Pneumocystis jiroveci pneumonia (PJP)
  • Honeycombing: end-stage interstitial lung disease
  • Lymphangiomyomatosis (LAM)
  • Langerhans cell histiocytosis (LCH)
  • Due to apical lung changes from ankylosing spondylitis
  • Cystic fibrosis

Parenchymal necrosis

  • Lung abscess, necrotic pneumonia, septic emboli, fungal disease, tuberculosis
  • Cavitating neoplasm, metastatic osteogenic sarcoma
  • Radiation necrosis
  • Pulmonary infarction


  • Catamenial pneumothorax – recurrent spontaneous pneumothorax during menstruation, associated with endometriosis of pleura
  • Rarely pleuroparenchymal fibroelastosis
  • Iatrogenic/traumatic causes include


  • Percutaneous biopsy
  • Barotrauma (e.g. divers), ventilator
  • Radiofrequency (RF) ablation of lung mass
  • Endoscopic perforation of the esophagus
  • Central venous catheter insertion, nasogastric tube placement


  • Pulmonary laceration
  • Tracheobronchial rupture
  • Acupuncture
  • Esophageal rupture
  • Pneumoperitoneum with passage through congenital/acquired diaphragmatic defects
  • Buffalo pneumothorax is the presence of bilateral pneumothoraces due to abnormal communication between the pleural spaces

The Main Risk Factors as Follows

  • Age and general condition – the patients who are elder than 60 or worse than ectomorphic body type are more likely to relapse and have a worse tolerance to surgery.
  • Smoking history – smokers are more likely to relapse and are prone to complications and sequelae.
  • Underlying diseases and special conditions – patients with COPD, bronchiectasis, tuberculosis, cystic fibrosis, interstitial lung diseases, AIDS, etc. Ventilating patients and pregnant women would be also paid more attention.
  • Initial or recurrent pneumothorax – the latter requires more aggressive treatment, including pleurodesis.
  • Symptoms –  extents of breathlessness and respiratory distress are the most two important standards. If accompanied by decreased oxygen saturation and instable hemodynamics, the patients must be treated actively and promptly.
  • The size of the pneumothorax – less important than the typical symptoms. Main guidelines simply distinguished small or large size, based on the two distances of the visceral pleural surface from the chest wall on the conventional X-ray. Expiration chest radiograph may show more information. CT scanning and lung ultrasonography have been used wildly and got more attention.
  • The special types of pneumothorax – such as tension, bilateral or catamenial pneumothorax.
  • The time of pneumothorax – with the duration increased, the more difficult of re-expansion would be. Lung re-expansion quickly in a short time may lead to a greater possibility of re-expansion pulmonary edema.
  • Patients’ willingness is also the most important factor.

    In general, patients with complex conditions often need earlier and more aggressive treatment or even earlier surgical referral. But initial oxygen supply and necessary observation (except first aid) would be allowed.


    The pressure gradient inside the thorax changes with a pneumothorax. Normally the pressure of the pleural space is negative when compared to atmospheric pressure. When there is communication between the alveoli and the pleural space, air fills this space changing the gradient. A tension pneumothorax occurs when this communication becomes a one-way valve without any outflow from the pleural space. The pressure in the pleural space increases causing hypoxia, mediastinal shift, and can compromise venous return as well. Clinical presentation of a pneumothorax can range anywhere from asymptomatic to chest pain and shortness of breath. A tension pneumothorax can cause severe hypotension (obstructive shock) and even death. Beck’s triad describes symptoms commonly associated with tension pneumothorax. The three components of Beck’s triad are distended neck veins, distant heart sounds, and hypotension. Other symptoms include tachypnea, dyspnea, tachycardia, and hypoxia.

