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Pneumothorax
Authors

Catherine L. McKnight1; Bracken Burns2.

Affiliations
1 University of TN, UT Medical Center
2 East Tennessee State University (ETSU)

Last Update: May 4, 2022.

Continuing Education Activity

A pneumothorax is a collection of air outside the lung but within the pleural cavity. It occurs when air accumulates
between the parietal and visceral pleura inside the chest. The air accumulation can apply pressure on the lung and
make it collapse. Pneumothoraces can be even further classified as simple, tension, or open. A simple pneumothorax
does not shift the mediastinal structures, as does a tension pneumothorax. An open pneumothorax also is known as a
"sucking" chest wound. This activity examines when this condition should be considered in differential diagnosis and
how to evaluate it properly. This activity highlights the role of the interprofessional team in caring for patients with
this condition.

Objectives:

Recall the presence of a pneumothorax.

Describe the pathophysiology of a tension pneumothorax.

Summarize the treatment options for pneumothorax.

Review the importance of improving care coordination among interprofessional team members to improve
outcomes for patients affected by pneumothorax.

Access free multiple choice questions on this topic.

Introduction
A pneumothorax is defined as a collection of air outside the lung but within the pleural cavity. It occurs when air
accumulates between the parietal and visceral pleurae inside the chest. The air accumulation can apply pressure on the
lung and make it collapse. The degree of collapse determines the clinical presentation of pneumothorax. Air can enter
the pleural space by two mechanisms, either by trauma causing a communication through the chest wall or from the
lung by rupture of visceral pleura. There are two types of pneumothorax: traumatic and atraumatic. The two subtypes
of atraumatic pneumothorax are primary and secondary. A primary spontaneous pneumothorax (PSP) occurs
automatically without a known eliciting event, while a secondary spontaneous pneumothorax (SSP) occurs
subsequent to an underlying pulmonary disease. A traumatic pneumothorax can be the result of blunt or penetrating
trauma. Pneumothoraces can be even further classified as simple, tension, or open. A simple pneumothorax does not
shift the mediastinal structures, as does a tension pneumothorax. Open pneumothorax is an open wound in the chest
wall through which air moves in and out.[1][2][3][4]

Etiology
Risk factors for primary spontaneous pneumothorax

Smoking 

Tall thin body habitus in an otherwise healthy person

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Pregnancy 

Marfan syndrome 

Familial pneumothorax

Diseases associated with secondary spontaneous  pneumothorax

COPD

Asthma 

HIV with pneumocystis pneumonia

Necrotizing pneumonia 

Tuberculosis 

Sarcoidosis

Cystic fibrosis 

Bronchogenic carcinoma 

Idiopathic pulmonary fibrosis 

Severe ARDS

Langerhans cell histiocytosis

Lymphangioleiomyomatosis

Collagen vascular disease

Inhalational drug use like cocaine or marijuana

Thoracic endometriosis 

Causes of iatrogenic pneumothorax

Pleural biopsy

Transbronchial lung biopsy

Transthoracic pulmonary nodule biopsy

Central venous catheter insertion

Tracheostomy

Intercostal nerve block

Positive pressure ventilation

Causes of traumatic pneumothorax

Penetrating or blunt trauma

Rib fracture

Diving or flying

Causes of tension pneumothorax

Penetrating or blunt trauma

Barotrauma due to positive pressure ventilation

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Percutaneous tracheostomy

Conversion of spontaneous pneumothorax to tension

Open pneumothorax when occlusive dressing work as one way valve

Causes of pneumomediastinum

Asthma

Parturition

Emesis

Severe cough

Traumatic disruption of oropharyngeal or esophageal mucosa

Epidemiology
Primary spontaneous pneumothorax mostly occurs in 20-30 years of age. The incidence of PSP in the United States is
7 per 100,000 men and 1 per 100,000 women per year[5]. The majority of recurrence occurs within the first year, and
incidence ranges widely from 25% to 50%. The recurrence rate is highest over the first 30 days. 

Secondary spontaneous pneumothorax is more seen in old age patients 60-65 years. The incidence of SSP is 6.3 and 2
cases for men and women per 100,000 patients, respectively. The male to female ratio is 3:1. COPD has an incidence
of 26 pneumothoraces per 100,000 patients.[6] The risk of spontaneous pneumothorax in heavy smokers is 102 times
higher than non-smokers.

