Spontaneous Pneumothorax

  • Can be either primary (absence of underlying lung pathology) or secondary (due to presence of underlying lung pathology)
  • Classic spontaneous pneumothorax occurs in a tall, thin, young male patient (Marfan Syndrome!)
  • In primary spontaneous pneumothorax: If the pneumothorax is small and symptomatic it usually resolves on its own, but if it is large and symptomatic, patient should be admitted
  • In secondary spontaneous pneumothorax: Most patients will require admission and chest tube drainage. Since, these patients usually have underlying lung pathology, other treatment will also be included (i.e. antibiotics, additional diagnostic tests, etc.)
  • Spontaneous pneumothorax may evolve into tension pneumothorax

 

Tension Pneumothorax

  • Forms due to a one-way valve where air can enter the pleural space upon inspiration, but not leave (MEDICAL EMERGENCY!!!)
  • Most commonly due to traumatic pneumothorax (due to blunt or penetrating trauma to the chest or due to iatrogenic causes such as diagnostic/therapeutic procedure)
  • Findings to help differentiate from spontaneous pneumothorax: contralateral tracheal deviation, hypotension, tachycardia, hypoxia, increased jugular venous pressure (JVP)
  • Physical exam findings on ipsilateral lung: hyper-resonance, absent breath sounds, decreased vocal fremitus, and diminished chest wall expansion
  • Treatment: IMMEDIATELY TREAT WITH DECOMPRESSION WITH OR WITHOUT RADIOGRAPHIC CONFIRMATION!!! DO NOT GET CHEST X RAY OF CLINICAL SUSPICION FOR TENSION PNEUMOTHORAX!
    • 14-16 gauge needle inserted in second intercostal space at the mid-clavicular line

 

Symptoms common to both spontaneous and tension pneumothorax include: chest pain localized to affected side and dyspnea. The chest pain may be pleuritic and is usually acute.

Patients with underlying asthma or COPD should be treated urgently if patient has a tension pneumothorax or a symptomatic spontaneous pneumothorax as this can result in life-threatening cardio-respiratory failures.

 

REFERENCES

  • Kemp, Walter L, Travis G Brown, and Dennis K Burns.The Big Picture: Pathology. 1st ed. The McGraw-Hill Companies-Lange, 2007. Print.
  • Ashby  M  et al. Conservative versus interventional management for primary spontaneous pneumothorax in adults. Cochrane Database Syst Rev. 2014 Dec 18;12:CD010565.
  • Bintcliffe  OJ  et al. Spontaneous pneumothorax: time to rethink management? Lancet Respir Med. 2015 Jul;3(7):578–88.
  • Grundy  S  et al. Primary spontaneous pneumothorax: a diffuse disease of the pleura. Respiration. 2012;83(3):185–9.
  • Stone, Keith c. Current Diagnosis and Treatment: Emergency Medicine. 7th ed. New York: McGraw-Hill education, 2011. Print.

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