Pneumothorax

Etiology

Malignancy

Infection

  • Pneumocystis Jirovecii (see Pneumocystis Jirovecii, [[Pneumocystis Jirovecii]]): rupture of pneumocyst into pleural space
  • Tuberculosis (see Tuberculosis, [[Tuberculosis]]): rupture of cavity into pleural space

Trauma/Surgery/Procedure-Related Pneumothorax

  • Chest Trauma: blunt or penetrating
  • Tracheobronchial Fracture (see Tracheobronchial Fracture, [[Tracheobronchial Fracture]])
  • Thoracentesis (see Thoracentesis, [[Thoracentesis]])
  • Central Venous Catheter Placement (see Central Venous Catheter, [[Central Venous Catheter]]): with inadvertent puncture of pleural space during procedure
    • French Multi-Center, Randomized Trial Examining Complication Rates of Three Different Central Venous Catheter Insertion Sites (2015) [MEDLINE]
      • Study: multi-center, randomized trial (n = 3471)
      • Main Findings: subclavian central venous catheters had 3x higher risk of pneumothorax requiring chest tube insertion (1.5% of cases), as compared to internal jugular sites (0.5% of cases)
  • Bronchoscopy with Bronchoalveolar Lavage (BAL) (see Bronchoscopy, [[Bronchoscopy]])
  • Bronchoscopy with Trans-Bronchial Biopsy (TBB) (see Bronchoscopy, [[Bronchoscopy]])
  • Mechanical Ventilation (se exxxx, [[xxxx]])
  • Forceful Coughing (see Cough, [[Cough]])
  • Inadvertent Placement of Nasogastric Tube Into Pleural Space (see Nasogastric Tube, [[Nasogastric Tube]])
  • Crack Cocaine Abuse (see Cocaine, [[Cocaine]])

Connective Tissue/Autoimmune Disease

  • Rheumatoid Arthritis (RA) (see Rheumatoid Arthritis, [[Rheumatoid Arthritis]]): rupture of necrobiotic nodule into pleural space
  • Scleroderma (see Scleroderma, [[Scleroderma]])
  • Ankylosing Spondylitis (see Ankylosing Spondylitis, [[Ankylosing Spondylitis]]): due to rupture of apical bullae

Drugs

  • Bleomycin (Blenoxane) (see Bleomycin, [[Bleomycin]])
    • Epidemiology: case reports
  • Nitrosoureas

Toxin

Other

  • Bullous Emphysema with Ruptured Bleb (see Chronic Obstructive Pulmonary Disease, [[Chronic Obstructive Pulmonary Disease]])
    • Bleb is an intrapleural air collection (therefore, it is a form of interstitial emphysema)
    • Bleb can develop in newborns or in the setting of ventilator-associated barotrauma
  • Cryptogenic Organizing Pneumonia (see Cryptogenic Organizing Pneumonia, [[Cryptogenic Organizing Pneumonia]]): rarely presents with pneumothorax
  • Idiopathic Pulmonary Fibrosis (IPF) (see Idiopathic Pulmonary Fibrosis [[Idiopathic Pulmonary Fibrosis]])
  • Langerhans Cell Histiocytosis (LCH) (see Langerhans Cell Histiocytosis, [[Langerhans Cell Histiocytosis]])
  • Lymphangioleiomyomatosis (see Lymphangioleiomyomatosis, [[Lymphangioleiomyomatosis]])
  • Neurofibromatosis (see Neurofibromatosis, [[Neurofibromatosis]])
  • Pneumomediastinum (see Pneumomediastinum, [[Pneumomediastinum]]): air dissects from mediastinum into pleural space
  • Sarcoidosis (see Sarcoidosis, [[Sarcoidosis]])
  • Spontaneous Pneumothorax

Physiology

  • Path of Air Movement Between These Spaces
    • Mediastinum <-> Left and Right Pleural Space (pneumothorax)
    • Mediastinum <-> Neck Soft Tissues (subcutaneous emphysema)
    • Mediastinum <-> Peritoneum (pneumoperitoneum)

Etiologies of Various Pleural Space Pressure States

PLEURAL SPACE

Diagnosis

Pleural Fluid

  • Pleural Eosinophilia: may be seen -> eosinophils appear within 3 days and peak at day 6

Thoracic U/S

  • Sensitivity: very sensitive in detecting pneumothorax and can be repeated at bedside multiple times, noninvasively, and quickly
  • Sliding Sign: normal finding, where the visceral pleura slides against the parietal pleura
    • In pneumothorax, “sliding” is absent
  • Lung Point Sign: where, in the presence of pneumothorax, the lung touches the chest wall intermittently

Clinical Manifestations

Cardiovascular Manifestations

  • Hypotension: may occur with tension pneumothorax
  • xxxx

Pulmonary Manifestations

Treatment

  • ACCP Recommendation: observation for small spontaneous PTX (<3 cm rim on CXR) and clinical stability
  • BTS Recommendation: observation for small spontaneous PTX (<2 cm rim on CXR) and clinical stability
  • Pleurodesis: recommended for patients with second ipsilateral spontaneous pneumothorax

References

  • Pleural ultrasonography. Clin Chest Med 2006;27:215-227
  • Clinical review: bedside lung ultrasound in critical care practice. Crit Care 2007;11:205
  • Intravascular Complications of Central Venous Catheterization by Insertion Site. N Engl J Med. 2015 Sep 24;373(13):1220-9. doi: 10.1056/NEJMoa1500964 [MEDLINE]