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    Causes of Pneumothorax

    • Traumatic – results from blunt or penetrating injuries to the chest wall.
    • Spontaneous – primary spontaneous pneumothorax occurs in people with no underlying lung disease or inciting event, secondary spontaneous pneumothorax occurs in people with significant underlying parenchymal lung disease and results from some inciting incident, such as a bleb rupture.
    • Iatrogenic – is a subtype of traumatic pneumothorax, where an injury occurs as a result of a diagnostic or therapeutic medical intervention (i.e., insertion of a central line, etc.)
    • Catamenial – is a non-traumatic pneumothorax that occurs in women in conjunction with their menstrual period. Although not entirely understood, the cause is believed to be endometriosis of the pleura.
    • Chronic obstructive pulmonary disease
    • Asthma
    • Cystic fibrosis
    • Pneumonia (e.g., necrotizing, Pneumocystis jirovecii)
    • Pulmonary abscess
    • Tuberculosis
    • Malignancy
    • Interstitial lung disease (e.g., idiopathic pulmonary fibrosis, sarcoidosis, lymphangioleiomyomatosis)
    • Connective tissue disease (e.g., Marfan syndrome, Ehlers-Danlos syndrome, rheumatoid arthritis)
    • Pulmonary infarct
    • Foreign body aspiration
    • Catamenial (i.e., associated with menses secondary to thoracic endometriosis)
    • Birt-Hogg-Dube syndrome

    Symptoms of Pneumothorax

    Symptoms of pneumothorax may hardly be noticeable at first and can be confused with other disorders. The symptoms of pneumothorax can vary from mild to life-threatening and may include:

    • Shortness of breath
    • Chest pain, which may be more severe on one side of the chest
    • Chest pain that usually has a sudden onset.
    • The pain is sharp and may lead to feelings of tightness in the chest.
    • Sharp pain when inhaling
    • Pressure in the chest that gets worse over time
    • Blue discoloration of the skin or lips
    • Increased heart rate
    • Rapid breathing
    • Confusion or dizziness
    • Loss of consciousness or coma
    • A steady ache in the chest
    • Dyspnea
    • Your skin is bluish.
    • You’re tired.
    • You breathe rapidly.
    • Your heartbeat speeds up.
    • Breaking out in a cold sweat
    • Tightness in the chest
    • Turning blue, or cyanosis
    • Severe tachycardia, or a fast heart rate

    Diagnosis of Pneumothorax

    A pneumothorax is, when looked for, usually easily appreciated. Typically they demonstrate

    • Visible visceral pleural edge is seen as a very thin, sharp white line
    • No lung markings are seen peripheral to this line
    • Peripheral space is radiolucent compared to the adjacent lung
    • The lung may completely collapse
    • Mediastinum should not shift away from the pneumothorax unless a tension pneumothorax is present (discussed separately)
    • Subcutaneous emphysema and pneumomediastinum may also be present
    • Lateral decubitus radiograph:
      • should be done with the suspected side up
      • the lung will then ‘fall’ away from the chest wall
    • Expiratory chest radiograph:
      • the lung becomes smaller and denser
      • pneumothorax remains the same size and is thus more conspicuous: although some authors suggest that there is no difference in detection rate
    • Chest CT scanning A CT scan is more sensitive than a chest radiograph in the evaluation of small pneumothoraces and pneumomediastinum, although the clinical significance of these occult pneumothoraces is unclear, particularly in the stable nonintubated patient.[] The occult pneumothorax is being diagnosed more frequently as methods of evaluating and diagnosing trauma patients become more sensitive. At present, CT scan is the gold standard for detecting occult traumatic pneumothorax not apparent on supine chest X-ray radiograph.[]
    • Ultrasonography – Use of bedside ultrasonography in the diagnosis of pneumothorax is a relatively recent development. In some trauma centers, pneumothorax detection is included as part of their focused abdominal sonography for trauma (FAST) examination.[] Ultrasonographic features used in the diagnosis of pneumothorax include the absence of lung sliding (high sensitivity and specificity), absence of comet-tail artifact (high sensitivity, lower specificity), and presence of lung point (high specificity, lower sensitivity). In a study, ultrasonography performed on patients with blunt thoracic trauma had 94% sensitivity and 100% specificity for pneumothorax detection compared with spiral CT scanning[,] .
    • Arterial blood gas analysis – Arterial blood gas (ABG) does not replace physical diagnosis nor should treatment be delayed while awaiting results if the symptomatic pneumothorax is suspected. However, ABG analysis may be useful in evaluating hypoxia, hypercarbia, and respiratory acidosis.
    • Electrocardiography – In left-sided pneumothorax electrocardiogram (ECG) shows rightward shift of the frontal QRS axis, diminution of the precordial R voltage, decrease in QRS amplitude, and precordial T-wave inversion. With right pneumothorax, ECG may show diminution of the precordial QRS voltage, right axis deviation, and a prominent R wave in V2 with associated loss of S wave voltage, mimicking posterior myocardial infarction. All these changes are thought to be due to mechanical effects and should not be taken for cardiac ischemia or infarction.

