Pneumothorax

Etiology

Malignancy

Infection

  • Pneumocystis Jirovecii (see Pneumocystis Jirovecii, [[Pneumocystis Jirovecii]])
    • Physiology: rupture of pneumocyst into pleural space
  • Septic Embolism
    • Epidemiology: case reports (Thorax, 1992) [MEDLINE]
  • Tuberculosis (see Tuberculosis, [[Tuberculosis]])
    • Epidemiology: xxx
    • Physiology: rupture of cavity into pleural space

Trauma/Surgery/Procedure-Related Pneumothorax

  • Bronchoscopy (see Bronchoscopy, [[Bronchoscopy]])
    • Bronchoalveolar Lavage (BAL): very low risk of pneumothorax
    • Transbronchial Biopsy (TBB): higher risk of pneumothorax than with BAL
  • Central Venous Catheter Placement (see Central Venous Catheter, [[Central Venous Catheter]])
    • Physiology: inadvertent puncture of pleural space during procedure
    • Clinical Data
      • French Multi-Center, Randomized Trial Examining Complication Rates of Three Different Central Venous Catheter Insertion Sites (NEJM, 2015) [MEDLINE]: multi-center, randomized trial (n = 3471)
        • Subclavian CVC had 3x Higher Risk of Pneumothorax Requiring Chest Tube Insertion (1.5% of Cases), as Compared to Internal Jugular Sites (0.5% of cases)
  • Chest Trauma
    • Blunt Thoracic Trauma (see Blunt Thoracic Trauma, [[Blunt Thoracic Trauma]])
    • Penetrating Thoracic Trauma
  • Crack Cocaine Abuse (see Cocaine, [[Cocaine]])
    • Physiology: forceful inhalation and/or breath-holding
  • Forceful Coughing (see Cough, [[Cough]])
  • Inadvertent Placement of Nasogastric/Orogastric Tube Into the Pleural Space (see Nasogastric-Orogastric Tube, [[Nasogastric-Orogastric Tube]])
  • Mechanical Ventilation (se eMechanical Ventilation-General, [[Mechanical Ventilation-General]])
    • Physiology: barotrauma
  • Methamphetamine Intoxication (see Methamphetamine, [[Methamphetamine]])
    • Physiology: xxx
  • Parathyroidectomy (see Parathyroidectomy, [[Parathyroidectomy]]) (J Surg Educ, 2007) [MEDLINE]
  • Thoracentesis (see Thoracentesis, [[Thoracentesis]])
    • Physiology
      • Inadvertent Introduction of Air Via Needle
      • Puncture of Lung During Procedure
  • Tracheobronchial Fracture (see Tracheobronchial Fracture, [[Tracheobronchial Fracture]])
  • Tracheostomy (see Tracheostomy, [[Tracheostomy]])
    • Physiology
      • Inadvertent Extraluminal Positioning of the Tracheostomy Fenestration During Tracheostomy Placement: for this reason, fenestrated tracheostomies are typically not selected for initial percutaneous tracheostomy placement
      • Laceration of the Posterior Tracheal Wall
    • Clinical

Connective Tissue/Autoimmune Disease

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

Drugs

Other

  • Birt-Hogg-Dube Syndrome (see Birt-Hogg-Dube Syndrome, [[Birt-Hogg-Dube Syndrome]])
    • High-Resolution Chest CT (HRCT) (see High-Resolution Chest Computed Tomography, [[High-Resolution Chest Computed Tomography]]): cystic lung lesions occur in 70-80% of cases
    • Clinical: pneumothorax may occur in 30% of cases, usually before age 40 (see Pneumothorax, [[Pneumothorax]])
  • 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]])
    • Epidemiology: rarely presents with pneumothorax
  • Idiopathic Pulmonary Fibrosis (IPF) (see Idiopathic Pulmonary Fibrosis [[Idiopathic Pulmonary Fibrosis]])
    • Epidemiology: xxx
    • Physiology: xxx
  • Langerhans Cell Histiocytosis (LCH) (see Langerhans Cell Histiocytosis, [[Langerhans Cell Histiocytosis]])
    • Epidemiology: xxx
  • Lymphangioleiomyomatosis (LAM) (see Lymphangioleiomyomatosis, [[Lymphangioleiomyomatosis]])
    • Epidemiology: xxx
    • Physiology: xxx
  • Neurofibromatosis (see Neurofibromatosis, [[Neurofibromatosis]])
    • Epidemiology: xxx
  • Pneumomediastinum (see Pneumomediastinum, [[Pneumomediastinum]])
    • Physiology: air dissects from mediastinum into pleural space
  • Sarcoidosis (see Sarcoidosis, [[Sarcoidosis]])
    • Epidemiology: xxx
  • Spontaneous Pneumothorax