The leading cause of iatrogenic pneumothorax is transthoracic needle aspiration (usually for biopsies), and the second
leading cause is central venous catheterization. These occur more frequently than spontaneous pneumothorax, and
their number is increasing as intensive care modalities are advancing. The incidence of iatrogenic pneumothorax is 5
per 10,000 admissions in the hospital.

The incidence of tension pneumothorax is difficult to determine as one-third of cases in trauma centers have
decompressive needle thoracostomies before reaching the hospital, and not all of these had tension pneumothorax.

Pneumomediastinum has an incidence of 1 case per 10,000 admissions in the hospital.

Pathophysiology
The pressure gradient inside the thorax changes with a pneumothorax. Normally the pressure of the pleural space is
negative when compared to atmospheric pressure. When the chest wall expands outwards, the lung also expands
outwards due to surface tension between parietal and visceral pleurae. Lungs have a tendency to collapse due to
elastic recoil. When there is communication between the alveoli and the pleural space, air fills this space changing the
gradient, lung collapse unit equilibrium is achieved, or the rupture is sealed. Pneumothorax enlarges, and the lung gets
smaller due to this vital capacity, and oxygen partial pressure decreases. Clinical presentation of a pneumothorax can
range anywhere from asymptomatic to chest pain and shortness of breath. A tension pneumothorax can cause severe
hypotension (obstructive shock) and even death. An increase in central venous pressure can result in distended neck
veins, hypotension. Patients may have tachypnea, dyspnea, tachycardia, and hypoxia.

Spontaneous pneumothorax in the majority of patients occurs due to the rupture of bullae or blebs. Primary
spontaneous pneumothorax is defined as occurring in patients without underlying lung disease but these patients had
asymptomatic bullae or blebs on thoracotomy. Primary spontaneous pneumothorax occurs in tall and thin young
people due to increased shear forces or more negative pressure at the apex of the lung. Lung inflammation and
oxidative stress are essential to the pathogenesis of primary spontaneous pneumothorax. Current smokers have
increased inflammatory cells in small airways and are at increased risk of pneumothorax.

Secondary spontaneous pneumothorax occurs in the presence of underlying lung disease, primarily chronic
obstructive pulmonary disease; others may include tuberculosis, sarcoidosis, cystic fibrosis, malignancy, idiopathic

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pulmonary fibrosis, and pneumocystis jiroveci pneumonia.

Iatrogenic pneumothorax occurs due to a complication of a medical or surgical procedure. Thoracentesis is the most
common cause.

Traumatic pneumothoraces can result from blunt or penetrating trauma, these often create a one-way valve in the
pleural space (letting the airflow in but not to flow out) and hence hemodynamic compromise. Tension pneumothorax
most commonly occurs in ICU settings, in positive pressure ventilated patients.

History and Physical

In primary spontaneous pneumothorax, the patient is minimally symptomatic as otherwise healthy individuals tolerate
physiologic consequences well. The most common symptoms are chest pain and shortness of breath. The chest pain is
pleuritic, sharp, severe, and radiates to the ipsilateral shoulder. In SSP, dyspnea is more severe because of decreased
underlying lung reserve. 

The history of pneumothorax in the past is important as recurrence is seen in 15-40% cases. Recurrence on the
contralateral side can also occur.

On examination, the following findings are noted

Respiratory discomfort

Increased respiratory rate

Asymmetrical lung expansion

Decreased tactile fremitus 

Hyperresonant percussion note

Decreased intensity of breath sounds or absent breath sounds

In tension pneumothorax following additional findings are seen

Tachycardia more than 134 beats per minute

Hypotension

Jugular venous distension

Cyanosis

Respiratory failure

Cardiac arrest

Some traumatic pneumothoraces are associated with subcutaneous emphysema. Pneumothorax may be difficult to
diagnose from a physical exam, especially in a noisy trauma bay. However, it is essential to make the diagnosis of
tension pneumothorax on a physical exam.

Evaluation
Chest radiography, ultrasonography, or CT can be used for diagnosis, although diagnosis from a chest x-ray is more
common. Radiographic findings of 2.5 cm air space are equivalent to a 30% pneumothorax. Occult
pneumothoraces may be diagnosed by CT but are usually clinically insignificant. The extended focused abdominal
sonography for trauma (E-FAST) exam has been a more recent diagnostic tool for pneumothorax. The diagnosis of
ultrasound is usually made by the absence of lung sliding, the absence of a comet-tails artifact, and the presence of a
lung point. Unfortunately, this diagnostic method is very operator dependent and sensitivity, and specificity can vary.
In skilled hands, ultrasonography has up to a 94% sensitivity and 100% specificity (better than chest x-ray). If a
patient is hemodynamically unstable with suspected tension pneumothorax, intervention is not withheld to await

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imaging. Needle decompression can be performed if the patient is hemodynamically unstable with a convincing
history and physical exam, indicating tension pneumothorax.[7][8][9][10][11]

Treatment / Management
Management depends on the clinical scenario.

