Pneumothorax

• Presence of air in pleural space.

• Classification;
1. Spontaneous;
Primary; occurs in patient with no history of lung disease. Smoking,
tall stature and presence of apical subpleural blebs are risk factors.
Secondary; occurs in patients with pre-existing lung disease and is
a/w higher mortality rates.
2. Traumatic; iatrogenic(e.g. following thoracic surgery or biopsy) or
chest wall injury
• Spontaneous pneumothorax; types;
1. Closed type; communication between airway and pleural space seals off as the lung deflates
and doesn’t reopen. Mean pleural pressure remains negative, spontaneous reabsorption of
air and re-expansion of lung occur over a few days or weeks, and infection is uncommon.
2. Open type; communication fails to seal and air continues to pass freely between bronchial
tree and pleural space. E.g bronchopleural fistula, facilitates transmission of infection from
airways into pleural space, leading to empyema. It is commonly seen following rupture of
emphysematous bulla, tuberculous cavity or lung abscess into pleural space. Mean arterial
pressure is atmospheric.
3. Tension type; communication acts as one way valve, allowing air to enter pleural space
during inspiration but not to escape on expiration. Mean pleural pressure is positive and
mediastinal shift to opposite side, with compression of opposite normal lung and
impairment of systemic venous return, causing cardiovascular compromise.
Clinical features
• Sudden onset unilateral pleuritic chest pain or breathlessness
• Secondary spontaneous pneumothorax- breathlessness is severe and may
not resolve spontaneously.
• Patients with small pneumothorax- physical examination may be normal.
• Patients with larger pneumothorax- decreased or absent breath sounds.
• Absent breath sounds+ resonant percussion note- diagnostic of
pneumothorax.
• Tension pneumothorax- rapidly progressive breathlessness a/w marked
tachycardia, cyanosis, hypotension and deviation of trachea to opposite
side.
Investigations
• Chest X-ray;
sharply defined edge of deflated lung with complete translucency(no
lung markings) between lung edge and chest wall,
extent of any mediastinal displacement,
any pleural fluid and underlying lung disease.
• CT- in difficult cases.
Management
• Small pneumothorax- requires no t/t apart from a few days bed rest until
it resolves.
• Large pneumothorax(i.e >25% of pleural space is filled with air);
It is treated by needle aspiration or intercostal drain which connects pleural
cavity with a drainage bottle creating an underwater seal.
SURGERY: is indicated in recurrent pneumothorax;
1. Pleurodesis; comprises insertion of powder into pleural cavity to adhere
both the pleura together.
2. Pleurectomy; removal of parietal pleura from chest wall leaving a raw
surface to which visceral layer sticks.