    Other tests you might have include

    • Pulse oximetry  – a device is clipped to your finger or ear lobe, and a light on it measures how much oxygen is in your blood.
    • Blood tests, including a complete blood count (CBC) – to see if you have anemia (when your body doesn’t make enough red blood cells) or infection and other tests to check for a blood clot or fluid in your lungs.
    • Chest X-ray or a computerized tomography (CT) scan – to see if you have pneumonia, blood clot in your lung, or another lung disease. A CT scan puts several X-rays taken from different angles together to make a more complete picture.
    • Electrocardiogram (ECG) –  to measure the electrical signals from your heart to see if you’re having a heart attack and find out how fast your heart is beating and if it has a healthy rhythm.
    • Patients should be tested for electrolyte abnormalities – endocrine disorders (specifically hyperthyroid) drug-induced causes, infections, drug or chemical withdrawal, and echocardiography to check for structural heart disease. In patients presenting with ischemic stroke and with no prior history of AF, 72-hour Holter monitoring improves the detection rate of silent paroxysmal.
    • Screening spirometry – Can assess how much air you can breathe
    • Complete pulmonary function testing – Can evaluate your breathing capabilities in more detail than screening spirometry by measuring how much air you can breathe in and out, as well as how quickly
    • Arterial blood gas measurement – Provides a measure of the oxygen content of your blood, which alerts your doctors if you are becoming low in oxygen
    • Echocardiography – May be ordered if your EKG suggests that you have heart disease
    • Standard exercise treadmill testing – Evaluates your breathing when you have increased oxygen demands
    • Complete cardiopulmonary exercise testing – Evaluates your heart and lung function in detail.

    Treatment of Pneumothorax

    First aid

    • Airway breathing – and circulation should be checked in all the patients of chest trauma. Patency of the airway and the adequacy of the ventilatory efforts should be evaluated with the assessment of the integrity of the chest and the circulatory status as pericardial tamponade can also cause signs and symptoms similar to tension pneumothorax. Upright positioning may be beneficial if there is no contraindication to it like a spinal injury.
    • Penetrating wounds – (also known as ‘sucking chest wounds’) require immediate coverage with an occlusive or pressure bandage made air-tight with clean plastic sheeting. The sterile inside of a plastic bandage packaging can be used in an emergency situation. No patient with penetrating chest wound should be left unattended as tension pneumothorax or another immediately life-threatening respiratory emergency can arise.
    • A thin needle – can be used for this purpose, to relieve the pressure and allow the lung to reinflate in suspected tension pneumothorax. An untreated pneumothorax is an absolute contraindication for evacuation or transportation by flight.
    • Breathing cooler air by lowering the temperature in a room
    • Breathing cleaner air by opening a window, using a humidifier, or getting rid of smoke and pet dander
    • Getting a sense of open space by seeing a view of the outside, opening windows, or being in an empty room
    • Keeping your head lifted, for example, by using pillows so that you are nearly sitting
    • Practicing techniques that take your focus away from the problem, such as relaxation and meditation

    Recommended initial management depending on the clinical condition

    Pneumothorax typeTreatment purposeRecommended treatment
    Tension pneumothoraxTo recover from acute respiratory dysfunctionAny intervention
    First: aspiration (diagnosis)
    Second: tube drainage
    Bilateral pneumothoraxTo recover from acute respiratory dysfunctionDrainage of at least one side of the lung
    With severe lung diseaseTo recover from acute respiratory dysfunctionAny intervention
    Suspected air leakTo avoid acute respiratory dysfunctionAny intervention
    Completely collapsed lungTo avoid acute respiratory dysfunctionAny intervention
    SymptomaticTo avoid acute respiratory dysfunction Symptomatic reliefAny intervention (aspiration > drainage)
    Supposed absence of air leakTo maintain stoppage of air leakObservational treatment
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    Tube drainage or repeating aspiration.

