Pneumothorax
Study Guide
definition:
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A disease defined as the accumulation of air in the pleural space leading to pulmonary collapse.
Types:

Epidemiology:
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Spontaneous pneumothorax is commonest in young adult males:
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The M-to-F ratio is 6: 1.
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Primary Spontaneous Pneumothorax (PSP) has an incidence of 7.4 to 18 cases among males and 1.2 to 6 cases among female per 100,000 populations each year.
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The general incidence of secondary spontaneous pneumothorax (SSP) is almost similar to that of PSP.
Causes and Risk factors:
Spontaneous:
Primary:
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More common in tall, thin young males because of apical subpleural blebs rupture.
Secondary:
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Most commonly COPD and TB; also seen in asthma, pulmonary infarcts, lung abscess, bronchogenic carcinoma, and all forms of fibrotic and cystic lung disease.
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More threatening , due to lack of pulmonary reserve.
Traumatic:
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Iatrogenic: secondary to transthoracic and trans-bronchial biopsy, central venous catheterization, pleural biopsy, thoracentesis.
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Non-iatrogenic: secondary to blunt or penetrating chest injury.
Pathophysiology:
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The pressure in the pleural space is negative with respect to the atmospheric pressure and the alveolar pressure. If there is a communication either between the alveoli and the pleural space or between the outside of the thoracic cavity and the pleural space, air will continue to enter the pleural space.
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The increase in the pleural pressure will result in both a hyperexpanded hemithorax and a collapsed lung.
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Because the alveolar pressure become very positive resulting in high/positive pleural pressure, producing a tension pneumothorax.
The main physiological consequences of pneumothorax are a decrease in the vital capacity of the lung and in PaO2. Total lung capacity, functional residual capacity and diffusing capacity are also decreased but less than vital capacity.
Sign & Symptoms:
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Sudden onset of unilateral chest pain on inspiration and progressively increasing dyspnea.
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Patient with large pneumothorax may develop pallor, tachycardia, and cough.

P-THORAX summaries the presentation of pneumothorax:
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Pleuritic chest pain
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Tracheal deviation
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Hyper-resonance on percussion.
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Onset is sudden
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Reduced breath sounds unilaterally.
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Absent fremitus
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X-ray shows lung collapse
Diagnosis:
- The diagnosis is done clinically due to emergent need of treatment.
- Chest X-ray:
- Reveals visible visceral pleural edge as a very thin, sharp white line with no lung markings are seen peripheral to this line.
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The peripheral space is radiolucent compared to adjacent lung.
The lung may completely collapse and the mediastinum should not shift away from the pneumothorax unless a tension pneumothorax is present.
treatment:
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Tension pneumothorax:
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Immediate decompression by large bore needle in the 2nd intercostal space mid-axillary line.
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Followed by chest tube placement under water seal.
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For small pneumothoraces:
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Supplemental O2 until it resolves spontaneously.
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Large symptomatic pneumothoraces:
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Chest tube placement under water seal.
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Spontaneous pnemothorax has a recurrence rate of 50% in 2 years.
References:
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George, R. (2005). Chest medicine. Philadelphia, PA: Lippincott Williams & Wilkins.
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Grippi, M., Elias, J., Fishman, J., Kotloff, R., Pack, A., Senior, R. and Siegel, M. (n.d.). Fishman's pulmonary diseases and disorders.
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Kumar, P. and Clark, M. (n.d.). Kumar & Clark's clinical medicine.
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Walker, B., Colledge, N., Ralston, S. and Penman, I. (n.d.). Davidson's principles and practice of medicine.
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Rightdiagnosis.com, (2016). Prevalence and Incidence of Pneumothorax - RightDiagnosis.com. [online] Available at: http://www.rightdiagnosis.com/p/pneumothorax/prevalence.htm [Accessed 13 Feb. 2016].
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Noppen, M. (2010). Spontaneous pneumothorax: epidemiology, pathophysiology and cause. European Respiratory Review, 19(117), pp.217-219.
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Agabegi S, Agabegi E, Ring A. Step-up to medicine. Philadelphia: Wolters Kluwer/Lippincott Williams & Wilkins; 2013.
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Le T, Bhushan V, Sochat M, Sylvester P, Mehlman M, Kallianos K. First aid for the® USMLE.
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Hall J, Premji A. Toronto Notes for Medical Students, Inc. © 2015. 2015.
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Fischer C. Master the boards.
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Le T, Bhushan V, Singh Bagga H. First aid for the USMLE step 2 CK. New York: McGraw-Hill Medical; 2010.
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EMR - EMT - Medical [Internet]. Pinterest. 2016 [cited 4 April 2016]. Available from: https://www.pinterest.com/AvrilLM/emr-emt-medical/ (Figure 1).
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354. Iñarritu J. You should never take this chest x-ray | Unbounded Medicine [Internet]. Unboundedmedicine.com. 2005 [cited 4 April 2016]. Available from: http://www.unboundedmedicine.com/2005/10/23/you-should-never-take-this-chest-x-ray/ (Figure 2).
Written by: Abdulrahman Alqahtani
Reviewed by: Salwa AlMakhdob
Areej Madani
Web Publisher : Adel Yasky