Pneumothorax: Clinical sciences

Chapters:

Watch video only

Introduction0:00–0:52

Pneumothorax refers to an abnormal presence of air within the pleural space that can result in a deflated or collapsed lung.
The pleural space has a parietal layer, which lines the chest wall, and a visceral layer, which lines the parenchyma of the lung.
Disruption of either of the pleural layers can allow air to enter the pleural space. This can occur spontaneously, usually due to rupture of anatomic lung defects called blebs and bullae, or traumatic, which might occur after a penetrating chest injury or even a medical procedure.
Based on the underlying cause, pneumothorax can be classified as spontaneous pneumothorax, which is further subdivided into primary- and secondary spontaneous pneumothorax; and non spontaneous pneumothorax.Now, if you suspect pneumothorax, you should first perform an ABCDE assessment to determine if your patient is unstable or stable.

Unstable patient0:52–3:15

If the patient is unstable, stabilize the airway, breathing, and circulation. This means that you’ll need to assess the need for ventilatory support and might need to intubate the patient.
Next, obtain IV access, provide supplemental O2 to maintain SaO2 >92% and put your patient on continuous vital sign monitoring, such as pulse oximetry, blood pressure, and heart rate.
Next, perform a focused history and physical and get a chest x-ray as soon as possible. Your patient might report sudden chest pain and shortness of breath while your exam will reveal an asymmetric chest and tracheal deviation away from the affected side, as well as hypotension, respiratory distress, and decreased or absent breath sounds on the affected side.
Keep in mind that tension pneumothorax is a clinical diagnosis and doesn’t need further testing. However, if you were to perform a chest x-ray, it would show a distinct visceral pleural edge with an absence of lung markings distally, often with a depressed hemidiaphragm ipsilateral to the collapsed lung, known as a deep sulcus sign.
In severe cases, you’d see shifting of the mediastinum contralateral to the collapsed lung. Okay, listen up!
Here’s a clinical pearl… Since tension pneumothorax is so dangerous, it should be diagnosed based on clinical suspicion, and treatment should not be delayed, even if imaging has not been performed or results are not yet available.
In fact, you’ll want to perform immediate decompression with needle thoracostomy. Identify the second intercostal space where it intersects with the midclavicular line, then insert an angiocatheter through the chest wall, just above the rib.
If effective, you will release the trapped air, allowing the lung to reinflate and relieve any mediastinal compression. You will later need to proceed with tube thoracostomy, or placement of a chest tube connected to continuous low pressure suction to allow full reinflation and decrease chances of recurrence.
Now, let’s jump back to the ABCDE assessment and take a look at stable patients. If your patient is stable, proceed with a focused history and physical examination.

Stable patient3:15–4:40

Your patient is likely to report the sudden onset of pleuritic chest pain, or pain that gets worse with deep breathing, as well as shortness of breath.
Common examination findings include tachypnea, shallow breathing, and decreased or absent breath sounds on the affected side of the chest.
If these findings are present, suspect pneumothorax and order a chest x-ray.Look for a visceral pleural edge, absence of lung markings, and a deep sulcus sign, while keeping in mind that a mediastinal shift is less likely to be present in a stable patient.
At this point, you can be sure that the diagnosis is pneumothorax. On other hand, if you notice findings that are inconsistent with pneumothorax, you should consider an alternative diagnosis.
Now that you’ve diagnosed pneumothorax, the next step is to assess the underlying cause. Ask about a history of trauma to the chest wall and any recent medical procedures where inadvertent trauma may have occurred.
If neither of these is present, then the pneumothorax is said to be spontaneous. If spontaneous pneumothorax occurs in the absence of trauma or known lung condition, the pneumothorax is said to be primary.