    Three-step management of pneumothorax

    StepTreatment objectiveRecommended treatment
    Step 1aAcute respiratory dysfunction
     To recover from respiratory function
    To avoid respiratory dysfunction
    Tube drainage (or simple aspiration)
    Tube drainage (or simple aspiration)
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    Step 2Air leak
     To maintain stoppage of air leak
    To stop air leak
    To stop air leak after drainage
    Observational treatment
    Repeating aspiration (vs tube drainage)
    Water seal management in tube drainage, surgery (bullectomy, bulla ligation, etc.), pleurodesis, bronchial intervention, others
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    Step 3Recurrence
     To prevent recurrencePleurodesis, surgery (bullectomy, pleurectomy, etc.), others

    step 1 is defined as initial management.

    efficacy of tube drainage in preventing recurrence is controversial.

    Pharmacological Treatment

    • Supplemental oxygen – If the pneumothorax is very small, the patient may only require supplemental oxygen. Patients should be observed to see whether their condition remains stable. Additional chest X-rays might be taken during that period.
    • Needle aspiration – A needle attached to a syringe is inserted into the chest cavity to remove air via suction.
    • Percutaneous chest tube drainage – If the pneumothorax is large or if the patient has trouble breathing, a small plastic tube may be inserted into the pleural space to remove air. The collapsed lung will reinflate as the pressure on the lung decreases. Ultrasound or other imaging methods may be used to guide the placement of the chest tube.
    • Open chest thoracotomy – An incision is made to allow insertion of a small-bore catheter or chest tube to remove air under suction pressure.
    • Video-assisted thoracoscopic surgery (VATS) – This is a minimally invasive procedure in which a tiny fiber-optic camera (thoracoscope) and surgical instruments are inserted through one or more small incisions. The camera displays video images on a monitor while the surgeon removes lung tissue.
    • Chemical pleurodesis – This procedure involves introducing a chemical irritant into the pleural space in order to attach the outside of the lung to the chest cavity. It is performed to prevent the lung from collapsing again.
    • Mechanical pleurodesis – This procedure is similar to chemical pleurodesis, except it is performed by a surgeon who uses a piece of dry gauze to roughen the pleural membrane.
    • Antianxiety medications – If you are experiencing anxiety with your pneumothorax, depending on the cause, your healthcare provider may prescribe an anti-anxiety medication, called an anxiolytic.  These medications will help you to relax. These may include lorazepam or alprazolam. It is important to take these medications only when you are feeling anxious. Do not operate heavy machinery, or drive an automobile while taking these. These medications must be used very cautiously if you have a severe pneumothorax. Discuss the risks and benefits of taking this medication with your doctor or healthcare provider.
    • Antibiotics – If your doctor or healthcare provider suspects that you have a lung infection, he or she may order antibiotic pills or intravenous (IV), depending on how severe your illness is, and your overall health status. Commonly prescribed antibiotics for bronchitis, pneumonia and respiratory (breathing) problems include azithromycin and levofloxacin. If you are prescribed antibiotic pills, take the full prescription. Do not stop taking pills once you feel better.
