Pneumothorax

Pneumothorax is the presence of gas in the pleural space. A spontaneous

pneumothorax is one that occurs without antecedent trauma to the thorax. A
primary spontaneous pneumothorax occurs in the absence of underlying lung
disease, while a secondary pneumothorax is related to parenchymal lung
disease.

Primary Spontaneous Pneumothorax

Primary spontaneous pneumothoraces are usually due to rupture of apical

pleural blebs, small cystic spaces that lie within or immediately under the
visceral pleura. Primary spontaneous pneumothoraces occur almost exclusively
in smokers, which suggest that these patients have subclinical lung disease.
Approximately one-half of patients with an initial primary spontaneous
pneumothorax will have a recurrence. The initial recommended treatment for
primary spontaneous pneumothorax is simple aspiration. If the lung does not
expand with aspiration, or if the patient has a recurrent pneumothorax,
thoracoscopy with stapling of blebs and pleural abrasion is indicated.
Thoracoscopy or thoracotomy with pleural abrasion is almost 100% successful
in preventing recurrences.

Secondary Pneumothorax

Most secondary pneumothoraces are due to chronic obstructive pulmonary

disease, but pneumothoraces have been reported with virtually every lung
disease. Pneumothorax in patients with lung disease is more life-threatening
than it is in normal individuals because of the lack of pulmonary reserve in
these patients. Nearly all patients with secondary pneumothorax should be
treated with tube thoracostomy. Most should also be treated with
thoracoscopy or thoracotomy with the stapling of blebs and pleural abrasion. If
the patient is not a good operative candidate or refuses surgery, then
pleurodesis should be attempted by the intrapleural injection of a sclerosing
agent such as doxycycline.

Causes of Secondary Pneumothorax

 Rupture of – Subpleural TB focus (active lesion or local emphysematous

area from old scarring), Emphysematous bullae, congenital cyst and
bullae, Honeycomb lung, Oesophageal rupture.
  Infections(other than TB) – Bacterial Pneumonia, Lung abscess,
Pneumocystis jiroveci pneumonia, whooping cough, bronchiectasis.

 Diffuse fibrosing Pulmonary disease – Sarcoidosis, Pneumoconiosis,

Interstitial fibrosis.

 Asthma – Chronic bronchitis and Emphysema

 Cystic Fibrosis

 Neoplasms - Bronchial or Pleural

 Secondary to spontaneous mediastinal emphysema

 Pulmonary Infarction

 Miscellaneous – Rheumatoid lung disease, Histiocytosis X, Tuberous

Sclerosis, Marfan’s syndrome, Ehlers – Danlos syndrome, Endometriosis
of pleura, Pulmonary alveolar proteinosis, Idiopathic pulmonary
hemosiderosis.

The other classification of Spontaneous Pneumothorax is – Closed, Open and

Valvular (tension)

Types of Spontaneous Pneumothorax

Type Pathophysiology Salient Features
Closed The communication between the The mean pleural pressure
lung and pleural space seals off as remains negative. Air in the
the lung deflates and does not pleural space gets reabsorbed
reopen spontaneously, the underlying
lung re-expands over a few
days or week. Infection is rare
Open The communication between the The mean pleural pressure
lung and pleural space fails to seal. remains equal to atmospheric
Air continues to transfer freely pressure; lung cannot expand.
between the lung and pleural space. Bronchopleural fistula, spread
Usually develops following rupture of infection from the airways
of a tuberculosis cavity, an into the pleural space resulting
emphysematous bulla or lung in empyema are common
abscess into the pleural space.
Valvular (tension) The communication between airway The intrapleural pressure may
and the pleura acts as a one-way become more than the
 valve allowing air to enter the atmospheric pressure. This may
pleural space during inspiration but cause mediastinal shift towards
not escape on expiration. This the opposite side, compression
results in large amounts of air being of the opposite normal lung,
trapped in the pleural space. impairment of systemic venous
return and may result in
cardiovascular compromise
Rarely, in patients with
splinting of the mediastinum
due to scarring (e.g. sequelae
of tuberculosis ) or malignancy,
a ‘tension’ pneumothorax may
occur without mediastinal shift

Clinical Features

Primary spontaneous pneumothorax is commonly encountered in males, aged

15- 30 yrs, tobacco smoking, tall strature and presence of apical subpleural
blebs are risk factors.

Secondary pneumothorax is more common in elderly individuals, affects

patients with pre- existing lung diseases. Common presenting symptoms
includes sudden onset of chest pain on the affected side and breathlessness.

In the closed type the breathlessness is mild. In open type, breathlessness is

severe and secondary infection of pleura is common.