For patients who have associated symptoms and are showing signs of instability, needle decompression is the
treatment of a pneumothorax. This usually is performed with a 14- to 16-gauge and 4.5 cm in length angiocatheter,
just superior to the rib in the second intercostal space in the midclavicular line. After needle decompression or for
stable pneumothoraces, the treatment is the insertion of a thoracostomy tube. This usually is placed above the rib in
the fifth intercostal space anterior to the midaxillary line. The size of the thoracostomy tube usually ranges depending
on the patient's height and weight and whether there is an associated hemothorax.

Open "sucking" chest wounds are treated initially with a three-sided occlusive dressing. Further treatment may require
tube thoracostomy and/or chest wall defect repair.

An asymptomatic small primary spontaneous pneumothorax (depth less than 2cm) patient is usually discharged with
follow up in outpatient after 2-4 weeks. If the patient is symptomatic or depth/size is more than 2cm needle aspiration
is done, after aspiration, if the patient improves and residual depth is less than 2cm then the patient is discharged
otherwise tube thoracostomy is done.

In secondary spontaneous pneumothorax, if size/depth of pneumothorax is less than 1cm and no dyspnea then the
patient is admitted, high flow oxygen is given and observation is done for 24 hours. If size/ depth is between 1-2cm,
needle aspiration is done, then the residual size of pneumothorax is seen, if the depth after the needle aspiration is less
than 1cm management is done with oxygen inhalation and observation and in case of more than 2cm, tube
thoracostomy is done. In case of depth more than 2cm or breathlessness, tube thoracostomy is done.

Air can reabsorb from the pleural space at a rate of 1.5%/day. Using supplemental oxygen can increase this
reabsorption rate. By increasing the fraction of inspired oxygen concentration, the nitrogen of atmospheric air is
displaced changing the pressure gradient between the air in the pleural space and the capillaries. Pneumothorax on
chest radiography approximately 25% or larger usually needs treatment with needle aspiration if symptomatic and if it
fails then tube thoracostomy is done.

Indications for surgical intervention(VATS vs. thoracotomy)

Continuous air leak for longer than seven days

Bilateral pneumothoraces

The first episode in high-risk profession patient, i.e., Divers, pilots

Recurrent ipsilateral pneumothorax

Contralateral pneumothorax

Patients who have AIDS

Patients who undergo a video-assisted thoracic surgery (VATS) get pleurodesis to occlude pleural space. Mechanical
pleurodesis with bleb/bullectomy decreases the recurrence rate of pneumothorax to <5%. Options for mechanical
pleurodesis include stripping of the parietal pleura versus using an abrasive "scratchpad" or dry gauze. A chemical
pleurodesis is an option in patients who may not tolerate mechanical pleurodesis. Options for chemical pleurodesis
include talc, tetracycline, doxycycline, or minocycline, which are all irritants to the pleural lining.

Differential Diagnosis
Differential diagnoses of pneumothorax include:

Aspiration, bacterial or viral pneumonia

Acute aortic dissection

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Myocardial infarction

Pulmonary embolism

Acute pericarditis

Esophageal spasm

Esophageal rupture

Rib fracture

Diaphragmatic injuries

Prognosis
PSP is usually benign and mostly resolves on its own without any major intervention. Recurrence can occur up to
three years period. Recurrence rate in the following five years is 30% for PSP and 43% for SSP. The risk of
recurrence increases with each subsequent pneumothorax; it is 30% with first, 40% after a send, and more than 50%
after the third recurrence. PSP is not considered a major health threat, but deaths have been reported. SSPs are more
lethal depending upon underlying lung disease and the size of the pneumothorax. Patients with COPD and HIV have
high mortality after pneumothorax. The mortality of SSP is 10%. Mortality of tension pneumothorax is high if
appropriate measures are not taken.