Primary spontaneous pneumothorax4:40–6:05

Risk factors for primary spontaneous pneumothorax include young age, tall height, thin body habitus, and being a biologically male individual.
Now, the first step in management of a patient with a primary spontaneous pneumothorax is to assess the size of the pneumothorax.
If it’s small, meaning the chest X-ray reveals less than 2 cm between the lung edge and chest wall, next you should assess for symptom severity.
As long as no symptoms are present, it may often resorb spontaneously, so you can observe your patient. However, if symptoms are present, then you'll need to perform simple needle aspiration or placement of a chest tube.
On the other hand, if the pneumothorax is large, in other words there’s 2 cm or more in depth, then you will place a chest tube and attach it to continuous suction.
Next, order a follow-up chest X-ray to evaluate the lung expansion. If there’s full lung expansion, stop the suction and observe your patient for an additional 24 hours.
But, if the X-ray reveals no lung expansion, make sure to consult the surgical team! Now that we are done with primary spontaneous pneumothorax, let’s go all the way back up to the assessment of the underlying cause.

Secondary spontaneous pneumothorax6:05–6:57

Next up are individuals that have no history of trauma but have an underlying lung condition, such as COPD or pulmonary fibrosis.
In this case, the pneumothorax is classified as a secondary spontaneous pneumothorax. Here, you will place a chest tube regardless of symptoms or the size of the pneumothorax and attach the tube to continuous suction, again followed by a repeat chest x-ray to evaluate lung expansion.
Just like mentioned previously, if there’s full lung expansion, stop the suction and observe your patient for an additional 24 hours.
But, if the X-ray reveals no lung expansion, then you consult the surgical team! Finally, let’s go back to the assessment of the underlying cause and we’ll take a look at patients that present with a history of trauma, such as blunt or penetrating trauma; or a history of medical intervention, such as central line placement, lung biopsy, and mechanical ventilation.

Non-spontaneous pneumothorax6:57–7:26

In this case, you should think of non spontaneous pneumothorax, so your next step is to assess the chest wall for penetrating injury.
If there’s no chest wall defect, non spontaneous pneumothorax is classified as a closed pneumothorax, so your next step is to assess the pneumothorax size and treat it just like you would treat the primary spontaneous pneumothorax.

Closed pneumothorax7:26–7:42

On the other hand, if there is a chest wall defect, then the diagnosis is open pneumothorax, so make sure to consult the surgery team because the chest wall may need surgical repair to allow for proper lung reinflation.Now here’s another high yield fact… If pneumothorax occurs as a result of a medical intervention, it’s called iatrogenic pneumothorax.

Open pneumothorax7:42–8:27

The most common cause is an inadvertent puncture of the pleura during insertion of a central venous catheter. However, it is also known to occur during needle based transthoracic procedures, like liver biopsy and thoracentesis.
They can even occur from mechanical ventilation, usually due to high expiratory pressure settings causing barotrauma.All right, as a quick recap… If you suspect pneumothorax, perform an ABCDE assessment to determine if your patient is unstable or stable.

Review8:27–10:22

Unstable individuals typically present with tension pneumothorax and usually require immediate decompression with needle thoracostomy prior to placement of a chest tube.
On the other hand, in stable individuals, use a chest X-ray to make the diagnosis. Next, review the patient’s history to determine the underlying cause and type of pneumothorax.
The initial step in the management of primary spontaneous pneumothorax is to determine the pneumothorax size. If it’s small, observe the patient as long as no symptoms are present.
However, if symptoms are present, treat the pneumothorax, either with simple needle aspiration or the placement of a chest tube.
On the other hand, if the pneumothorax is large, place a chest tube with continuous suction. Next, order a follow-up chest X-ray to evaluate lung expansion.
If the X-ray reveals full lung expansion, stop suction and observe the patient for 24 hours. But, if there's no lung expansion, consult the surgical team.
On the other hand, in secondary spontaneous pneumothorax, place a chest tube regardless of the size of the pneumothorax, attach the tube to continuous suction, and again order a follow-up chest X-ray to evaluate lung expansion.
Finally, in non spontaneous pneumothorax, assess the chest wall for penetrating injury. If there’s no chest wall defect, the diagnosis is closed pneumothorax, so your next step is to determine the pneumothorax size and treat it just like you would treat the primary spontaneous pneumothorax.
On the flip side, if you notice any chest wall defects, the diagnosis is open pneumothorax, so immediately consult the surgical team.