Tension pneumothorax is an acute medical emergency, the patient is severely

dyspnoeic, cyanosis, marked tachycardia, profuse sweating may be present. In
tension pneumothorax the pressure in the pleural space is positive throughout
the respiratory cycle.
Physical signs vary according to the type and size of the pneumothorax.
Mediastinum is shifted to the opposite side. On the affected side there is
intercoastal fullness, diminished movements, hyper resonant percurssion note,
reduced or absent breath sounds.

In hydropneumothorax or pyopneumothorax a horizontal “fluid level” marks

the interface between the liquid and the air.

Other important physical sign include amphoric breath sounds (in

bronchopleural fistula, tension pneumothorax), Succussion splash
(hydropneumothorax).

Recurrent pneumothorax can occur in patients with emphysematous bullae or

lymphangioleiomyomatosis.

Investigations

Chest radiograph findings include mediastinal shift to the opposite side,

presence of air in the pleural cavity as a translucent shadow along with the
sharply defined edge of the collapsed lung (Fig of chest X- ray 5A and 5B-
API/pg 1778). Hydropneumothorax and underlying pulmonary disease may
also be seen.

Chest radiograph helps identifying underlying pulmonary parenchymal lesions

and in differentiating pneumothorax from large emphysematous bullae and
cyst of the lung.

Treatment

1. No treatment – Only observation if small pneumothorax (occupying less

than 20% of the hemithorax) as the air usually gets absorbed within a
few days. The exception is the patient with severe lung disease who
cannot tolerate even a small pneumothorax and air has to be removed.
Antituberculous therapy if there is evidence of tubercle.

2. Simple aspiration – It is indicated when there is significant dyspnoea

or traumatic pneumothorax.

3. Tension pneumothorax is a medical emergency and requires immediate

release of tension in the pleural space using a wide bore plastic cannula
connected to a water seal drainage system. Tube thoracostomy,
 appropriate antibiotic therapy and/or anti-tuberculosis treatment may
be necessary.

4. Surgical treatment – It is suggested in cases of Bilateral pneumothorax,

Hemopneumothorax, Persistent leak due to broncho-pleural fistula, Air
leak that persist for more than one week, recurrent pneumothorax,
patient whose occupation poses special risks e.g pilots, seamen etc.

Traumatic Pneumothorax

A traumatic pneumothorax results from penetrating (e.g stab wound, gun shot
wound etc) or nonpenetrating chest injuries(e.g blunt injury can cause rib
fracture which increases intrathoracic pressure and bronchial rupture
manifested by “fallen lung sign”

Traumatic pneumothoraces should be treated with tube thoracostomy unless

they are very small. If a hemopneumothorax is present, one chest tube should
be placed in the superior part of the hemithorax to evacuate the air, and
another should be placed in the inferior part of the hemithorax to remove the
blood. Iatrogenic pneumothorax is a type of traumatic pneumothorax that is
becoming more common. The leading causes are transthoracic needle
aspiration, thoracentesis, and the insertion of central intravenous catheters.
Most can be managed with supplemental oxygen or aspiration, but if these are
unsuccessful a tube thoracostomy should be performed.

Recurrent Pneumothorax

Recurrent pneumothorax in individuals with a low respiratory reserve in whom

further recurrence may be hazardous and in those indulging in activities such
as flying or diving should be treated by surgical pleurodesis by surgical abrasion
or parietal pleurectomy at thoracoscopy or thoracotomy.

Hydropneumothorax

Cause of Hydropneumothorax

1. Rupture of the subpleural tuberculous focus (common cause)

2. Rupture of subpleural lung abscess (pyopneumothorax)
 3. Pulmonary Infarction
4. Penetrating chest injury (haemopneumothorax), Iatrogenic – mainly
after cardiac surgery, aspiration of pleural fluid, secondary infection of
pneumothorax following water seal drainage.

Diagnostic signs in hydropneumothorax

1. Shifting dullness – The upper limit of dullness is horizontal and shifts

when patient’s position is altered.
2. Succussion splash (Hippocratic succession)
3. Tinkling sound may be heard particularly after coughing.

Chronic Pneumothorax

Pneumothorax persisting for more than 3 months is called chronic

pneumothorax.

Causes

1. Failure of collapse of lung due to adhesion

2. Air leak through congenital cyst.
3. Generalised emphysema causing multiple leaks.

Pulmonary Barotrauma

Pulmonary Barotrauma usually occurs at a high attitude of 3050m or in scuba

drivers.

Iatrogenic Pneumothorax

It occurs as a complication of a transthoracic puncture or a puncture of teh

subclavian vein.
Mediastinal Emphysema

It is due to the passage of air from the lung to the mediastinum and may occur
during coughing or an extreme Valsalva manouver. It is suspected when
subcutaneous emphysema occurs at the upper chest and the neck level.

Catamenial Pneumothorax

It is a rare condition occurring in females of 25-30 yrs. Repeated attacks of

spontaneous pneumothorax occur usually on the right side in association with
menstruation generally within 48hrs before or after onset of menstruation.