RISK FACTORS
β’ Trauma (broken rib, ruptured bronchus, perforated
esophagus)
β’ Rupture of superfi cial lung bulla following cough or
blowing a musical instrument
β’ Strenuous activity
β’ Flying (high altitude) after loss of pressurization
β’ Divin
RISK FACTORS
β’ Trauma (broken rib, ruptured bronchus, perforated esophagus)
β’ Rupture of superfi cial lung bulla following cough or blowing a musical instrument
β’ Strenuous activity
β’ Flying (high altitude) after loss of pressurization
β’ Diving (at ascension or rapid decompression)
β’ Pneumoconioses
β’ Tuberculosis
β’ Pneumonia due to TB, Klebsiella, Staph aureus
β’ Subpleural Pneumocystis carinii pneumonia (PCP) (in AIDS patients on PCP prophylaxis via pentamidine
aerosol)
APPROPRIATE HEALTH CARE
. Outpatient - lung collapse less than 30%, no dyspnea, no signs of tension pneumothorax, no underlying lung
disease
. Inpatient - if more than 30% collapse, tension pneumothorax or underlying lung disease
. Tension pneumothorax is a medical emergency. Decompress as soon as possible.
GENERAL MEASURES
. Outpatient
. Bed rest
. Inpatient
. Monitoring blood pressure, pulse rate, respirations
. Oxygen at high concentration will accelerate rate of absorption by 4 times
. Treatment of any underlying condition
. Serial radiographs to document improvement
. Open pneumothorax - place dressing over wound. Secure only on three sides to avoid tension pneumothorax.
SURGICAL MEASURES
. Simple aspiration - fi rst step for primary spontaneous pneumothorax unless unstable. Insert 16 gauge cannula into 2nd anterior intercostal space at midclavicular line and attach a 3-way stopcock and 60 mL syringe. Withdraw air manually until no more can be aspirated. Close stopcock and CXR after 4 hours. Remove if reexpanded. Observe 2 more hours.
. Thoracotomy tube (16F to 22F) - Usually first step for secondary spontaneous pneumothorax. Insert in 4th,
5th or 6th intercostal space at midaxillary line and connect underwater seal. Clamp after 12 hours of no
bubbles.
. Tension pneumothorax - immediate decompression. Insert 19 gauge or larger needle into the second intercostal space at midclavicular line over superior aspect of rib to avoid vessels, and attach a 3-way stopcock. Use a large syringe to withdraw air. Follow with chest tube.
. Recurrent pneumothorax (more often occurs with larger pneumothoraces)
. Consider chemical pleurodesis with talc or other agents
. Consider thoracoscopy or video assisted thoracoscopy (VAT) following:
- 2 or more spontaneous pneumothoraces
- If lungs not expanded after 7 days therapy
- Persistent bronchopleural fi stula
- Recurrence of pneumothorax after pleurodesis
. Consider surgical correction for occupation or avocation that would put person at risk if pneumothorax
recurs (eg, pilot, diver)
. Open thoracotomy in patients who fail the VAT procedure
ACTIVITY
. Bed rest until re-expanded
. No air travel until x-ray normal
. Athletes with pneumothorax may return to their sport after 2-3 weeks of rest as symptoms allow; athletes
requiring inpatient care should have a follow up chest radiograph before returning to sport
DIET No special diet
PATIENT EDUCATION Stop smoking
DRUG(S) OF CHOICE
. Pleurodesis for recurrent pneumothorax:
. Intrapleural doxycycline, 5 mg/kg in a total volume of 50 mL. Intrapleural doxycycline is painful so
premedicate with short-acting benzodiazepine and give 4 mg/kg lidocaine in a total volume of 50 mL
intrapleurally before doxycycline is injected.
. Intrapleural talc, 5g in 250 mL isotonic saline; more effective than tetracycline derivatives, but safety
concerns exist
PATIENT MONITORING
β’ Outpatient management should include follow up chest x-ray to document resolution of pneumothorax. Typically in several days.
β’ Blood pressure, respiratory rate, arterial blood gases, for hospitalized patients
β’ After simple aspiration - clamp chest tube for 24 hours, then remove if no recurrence on x-ray. If lung not
fully re-expanded after 7 days, consider persistent air leak/bronchopleural fistula.
PREVENTION/AVOIDANCE No preventive measures known, but patients may avoid some risk factors, e.g., exposure to high altitudes, flying in unpressurized aircraft, scuba diving, smoking
POSSIBLE COMPLICATIONS
β’ Re-expansion pulmonary edema following suction
β’ Bronchopleural fi stulae requiring surgical repair
β’ Surgery indicated following 2 spontaneous pneumothoraces on the same side
β’ Myocardial infarction (MI)
β’ Respiratory arrest
EXPECTED COURSE/PROGNOSIS
β’ Air reabsorbed from small spontaneous pneumothorax in a few days
β’ Air reabsorbed from larger air space in 2-4 weeks
β’ Risk of recurrence is 30-50%