Clinical Review - Full
Clinical Review - Full
Clinical Review - Full
Academic Respiratory Unit, School Pneumothorax describes the presence of gas within the pleu- Secondary pneumothorax is associated with considerably
of Clinical Sciences, University of ral space, between the lung and the chest wall. It remains a more morbidity and mortality than primary pneumothorax,
Bristol, Bristol BS10 5NB, UK globally important health problem, with considerable associ- in part resulting from the reduction in cardiopulmonary
Correspondence to: N Maskell
[email protected] ated morbidity and healthcare costs. Without prompt man- reserve in patients with pre-existing lung disease.
Cite this as: BMJ 2014;348:g2928 agement pneumothorax can, occasionally, be fatal. Current Tension pneumothorax is a life threatening complication
doi: 10.1136/bmj.g2928 research may in the future lead to more patients receiving that requires immediate recognition and urgent treatment.
ambulatory outpatient management. This review explores Tension pneumothorax is caused by the development of a
bmj.com the epidemiology and causes of pneumothorax and dis- valve-like leak in the visceral pleura, such that air escapes
Previous articles in this cusses diagnosis, evidence based management strategies, from the lung during inspiration but cannot re-enter the lung
series and possible future developments. during expiration. This process leads to an increasing pres-
ЖЖManagement of sure of air within the pleural cavity and haemodynamic com-
women at high risk of How common is pneumothorax? promise because of impaired venous return and decreased
breast cancer Between 1991 and 1995 annual consultation rates for cardiac output. Treatment is with high flow oxygen and
(BMJ 2014;348:g2756) pneumothorax in England were reported as 24/100 000 emergency needle decompression with a cannula inserted
ЖЖGallstones for men and 9.8/100 000 for women, and admission rates in the second intercostal space in the midclavicular line. An
(BMJ 2014;348: g2669) were 16.7/100 000 and 5.8/100 000, respectively, in a intercostal drain is then inserted after decompression. Often
ЖЖFirst seizures in adults study analysing three national databases.1 The overall emergency treatment must be based on a clinical diagnosis
(BMJ 2014;348:g2470) incidence represents a rate of one pneumothorax a year of tension pneumothorax before radiological confirmation,
in an average sized general practice population. Across because of life threatening haemodynamic compromise.
ЖЖObsessive-compulsive
the United Kingdom this equates to around 8000 admis- Radiographic features suggesting tension pneumothorax
disorder
sions for pneumothorax each year, accounting for 50 000 include cardiomediastinal shift away from the affected side
(BMJ 2014;348:g2183)
bed days given an average length of stay of just under one and, in some cases, inversion of the hemidiaphragm and
ЖЖModern management week.2 These admissions alone have estimated costs of widening of intercostal spaces from the increased pressure
of splenic trauma £13.65m for the National Health Service. Annual costs in within the affected hemithorax.
(BMJ 2014;348:g1864) the United States have been estimated at $130m.3
How is pneumothorax diagnosed?
What are the types of pneumothorax? Pneumothorax may be asymptomatic and diagnosed radio-
Pneumothorax is categorised as primary spontaneous, sec- logically or may be suspected on the basis of typical clini-
ondary spontaneous, or traumatic (iatrogenic or otherwise). cal features. The most common symptoms are chest pain
Traumatic pneumothorax is out of the remit of this review and breathlessness, characteristically with an acute onset,
and will not be discussed. although these may be subtle or even absent. Patients with
The distinction between primary and secondary pneumo secondary pneumothorax tend to have more symptoms than
thoraces is based on the absence or presence of clinically those with primary pneumothorax as a result of coexistent
apparent lung disease. Primary and secondary pneumo lung disease. Clinical signs of pneumothorax include a
thoraces are distinct groups regarding morbidity and mortality, reduction in lung expansion, a hyper-resonant percussion
rates of hypoxia at presentation, and recommended manage- note, and diminished breath sounds on the affected side.
