Pneumothorax

Definition

Pneumothorax is the presence of air in the pleural space, causing partial or complete lung collapse due to loss of negative intrapleural pressure.

Epidemiology

  • Incidence: Approximately 5-10 per 100,000 people per year.

  • More common in males, smokers, and individuals with underlying lung diseases.

  • Recurrence rates can be high, especially without treatment.

Etiology

  1. Primary Spontaneous Pneumothorax (PSP): Occurs without apparent lung disease, often in young, tall, thin males.

  2. Secondary Spontaneous Pneumothorax (SSP): Occurs due to underlying lung conditions like COPD, asthma, cystic fibrosis, or tuberculosis.

  3. Traumatic Pneumothorax: Due to chest injury (e.g., blunt trauma, stab wounds).

  4. Iatrogenic Pneumothorax: Caused by medical procedures (e.g., central line insertion, mechanical ventilation).

Pathophysiology

  • Air enters the pleural space due to rupture of alveoli, chest trauma, or procedural injury.

  • Loss of negative pressure causes lung collapse.

  • Tension pneumothorax develops if air cannot escape, leading to mediastinal shift and hemodynamic compromise.

Appearance (Patient History, Signs, and Symptoms)

Patient History:

  • Sudden onset of chest pain (sharp, pleuritic).

  • Dyspnea (shortness of breath).

  • History of recent trauma or lung disease.

Signs and Symptoms:

  • Inspection: Asymmetrical chest movement.

  • Palpation: Subcutaneous emphysema (crepitus), reduced chest expansion.

  • Percussion: Hyperresonance on the affected side.

  • Auscultation: Decreased or absent breath sounds on the affected side.

  • Severe Cases (Tension Pneumothorax): Hypotension, tachycardia, distended neck veins, cyanosis, tracheal deviation.

Investigations

  1. Chest X-ray: Primary diagnostic tool; shows lung collapse and air in the pleural space.

  2. CT Scan: Used for unclear cases or complex pneumothorax.

  3. Ultrasound: Quick bedside diagnostic tool, especially in emergency settings.

  4. Arterial Blood Gas (ABG): May reveal hypoxemia and respiratory acidosis.

Management

Initial Stabilization:

  • Administer oxygen.

  • Monitor vital signs closely.

Specific Treatments:

  1. Observation: For small, asymptomatic pneumothorax.

  2. Needle Aspiration: First-line treatment for symptomatic PSP.

  3. Chest Tube Insertion (Thoracostomy): For large, recurrent, or tension pneumothorax.

  4. Pleurodesis: Considered in recurrent cases to prevent reoccurrence.

  5. Surgical Intervention: Video-assisted thoracoscopic surgery (VATS) for persistent air leaks.

Tension Pneumothorax Emergency Management:

  • Immediate needle decompression (2nd intercostal space, midclavicular line).

  • Follow with chest tube placement.

Prevention and Follow-Up:

  • Smoking cessation.

  • Avoidance of high-altitude or deep-sea diving.

  • Regular follow-up with chest imaging for high-risk patients.