    • Anticoagulants – These medications prevent your blood from clotting, or may be ordered by your healthcare provider if you have a blood clot. Each of them works in a variety of ways. Depending on your overall health status, the kind of chemotherapy you are receiving, and the location of the blood clot, your healthcare provider may suggest warfarin sodium or enoxaparin ).
    • Anticholinergic agents – these drugs are given to persons with chronic bronchitis, emphysema, and chronic obstructive lung disease (COLD). Anticholinergic agents work in a complex manner by relaxing the lung muscles, which will help you to breathe easier. A commonly prescribed drug is ipratropium bromide.
    • Bronchodilators – These drugs work by opening (or dilating) the lung passages, and offering relief of symptoms, including shortness of breath. These drugs, typically given by inhalation (aerosol), but are also available in pill form.
    • Beta-adrenergic receptor agonists (beta-agonists) – Beta-agonists can be considered bronchodilators, as these drugs relax airway smooth muscle, and block the release of substances that cause bronchoconstriction, or narrowing of your lungs if you are having a lung “spasm.” Drugs such as albuterol, or terbutaline, are commonly used.
    • Corticosteroids – Steroids work by decreasing inflammation and swelling, which may be present with certain lung disorders. People may benefit from steroids, either inhaled, by pill form, or in the vein (IV).
    • Beclomethasone –  an inhaled steroid, is useful in the treatment of chronic asthma and bronchitis.  Inhaled steroids act directly on the lung tissue, so there are fewer long-term side effects, compared with a pill or IV form. People who have an outbreak of severe shortness of breath and airway inflammation may be ordered a steroid pill, such as prednisone, for a short period of time. This is usually given with inhaled steroids. Patients with severe asthma may require IV administration of another steroid, methylprednisolone.
    • Cough medications/Decongestants – may help you to be more comfortable if you are coughing a lot. Guaifenesin is an active ingredient in many cough medications, may be given alone, but is often combined with other drugs, such as codeine, to help your cough.  Guaifenesin may also be combined with pseudoephedrine as a decongestant, or anyone of many medications, depending on your symptoms.  Another common medication you may receive is Hydrocodone Bitartrate-Homatropine Methylbromide. This is a narcotic antitussive (anti-cough medication), which will help relieve your cough.
    • Diuretics – may be known as “water pills” as they work to prevent or treat lung congestion by making you urinate out extra fluid. Some examples of this medication may include furosemide and Hydrochlorothiazide. You may receive this medication alone or in combination with other medications.
    • Oxygen therapy – Gas within the pleural cavity is absorbed by diffusion and can be facilitated by changing the composition of the intra-pleural cavity gas. Oxygen is absorbed 62 times faster than nitrogen, and carbon dioxide (CO2) is absorbed 23 times faster than oxygen. When the patient inhales 100% oxygen, nitrogen will disappear from the pleural cavity, leaving only oxygen, which is absorbed faster from the pleural cavity into veins.
    • Simple aspiration – Aspiration of a pneumothorax is performed using a small catheter. The catheter is inserted into the pleural cavity and either removed immediately after evacuating the air from the pleural cavity or left inserted while the patient if observed. When left inserted in the thoracic wall, the catheter is still considered a chest tube despite its small size. In patients diagnosed with spontaneous pneumothorax, the mean success rate of aspiration is between 53% and 58%. Specifically, the mean success rate for PSP is 75%, which is comparatively higher than the SSP mean success rate of approximately 37%.

