Types of

Pneumothorax
Types of Pneumothorax
• 2 main types based on cause: spontaneous and
traumatic
• Can also be classified according to communication
between pleural space and airway
1. Spontaneous Pneumothorax

• Can be divided into primary and secondary

• Primary = no underlying pulmonary disease
• Secondary = with underlying pulmonary disease
• Primary Spontaneous Pneumothorax (PSP)
• Occurs as a result of spontaneous rupture of blebs or
bullae
• Presence of asymptomatic blebs and bullae (usually
apical)
1. Spontaneous
Pneumothorax
• Risk factors:

• Smoking • 80-90% PSP in smokers

• Familial association • >10% PSP have familial
association (some due to
connective tissue disorders e.g
Marfan syndrome)
• Tall, thin stature
• Increased
intrathoracic pressure
• Changes in
atmospheric pressure
• Secondary Spontaneous Pneumothorax (SSP)
• Occurs in the presence of known lung disease
• Associated with increased symptoms, morbidity and
higher rates of developing tension pneumothorax
• Causes:
Obstructive airway disease • COPD
• asthma
Suppurative lung disease • Bronchiectasis
• Cystic fibrosis
Malignant disease • Lung carcinoma
• Secondary metastasis
Interstitial lung disease • sarcoidosis
• Wegener’s granulomatosis
• Idiopathic interstitial fibrosis
• lymphangioleiomyomatosis

Infections • Pneumocystis jirovecii pneumonia

(in patients with AIDS )
• tuberculosis
2. Traumatic & Iatrogenic
• Traumatic pneumothorax causes include:
• Trauma - Penetrating and nonpenetrating injury
• Rib fracture
• High-risk occupation (eg, diving, flying)
• Traumatic pneumothorax can often lead to
formation of one-way valve causing tension
pneumothorax
2. Traumatic & Iatrogenic
• Iatrogenic pneumothorax occurs as a complication
of medical or surgical procedures.
• Iatrogenic pneumothorax causes include:
• Central vein cannulation
• Pleural tap or biopsy
• Transthoracic needle aspiration biopsy
• Transbronchial biopsy
• Fine needle aspiration
• Positive pressure ventilation - High peak airway
pressures results in pulmonary barotrauma
Tension Pneumothorax
• Is a medical emergency
• Occurs when the communication between the
airway and pleural space acts as a one-way valve.
• Air enters pleural space during inspiration but is not
expelled during expiration
• High intrapleural pressure causes mediastinal shift
to opposite side, compression of contralateral lung
and reduced venous return, causing cardiovascular
compromise.
Tension Pneumothorax
• Usually traumatic or iatrogenic causes
• Includes:
• Blunt or penetrating trauma - often associated with rib
fractures
• Barotrauma secondary to positive-pressure ventilation
(PPV), especially when high amounts of positive end-
expiratory pressure (PEEP) are used
• Percutaneous tracheostomy
• Conversion of spontaneous pneumothorax to tension
pneumothorax
Clinical Features
• Symptoms
• Sudden onset of unilateral pleuritic chest pain and/or
breathlessness
• Depending on severity of pneumothorax, symptoms can
be well-tolerated
• Usually more severe in SSPs due to existing lung disease
• Other symptoms include: anxiety, cough, generalised
malaise and fatigue
• History of previous similar episodes: high rates of
recurrence especially with SSPs
• History of other pulmonary disease and thoracic
procedures may indicate cause of pneumothorax
Clinical Features
• Signs
• Depending on severity, presentation may range from
minimal findings to severe respiratory distress
Respiratory • Respiratory distress
• Tachypnoea (bradypnea in later stages)
• Tracheal deviation to opposite side* – late sign
• Ipsilateral reduced chest movements
• Reduced tactile fremitus
• Hyperresonance on percussion
• Reduced or absent breath sounds unilaterally
• Adventitious lung sounds (features of
underlying disease)

Cardiovascular • Tachycardia - most common finding

• Pulsus paradoxus*
• Hypotension*
• Jugular venous distention*
• Cardiac apical displacement* – rarely seen
*more commonly seen and marked in tension pneumothorax
Clinical Features
• In tension pneumothorax,
• Symptoms and signs are usually more severe
• There is rapidly progressive breathlessness and chest
pain in addition to air hunger and increased anxiety
• In patients on PPV, ventilation becomes progressively
more difficult
• Cyanosis may be present
• Cardiac signs such as tachycardia and hypotension are
more marked
• Advanced (pre-terminal) stage is characterised by
reduced breathing rate, reduced consciousness and
hypotension