Pneumothorax
(plural pneumothoraces) is a collection of air or gas in the pleural cavity of the chest
between the lung and the chest wall. It may occur spontaneously in people without chronic lung
conditions ("primary") as well as in those with lung disease ("secondary"), and many pneumothoraces
occur after physical trauma to the chest, blast injury, or as a complication of medical treatment.[1][2] A
pneumothorax is a collection of free air in the chest outside the lung that causes the lung to collapse.
What are the types of pneumothorax?
A spontaneous pneumothorax, also referred to as a primary pneumothorax, occurs in the absence of a traumatic
injury to the chest or a known lung disease. A secondary (also termed complicated) pneumothorax occurs as a result
of an underlying condition. The major types of pneumothorax are:
Open pneumothorax results when a penetrating chest wound enables air
to rush in and cause the lungs to collapse.
Closed pneumothorax results when the chest wall is punctured or air leaks
from a ruptured bronchus (or a perforated esophagus) and eventually
ruptures into the pleural space.
Spontaneous pneumothorax occurs in a previously healthy individual with
no prior trauma. This is thought to be due to rupture of a bleb (a blister
containing air) on the surface of the lung. This spontaneous pneumothorax is
most frequent in people under the age of 40.
Pulmonary barotrauma occurs when a patient whose lung function is
being maintained mechanically may have air forced into the lungs, which
may rupture the pleural space.
Other things can cause pneumothorax. Air can enter the mediastinum (the
space in the center of the chest between the lungs), especially during an
asthmatic attack, and then rupture into the pleural space, causing a
pneumothorax. When a lung biopsy specimen is taken at the time of
bronchoscopy or during thoracentesis (removal of fluid from the pleural
space), the pleura lining the lung may be penetrated, causing a leak of air
which may then cause a pneumothorax.
What causes a pneumothorax?
Spontaneous pneumothorax is caused by a rupture of a cyst or a small sac (bleb) on the surface of the lung.
Pneumothorax may also occur following an injury to the chest wall such as a fractured rib, any penetrating injury (gun
shot or stabbing), surgical invasion of the chest, or may be deliberately induced in order to collapse the lung. A
pneumothorax can also develop as a result of underlying lung diseases, including cystic fibrosis,chronic obstructive
pulmonary disease (COPD), lung cancer, asthma, and infections of the lungs.
What are the signs and symptoms of pneumothorax?
Symptoms of a pneumothorax include chest pain that usually has a sudden onset. The pain is sharp and may lead to
feelings of tightness in the chest. Shortness of breath, rapid heart rate, rapid breathing, cough, and fatigue are other
symptoms of pneumothorax. The skin may develop a bluish color (termed cyanosis) due to decreases in
blood oxygen levels.
the symptoms of a pneumothorax are determined by the size of the air leak and the speed by
which it occurs; they may include chest painin most cases and shortness of breath in many. The
diagnosis can be made by physical examination in severe cases but usually requires achest X-
ray or computed tomography (CT scan) in milder forms. In a small proportion, the pneumothorax
leads to severe oxygen shortageand low blood pressure, progressing to cardiac arrest unless
treated; this situation is termed tension pneumothorax.
How is pneumothorax diagnosed?
Examination of the chest with a stethoscope reveals decreased or absent breath sounds over the affected lung. The
diagnosis is confirmed by chest x-ray.
How is a pneumothorax treated?
The treatment of pneumothorax depends on a number of factors, and may vary from discharge with early
follow-up to immediate needle decompression or insertion of a chest tube. Treatment is determined by the
severity of symptoms and indicators of acute illness, the presence of underlying lung disease, the
estimated size of the pneumothorax on X-ray, and in some instances also on the personal preference of
the person involved. In spontaneous pneumothorax, air travel is discouraged until it has completely
resolved.[4]
In traumatic pneumothorax, chest tubes are usually inserted (unless iatrogenic, see below). It is not yet
clear if there is a subgroup of patients with small pneumothoraces who do not require tube treatment and
could be managed conservatively. If mechanical ventilation is required, the insertion of a chest tube is
mandatory as it would increase the risk of tension pneumothorax.[2][12]
Tension pneumothorax is usually treated with urgent needle decompression. This may need to happen
before transport to hospital, and can be performed by an emergency medical technician or other trained
professional. The needle or cannula is left in place until a chest tube can be inserted.[3][13] Any open chest
wound is covered, as it carries a high risk of leading to tension pneumothorax, ideally with a dressing
called the Asherman seal, which appears to be more effective than standard "three-sided" dressing. The
Asherman seal is a specially designed device that adheres to the chest wall and allows air to escape but
not to enter the chest through a valve-like mechanism.[13]
A small pneumothorax without underlying lung disease may resolve on its own in one to two weeks. A larger
pneumothorax and a pneumothorax associated with underlying lung disease often require aspiration of the free air
and/or placement of a chest tube to evacuate the air. Possible complications of chest tube insertion include pain,
infection of the space between the lung and chest wall (the pleural space), hemorrhage (bleeding), fluid accumulation
in the lung, and low blood pressure (hypotension). In some cases, the leak does not close on its own. This is called a
bronchopleural fistula, and may require chest surgery to repair the hole in the lung.