    Aspiration Procedures of Pneumothorax

     Chest tube placement

    Simple aspiration

    • It is done by a plastic iv cannula instead of traditionally used needle which was associated with the risk of laceration of the lung. The site of the second intercostals space in the midclavicular line is conventional. It can also be performed in fifth intercostals space in the anterior axillary line to prevent life-threatening hemorrhage. Available literature of American College of Chest Physician (ACCP) and British Thoracic Society (BTS) says that the needle aspiration and/or small catheter insertion are effective, comfortable, safe, and economical alternatives to thoracostomy in selected patients.[,]

    Tube thoracostomy

    • This procedure is recommended if simple aspiration proves ineffective and thoracoscopy is not readily available. The site for the insertion is the same as for simple aspiration. It rapidly results in the re-expansion of the underlying lung and does not require prolonged hospitalization

    Primary spontaneous pneumothorax

    ACCP recommends the placement of a chest tube in a case of large pneumothorax, regardless of whether the patient is clinically stable or unstable, and that in most instances, patients with a large pneumothorax should be hospitalized. In comparison, BTS recommends placement of a chest tube when the simple aspiration procedure fails to resolve the pneumothorax.

    Secondary spontaneous pneumothorax

    • ACCP recommends either observation or chest tube placement in clinically stable patients diagnosed with a small SSP. In a clinically stable patient diagnosed with a large pneumothorax or a clinically unstable patient, AACP recommends chest tube placement. BTS also recommends chest tube placement, except in patients diagnosed with a very small pneumothorax (1-2 cm) and no respiratory symptoms.
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    Chest tube management

    The thickness of the chest tube

    • Both ACCP and BTS recommend physicians avoid placing a thick chest tube in both primary and SSP. The ACCP does recommend inserting a thick chest tube (24 to 28F) in a patient experiencing a large-scale air leak, such as a bronchopleural fistula, or receiving mechanical ventilation. In the stable patient diagnosed with PSP, ACCP recommends a chest tube thickness of 14 to 22F or less. BTS always recommends using a 14F chest tube, as there is no evidence that a thick chest tube (20-24F) is more clinically effective than a thin chest tube (10-14F)

    The suction of the chest tube

    • The efficacy of suction after the placement of a chest tube is not well verified; one study reported that suction was not an effective treatment in patients diagnosed with the primary or the SSP.
    • In another study investigating pneumothorax treatment in 71 patients, the lungs re-expanded and the air leaks dissipated without the clinicians performing any suction through the chest tube in 77% of the patients treated. Similarly, in another report, chest tube suction did not affect the severity of lung collapse.
    • ACCP recommends suction only when the lung fails to re-expand following chest tube placement and observation. BTS does not recommend suction because of the risk of pulmonary edema induced by re-expansion. Alternatively, suction may be applied if the air leak lasts ≥ 48 hours or there is no pulmonary re-expansion after chest tube placement. The BTS also recommends performing suction at a higher velocity and lower pressure (-10 to -20 cm H2O).

    Chest tube removal

    • Chest tubes should be removed only when a chest radiograph demonstrates re-expansion of lung, complete resolution of the pneumothorax, and no clinical evidence of an ongoing air leak. ACCP and BTS provide similar guidelines for the timing of chest tube removal. ACCP recommends that any suction in progress be suspended prior to chest tube removal. However, the two organizations have different recommendations on clamping the chest tube closed before its removal.
    • ACCP has a 47% consensus for using clamping in PSP and a 59% of consensus in SSP. Those who support clamping express concern for a potential small air leak and feel that clamping may be useful in locating a leak. BTS does not recommend clamping when there is no air leak visible. However, it recommends additional precautions in observing the patient if clamping is performed.

    Definition of persistent air leaks

    • Intervention to eliminate the leak is generally recommended if the air leak persists for 2 days up to 14 days,,. ACCP recommends intervention for air leaks persisting beyond 4 days in PSP cases and over 5 days in SSP cases. BTS recommends thoracic surgery if the air leaks persist beyond 2 days or if the lung does not re-expand. If air leaks caused by spontaneous pneumothorax are allowed to persist, the cost of treatment increases, and the therapeutic success rate of thoracoscopy decreases.


    • ACCP and BTC recommend surgical intervention –  to prevent recurrence or to stop persistent air leaks. Although the advantage of surgical treatment is not clearly identified yet, ACCP recommends either parietal pleurectomy and bullectomy or parietal pleural abrasion of one pleural upper half and bullectomy. BTS recommends several possible interventions including parietal pleurectomy in addition to parietal pleural abrasion and talc-utilized pleurodesis.
    • Pleurodesis and Heimlich valve – ACCP recommends performing pleurodesis, using medications such as talc and doxycycline administered through the chest tube, in cases of primary and SSP if the patient declines surgical intervention or is not a suitable surgical candidate. Similarly, BTS recommends pleurodesis for patients that are not suitable surgical candidates. Appropriately sized talc may actually reduce the risk of respiratory failure. In patients diagnosed with SSP who cannot undergo surgery, outpatient treatment with a Heimlich valve may be considered.
    • Timing of intervention for recurrence prevention of spontaneous pneumothorax – Excluding persistent air leaks, 85% of ACCP panel members recommend surgical intervention for the second recurrence of PSP, whereas 81% supported surgical intervention at the first recurrence in cases of SSP. BTS recommends surgical treatment when the pneumothorax at the second occurrence on the same side, the first recurrence on the opposite side, and in cases of bilateral pneumothorax.