ment.4 Although primary pneumothorax is not associated with The presence of hypotension and tachycardia may indicate
known lung disease, most affected patients have unrecognised tension pneumothorax.
lung abnormalities that may predispose to pneumothorax. A In most patients the diagnosis will be confirmed on a
small case-control study found that emphysema-like changes standard, inspiratory chest radiograph. Routine expiratory
were identified on computed tomography in 81% of 27 non- films are not recommended routinely as they do not improve
smokers with primary pneumothorax compared with 0% in diagnostic yield, contrary to historical recommendations.4
the control group of 10 healthy volunteers who did not smoke.5 The hallmark of a pneumothorax on a radiograph is a white
visceral pleural line separated from the parietal pleura and
SUMMARY POINTS chest wall by a collection of gas, resulting in a loss of lung
Primary spontaneous pneumothorax is associated with smoking but defined as occurring in markings in this space (fig 1).
the absence of known lung disease Features of pneumothorax may be more subtle on supine
Secondary spontaneous pneumothorax occurs in the presence of known lung disease and is radiographs, with more air needed within the pneumotho-
associated with increased symptoms, morbidity, and rates of tension pneumothorax rax to confidently make a diagnosis. The deep sulcus sign,
Immediate recognition and management of tension pneumothorax is required to prevent death caused by air collecting in the costophrenic sulcus, appar-
Smoking increases the risk of pneumothorax and rates of recurrence, and smoking cessation ently deepening it, may indicate pneumothorax on a supine
is strongly advised radiograph.
Surgical intervention is warranted for patients with recurrent pneumothorax as the risk of Computed tomography provides sensitive and specific
further recurrence is high
imaging for pneumothorax and is particularly useful for
Fig 1 | Large right sided to increase with worsening chronic obstructive pulmonary
secondary pneumothorax in disease; around 30% of patients with secondary pneumo-
patient with severe chronic thorax have a forced expiratory volume in one second of
obstructive pulmonary
less than 1 litre.10 Other causes of secondary pneumothorax
disease and acute dyspnoea.
include asthma, Pneumocystis jirovecii pneumonia related
White arrows indicate
visceral pleura surrounding to HIV infection, cystic fibrosis, lung cancer, tuberculosis,
collapsed lung interstitial lung disease, and endometriosis.
Thoracic endometriosis seems to have been an under-rec-
ognised cause of pneumothorax; a prospective study evalu-
ating 32 women with pneumothorax referred for surgery
found that 25% (n=8) had features suggesting pneumotho-
rax associated with menses and seven of these women had
histopathological confirmation of diaphragmatic endome-
triosis.11 Specifically evaluating women for this possibility
may significantly alter management.
complex disease processes, including pneumothoraces that What predicts recurrence of pneumothorax?
are loculated as a result of areas of lung remaining adherent Primary spontaneous pneumothorax
to parietal pleura, as well as facilitating radiologically guided Smoking cessation is the only proved modifiable risk factor
drain insertion in difficult cases. Additionally, computed for recurrence of primary pneumothorax. In a retrospective
tomography is useful in distinguishing a pneumothorax study of patients with primary pneumothorax, including 99
from large bullae, which may occur in severe emphysema smokers, the absolute risk of recurrent pneumothorax in the
and can mimic the appearance of pneumothorax due to the four year follow-up period was 40% in those who stopped
absence of lung markings within a bulla. Typically, on chest smoking compared with 70% in those who continued to
radiographs bullae are indicated by a concave appearance, smoke.12 Recurrence of primary pneumothorax is also asso-
whereas a pneumothorax is suggested by a visceral pleural ciated with increased height in men12 and is significantly
line running parallel to the chest wall; however, this distinc- reduced by open surgery or video assisted thoracic surgery.13
tion may be made clearly with computed tomography, poten-
tially avoiding the serious complication of inserting a drain Secondary spontaneous pneumothorax
into lung parenchyma. Patients with pre-existing lung disease are more likely to
experience a recurrent pneumothorax than those with pri-