Complications

Respiratory failure or arrest

Cardiac arrest

Pyopneumothorax

Empyema

Rexpansion pulmonary edema

Pneumopericardium

Pneumoperitoneum

Pneumohemothorax

Bronchopulmonary fistula

Damage to the neurovascular bundle during tube thoracostomy

Pain and skin infection at the site of tube thoracostomy

Consultations

Interventional radiologist

Thoracic surgeon

Pulmonology consultant

Deterrence and Patient Education

Patients with pneumothorax should be educated that they should not travel by air or to remote areas until after the
complete resolution of pneumothorax. Patients with high-risk occupations like scuba divers and pilots should be
advised that they should not dive or fly until definitive surgical management of their pneumothorax is done.

All patients are advised to stop smoking. They should be assessed for their will to quit smoking; they should be
educated and provided pharmacotherapy if they decided to quit.

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Pearls and Other Issues

Do not let a chest radiograph or CT scan delay treatment with needle decompression or thoracostomy tube if the
patient is clinically unstable, i.e., tension pneumothorax.

Worsening subcutaneous emphysema can be associated with malposition of a chest tube and repositioning with a new
chest tube is recommended. A chest tube should never be reinserted as this can increase the patient's risk for
empyema.

An untreated pneumothorax is a contraindication for flying or scuba diving. If air transport is required, then a
thoracostomy tube should be placed before transport. 

If there is a persistent or recurrent pneumothorax despite treatment with thoracostomy tube, these patients need
specialty consultations for a possible video-assisted thoracoscopic surgery (VATS) with or without pleurodesis or
thoracotomy.

If the patient is discharged from the hospital after a resolved pneumothorax, recommendations should be made for no
flying or scuba diving for a minimum of two weeks. Patients with a known history of spontaneous pneumothorax
should not be medically cleared for occupations involving flying or scuba diving.

Enhancing Healthcare Team Outcomes

The management of a pneumothorax is often done by the emergency department physician. In some cases, the
disorder may be managed by the ICU staff and the thoracic surgeon. The care of patients who have a chest tube is
done by the nurse. All nurses who manage patients with a chest tube should know how a chest drain functions.
Patients need to be examined every shift and the patency of the chest tube is important. Patients with small
pneumothorax can be observed if they have no symptoms. If discharged the patient should be seen within 24 hours.

Review Questions

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Comment on this article.

References
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acute respiratory distress syndrome. Med Intensiva (Engl Ed). 2019 Nov;43(8):516. [PubMed: 30799041]
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Gen Thorac Cardiovasc Surg. 2019 Sep;67(9):794-799. [PubMed: 30798488]
3. Singh SK, Tiwari KK. Analysis of clinical and radiological features of tuberculosis associated pneumothorax.
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E, Rotolo N. Video-assisted thoracoscopic resection of lung nodules localized with a hydrogel plug. Interact
Cardiovasc Thorac Surg. 2019 Jul 01;29(1):137-143. [PubMed: 30793736]
5. Melton LJ, Hepper NG, Offord KP. Incidence of spontaneous pneumothorax in Olmsted County, Minnesota: 1950
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Thoracostomy Utilizing Computed Tomography. Prehosp Emerg Care. 2019 Sep-Oct;23(5):663-671. [PubMed:
30624127]
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Pneumothorax in Children. J Laparoendosc Adv Surg Tech A. 2019 Apr;29(4):551-556. [PubMed: 30592692]
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Zaporozhan J, Scheubel R, Walles T, Wiesemann S, Worth H, Stoelben E. Management of Spontaneous

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Pneumothorax and Post-Interventional Pneumothorax: German S3 Guideline. Respiration. 2019;97(4):370-402.

[PubMed: 30041191]
10. Wong A, Galiabovitch E, Bhagwat K. Management of primary spontaneous pneumothorax: a review. ANZ J
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11. Bertolaccini L, Congedo MT, Bertani A, Solli P, Nosotti M. A project to assess the quality of the published
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Figures

Portable Chest Radiograph Left Deep Sulcus Pneumothorax. Contributed by Scott Dulebohn, MD

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Chest Radiograph Tension Pneumothorax. Contributed by Scott Dulebohn, MD

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Ct rib fracture, CT Scan, pneumothorax, collapsed lung. Contributed by Steve Bhimji, MS, MD, PhD

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upper lobe pneumothorax. Contributed by S bhimji MD

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left sided tension pneumothorax. Contributed by Wikimedia User: Karthik Easvur, (CC BY-SA 3.0
https://creativecommons.org/licenses/by-sa/3.0/)

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