    Physiotherapy Management

    Indications for Physiotherapy

    • Lung collapse
    • Increased work of breathing
    • Thick sputum plugs predisposing to ventilation difficulty
    • Blood gas abnormalities
    • Sputum retention

    Goals for Physiotherapy

    • To reinflate atelectatic lung areas
    • To improve ventilation
    • To increase oxygenation
    • Maintain airway clearance
    • Improve exercise tolerance

    Physiotherapy Management

    To reduce work and difficulty of breathing

    • Body positioning
    • Breathing control
    • Relaxation technique

    To improve ventilation

    • Localized thoracic expansion exercise

    Sputum mobilization techniques

    • Postural drainage
    • Deep breathing exercise
    • Percussion, shaking and vibrations

    Sputum removal techniques

    • Coughing and huffing
    • Airway suctioning

    Physiotherapy outcome evaluation includes

    • Respiratory rate
    • Breathing pattern
    • Sputum quantity
    • Auscultation
    • Cough sound
    • Oxygen requirement
    • SpO2
    • Arterial blood gases
    • Chest x-ray changes
    • Muscle strength
    • Functional performance


    Misdiagnosis is a frequent complication of pneumothorax. Multiple factors, such as incomplete or inadequate history or physical exam, low index of clinical suspicion, failure to obtain a chest radiograph, or failure to recognize a pneumothorax on a chest radiograph, can contribute to misdiagnosis. Misdiagnosis leads to failure to treat the pneumothorax, and in some cases can lead to devastating consequences such as:

    • Conversion to tension pneumothorax
    • Hypoxemic Respiratory Failure
    • Shock
    • Respiratory arrest
    • Cardiac arrest
    • Empyema
    • Re-expansion pulmonary edema
    • Iatrogenic complications from the needle decompression or thoracostomy procedure – the failure of the lung to re-expand, lung laceration, infection of the insertion site and pleural space, laceration of intercostal vessels or internal mammary artery, hemothorax, persistent air leak, damage to the intercostal neurovascular bundle, etc
    • Chest tube-induced arrhythmia

    Important points to remember

    • As tension pneumothorax is a life-threatening condition, the diagnosis of tension pneumothorax should be made based on the history and physical examination findings. A chest radiograph or CT scan should be used only in those instances where one is in doubt regarding the diagnosis and when the patient’s clinical condition is sufficiently stable.
    • Premature diagnosis of tension pneumothorax in a patient without respiratory distress, hypoxia, hypotension, or cardiopulmonary compromise should not be made. Immediate portable chest X-ray must be done to confirm the diagnosis.
    • Consider the diagnosis of a pneumothorax and/or tension pneumothorax with blunt and penetrating trauma. In the patient with blunt trauma; mental status changes, hypoxia, and acidosis may be attributed to a suspected intracerebral injury rather than a tension pneumothorax. Portable chest radiography should always be included in the initial radiographic evaluation of major trauma.
    • Myocardial rupture with tamponade may clinically mimic tension pneumothorax.
    • Maintain a high index of suspicion for a tension pneumothorax in patients using ventilators who have a rapid onset of hemodynamic instability or cardiac arrest, particularly if they require increasing peak inspiratory pressures.
    • Avoid assuming that a patient with a chest tube does not have a tension pneumothorax if he or she has respiratory or hemodynamic instability. Chest tubes can become plugged or malpositioned and cease to function.
    • Avoid the “one size fits all” approach for tube thoracostomy placement.
    • Tube thoracostomy is an extremely painful procedure. In stable patients, adequate analgesia/sedation should be administered, followed by generous amounts of local anesthetics when chest tubes are placed.
    • An initial parenteral dose of a first-generation cephalosporin should be administered for chest tube insertion in the emergency department to decrease the risk of empyema and pneumonia.
    • Small pneumothoraces should be treated with thoracostomy tubes if the patient is undergoing mechanical ventilation or undergoing air transport prior to transfer to another facility.
    • Advise persons to wear safety belts and passive restraint devices while driving.
    • When subclavian vein cannulation is required, use the supraclavicular approach rather than the infraclavicular approach when possible to help decrease the likelihood of pneumothorax formation.
    • Transbronchial, transthoracic, and other procedures preferably be done under ultrasound guidance.


    What Is a Pneumothorax And How Can It Be Caused?

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