What predisposes to pneumothorax? mary pneumothorax.14 15 In a retrospective study of 182
Primary spontaneous pneumothorax patients, of whom around half had chemical pleurodesis,
The most important risk factor contributing to risk of primary recurrence rates at one year were 15.8% for primary pneu-
pneumothorax is tobacco smoking. A retrospective study mothorax and 31.2% for secondary pneumothorax.15 Rates
over 10 years conducted in Stockholm assessed the smok- of recurrence of secondary pneumothorax are noticeably
ing habits of 138 patients with primary pneumothorax and lowered by thoracic surgery: after video assisted thoracic
compared their rates of smoking with a contemporary ran- surgery or axillary minithoracotomy, recurrence rates of
dom sample of over 15 000 people from the same geographi- around 3% were reported in a study with a mean follow-
cal area. Within this study, 88% of the patients with primary up period of 30 months,13 whereas a separate study, with
pneumothorax smoked. Compared with non-smokers the a similar duration of follow-up, reported recurrence rates
relative risk of a first pneumothorax is increased by ninefold of 43% in a control group of 86 patients with secondary
in women who smoke and by 22-fold in men who smoke.6 In pneumothorax.10
addition this study found a striking dose-response relation
between number of cigarettes smoked a day and risk of pneu- What is the goal of management?
mothorax.6 Cannabis smoking is associated with pneumo- The goal of acute treatment in pneumothorax is to exclude a
thorax, an effect that may be attributed to both parenchymal tension pneumothorax and to relieve any dyspnoea. These
damage from smoke and the longer breath-holds or valsalva goals are reflected by the different treatment algorithms
manoeuvres that may be associated with smoking cannabis.7 in patients with primary or secondary pneumothorax, as
The risk of primary pneumothorax is greater in tall men, patients with the latter are more likely to be symptomatic
which has led to the hypothesis that a greater alveolar stretch and more prone to associated cardiopulmonary compromise,
at the lung apex in tall men contributes to the increased risk.8 in view of pre-existing disease. In contrast, patients with pri-
Pneumothorax as a whole has a biphasic age distribution mary pneumothorax are often asymptomatic and tension
with primary pneumothorax peaking in those between the pneumothorax is uncommon in this population.
ages of 15 and 34 and secondary pneumothorax in those Early studies evaluating treatment of pneumothorax
aged more than 55.1 focused on radiological resolution rather than patient cen-
tred outcomes, and this may have previously resulted in
Secondary spontaneous pneumothorax guidelines focused on intervention to remove air from the
Chronic obstructive pulmonary disease is the most common pleural space. Goals of treatment in pneumothorax are to
lung disease causing secondary pneumothorax, accounting exclude tension and reduce early morbidity and symp-
for around 57% of cases.9 The risk of pneumothorax seems toms associated with pneumothorax, to limit inpatient
This week our State of the Art review is painful diabetic and its subtypes. The various diagnostic scores and
State of the neuropathy (http://www.bmj.com/content/348/bmj. surveys used to diagnose painful diabetic neuropathy in
Art reviews: g1799). Diabetic sensorimotor polyneuropathy is the clinical and research settings are summarised.
Painful diabetic most common complication of diabetes and one third of Management of the underlying diabetes is the mainstay
people with it develop painful diabetic neuropathy. of preventing and delaying the progression of neuropathy.
neuropathy Painful diabetic neuropathy is more prevalent in type 2 However, glucose control is more effective in decreasing the
diabetes than in type 1 disease and has a negative impact incidence of neuropathy in patients with type 1 diabetes than
on physical and mental quality of life compared with in those with type 2 disease. The evidence behind the three
painless diabetic neuropathy. main categories of medication—antiepileptic medications,
The review uses the latest evidence and guidelines to antidepressants affecting norepinephrine reuptake, and
discuss the classification of painful diabetic neuropathy non-specific analgesics including opioids— is reviewed.
Patterns of nerve injury in patients with diabetic neuropathy Algorithm for the treatment of diabetic neuropathy