Physiology

Path of Air Movement Between Anatomic Spaces

  • Mediastinum <-> Left and Right Pleural Space (Pneumothorax)
  • Mediastinum <-> Neck Soft Tissues (Subcutaneous Emphysema)
  • Mediastinum <-> Peritoneum (Pneumoperitoneum)

Etiologies of Various Pleural Space Pressure States


Diagnosis

Pleural Fluid (see Thoracentesis, [[Thoracentesis]])

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

Thoracic Ultrasound (see Thoracic Ultrasound, [[Thoracic Ultrasound]])

  • 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

Unilateral or Bilateral Pneumothorax

  • Physiology
  • Diagnosis
    • Unilateral Pneumothorax
    • Bilateral Pneumothorax: may occur in cases with “buffalo chest” (where mediastinum has been previously entered during prior mediastinal surgery, lung transplant, etc) (see Buffalo Chest, [[Buffalo Chest]])
  • Clinical

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

  • Radiology in heart disease. Br Med J 1933; 2:594 [MEDLINE]
  • Pneumothorax secondary to septic pulmonary emboli in tricuspid endocarditis. Thorax. 1992 Dec;47(12):1080-1 [MEDLINE]
  • A bedside ultrasound sign ruling out pneumothorax in the critically ill. Lung sliding. Chest 1995;108(5):1345-1348 [MEDLINE]
  • The comet-tail artifact: An ultrasound sign of alveolar-interstitial syndrome. Am J Respir Crit Care Med 1997; 156:1640-1646 [MEDLINE]
  • The comet-tail artifact, an ultrasound sign ruling out pneumothorax. Intensive Care Med 1999; 25:383–388 [MEDLINE]
  • The “lung point”: an ultrasound sign specific to pneumothorax. Intensive Care Med  2000; 26:1434-1440 [MEDLINE]
  • Ultrasonic examination: an alternative to chest radiography after central venous catheter insertion? Am J Respir Crit Care Med. 2001;164(3):403-405 [MEDLINE]
  • Emphysema and pneumothorax after percutaneous tracheostomy: case reports and an anatomic study. Chest. 2004;125(5):1805 [MEDLINE]
  • Ultrasound diagnosis of occult pneumothorax. Crit Care Med 2005; 33(6):1231-1238 [MEDLINE]
  • Ultrasound comet-tail images: a marker of pulmonary edema: a comparative study with wedge pressure and extravascular lung water. Chest 2005;127(5):1690-1695 [MEDLINE]
  • Pleural ultrasonography.  Clin Chest Med 2006; 27:215-227 [MEDLINE]
  • Clinical review: bedside lung ultrasound in critical care practice.  Crit Care 2007; 11:205 [MEDLINE]
  • Minimally invasive parathyroidectomy complicated by pneumothoraces: a report of 4 cases. J Surg Educ. 2007 Mar-Apr;64(2):101-7; discussion 113 [MEDLINE]
  • Relevance of lung ultrasound in the diagnosis of acute respiratory failure: the BLUE protocol. Chest 2008;134(1):117-125 [MEDLINE]
  • A-lines and B-lines: lung ultrasound as a bedside tool for predicting pulmonary artery occlusion pressure in the critically ill. Chest. 2009;136(4):1014-1020 [MEDLINE]
  • Pleural procedures and thoracic ultrasound: British Thoracic Society Pleural Disease Guideline.  Thorax 2010; 65(Suppl 2):ii61-ii76 [MEDLINE]
  • Bilateral hydrothorax and cardiac tamponade after right subclavian vein catheterization. A case report. Korean J Anesthesiol. 2010 Dec;59 Suppl:S211-7. doi: 10.4097/kjae.2010.59.S.S211. Epub 2010 Dec 31 [MEDLINE]
  • Thoracic Ultrasonography for the Pulmonary Specialist. Chest 2011; 140(5):1332–1341 [MEDLINE]
  • Sonographic diagnosis of pneumothorax. Intensive Care Med 2011; 37:224-232 [MEDLINE]
  • Clinical applications of bedside ultrasonography in internal and emergency medicine. Intern Emerg Med 2011 Jun;6(3):195-201. doi: 10.1007/s11739-010-0424-3. Epub 2010 Aug 3 [MEDLINE]
  • Can chest ultrasonography substitute standard chest radiography for evaluation of acute dyspnea in the emergency department? Chest 2011; 139(5):1140-1147 [MEDLINE]
  • Lung ultrasound in the ICU: From diagnostic instrument to respiratory monitoring tool.  Minerva Anestesiol  2012; 78:1282-1296 [MEDLINE]
  • Pneumothorax in the critically ill patient.  Chest 2012; 141:1098-1105 [MEDLINE]
  • Lung ultrasound in the critically ill. Ann Intensive Care. 2014;4:1 [MEDLINE]
  • Bedside ultrasonography for the intensivist. Crit Care Clin. 2015 Jan;31(1):43-66. doi: 10.1016/j.ccc.2014.08.003. Epub 2014 Oct 3 [MEDLINE]
  • 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]