Pneumothorax or collapsed lung symptoms
A pneumothorax is defined as the entry of air into the pleural space; it is classified as spontaneous when there is no evidence of any precipitating cause
Primary spontaneous pneumothorax
Secondary spontaneous pneumothorax
Central line insertion
Chronic obstructive pulmonary disease
Barotrauma ( ventilation )
The overall incidence of pneumothorax is 16.8 per 100 000 per year. There is a biphasic age distribution: the initial peak at 15-34 years is followed by one at over 55 years, corresponding to the incidence of primary and secondary pneumothoraces respectively. Pneumothorax is 2.5 times more common in males than in females and does not exhibit seasonal variation.
Pneumothoraces are categorized as primary when there is no evidence of underlying lung disease. Despite this nomenclature, subpleural bullae are found in the majority during video-assisted thoracoscopy (VATS), and 'primary' pneumothoraces are often attributed to rupture of these bullae. Secondary pneumothoraces occur as a complication of pre-existing lung disease, most commonly chronic obstructive pulmonary disease. Acquired causes of pneumothoraces are traumatic and iatrogenic (central line insertion, pleural aspiration, barotrauma from ventilation).
Scope of disease
Progression to tension pneumothorax is an uncommon but potential complication. The increasing amount of air accumulating in the pleural space leads to mediastinal shift, reducing venous return to the heart and resulting in circulatory shock.
A tension pneumothorax is diagnosed by severe dyspnoea, cyanosis, tachycardia, tracheal deviation (away from the affected site) and absent breath sounds. It is treated initially by a large bore (14 G) cannula introduced into the pleura via the second intercostal space in the midclavicular line. A gush of air confirms the diagnosis. A chest X-ray should be performed prior to insertion of an intercostal chest drain.
Sudden onset ipsilateral pleuritic chest pain and dyspnoea are the most common symptoms. The degree of dyspnoea depends on the size of pneumothorax and presence of underlying lung disease. Most episodes of spontaneous pneumothoraces occur at rest and symptoms tend to settle within 24 hours even without resolution of the pneumothorax.
Clinical examination may reveal tachycardia, tracheal deviation (away from the side of the pneumothorax), decreased expansion, vocal resonance and air entry on the affected side. Although hyper-resonance of the affected side is often reported, relative dullness of the unaffected side is often better appreciated. Features of underlying disease resulting in secondary pneumothoraces may be evident on clinical examination.
In addition to the aforementioned clinical features, tension pneumothorax is characterized by severe dyspnoea, tachycardia and hypotension. Treatment should be instituted immediately on clinical diagnosis.
The diagnosis of pneumothorax is suggested by the history and examination and confirmed by a standard chest film. The thin pleural edge will be visible as a faint line with loss of lung markings distal to it . A chest film on expiration will accentuate any pneumothorax that is difficult to diagnose on a standard view. It is inappropriate to request a chest film to diagnose a tension pneumothoraxas this can result in an unacceptable delay in treatment.
The principal aims for the management of pneumothoraces are lung re-expansion and prevention of recurrence . Estimation of the size of a pneumothorax is useful to direct further treatment. However, visual estimation of size as a percentage is imprecise, and sophisticated nomograms are cumbersome to use. The American College of Chest Physicians has defined a small pneumothorax to be less than 3 cm and a large pneumothorax to be more than 3 cm when measuring from the apex of the lung to the top of the thoracic cavity (apex to cupola distance).
A period of observation in the emergency department with a repeat chest film in 6-12 hours prior to discharge is appropriate for patients with a small pneumothorax who are clinically stable and have no underlying lung disease. The rate of resolution is approximately 1% per day. Patients may be discharged with clear follow-up instructions if there is no evidence of progression. All patients with underlying lung disease should be admitted for inpatient observation.
Simple aspiration is recommended by the British Thoracic Society for the treatment of moderate to large pneumothoraces in clinically stable patients. The use of this technique is controversial and it has an overall success rate of 55%. Occasionally, multiple aspirations may be required. When compared to chest tube insertion as first line treatment, simple aspiration results in more patients having a subsequent air leak at 10 days.
Chest tube insertion
The insertion of an intercostal chest tube is indicated for patients who are unstable, or when simple aspiration fails, or in the presence of a large pneumothorax. The size of the tube should be 28 F and it should be directed as high into the apex of the thoracic cavity as possible. Initially, 7.5 cm H2O or 0.75 kPa of suction should be applied. A repeat chest film should be performed to assess the position of the drain and confirm full re-expansion of the lung . Suction should continue until any air leak has resolved. Once the patient has been taken off suction, a repeat chest film should be taken after 12-24 hours to confirm full re-expansion of the lung before the chest tube is removed. After 5 days, if there is a persistent air leak, surgical intervention should be considered.
Prevention of recurrence
Unless a persistent air leak occurs or occupational requirements demand (divers, pilots), measures to prevent recurrence of pneumothorax are usually reserved for the second episode.
Chemical pleurodesis can be achieved with talc, tetracycline, or bleomycin. This form of therapy is suitable for patients who are at high risk for surgery. In the absence of contraindications, however, surgical therapy is preferred due to lower recurrence rates.
The main aims for surgical intervention are to address the air leak and prevent recurrence. The indications for surgical intervention are ( first episodes of spontaneous pneumothorax) persistent air leak for more than 5 days,secondary pneumothorax,occupational requirements such as pilots or divers, previous contralateral pneumonectomy and recurrent pneumothoraces for 2 or more episodes. Surgeons and patients differ in their preference to the approach (minimal access or open thoracotomy) for pleurodesis.
Bullectomy and pleurodesis (video-assisted thoracoscopic (VATS) approach)
Two to three thoracoscopic ports are introduced into a laterally positioned patient . The entire lung is examined for bullae and the apex (the most common site) is carefully scrutinized . Offending bullae are stapled and excised , then either pleural abrasion, apical pleurectomy or talc insufflation is performed to prevent recurrence. One or two apical drains are positioned, the lung re-inflated under direct vision and the remaining port sites sutured. The recurrence rate following VATS pleurectomy has been reported as 6.7% after 15 months.
Bullectomy and pleurodesis (open thoracotomy approach)
Bullectomy and pleurectomy via a thoracotomy is the preferred approach for patients with previous thoracic surgery (due to adhesions). Axillary mini-thoracotomy or limited posterolateral thoracotomy is used. The lung is collapsed and complete parietal pleurectomy can be performed by peeling the pleura from the chest wall. The recurrence rate is less than 1% at 4 years.
Overall, the in-hospital recurrence rate is 2.5% and persistent air leak (more than 5 days) occurs in 3%.
A third of pneumothoraces treated by lung expansion alone will recur. The aforementioned recurrence rates are dependent on the type of procedure and the approach used
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