Pneumothorax

A pneumothorax is an abnormal collection of air in the pleural space between the lung
and the chest wall.

Pneumothorax” is the medical term for a collapsed lung. Pneumothorax occurs when air
enters the space around the lungs (the pleural space). Air can find its way into the pleural
space when there’s an open injury in the chest wall or a tear or rupture in the lung tissue,
disrupting the pressure that keeps the lungs inflated.

Risk factors for a pneumothorax

The risk factors are different for a traumatic and spontaneous pneumothorax.

Risk factors for a traumatic pneumothorax include:

 playing hard contact sports, such as football or hockey

 performing stunts that may cause damage to the chest
 having a history of violent fighting
 having a recent car accident or fall from a height
 recent medical procedure or ongoing assisted respiratory care

The people at highest risk for a PSP are those who are:

 young
 thin
 male
 between the ages of 10 and 30
 affected by congenital disorders like Marfan’s syndrome
 smokers
 exposed to environmental or occupational factors, such as silicosis
 exposed to changes in atmospheric pressure and severe weather changes

The main risk factor for SSP is having previously been diagnosed with a lung disease. It’s
more common in people over 40.

Causes of pneumothorax

Causes of ruptured or injured chest or lung walls can include lung disease, injury from a
sport or accident, assisted breathing with a ventilator, or even changes in air pressure that

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an individual experience when scuba diving or mountain climbing. Sometimes the cause
of a pneumothorax is unknown.

Types of pneumothorax

The two basic types of pneumothorax are traumatic pneumothorax and nontraumatic
pneumothorax. Either type can lead to a tension pneumothorax if the air surrounding the
lung increases in pressure. A tension pneumothorax is common in cases of trauma and
requires emergency medical treatment.

Traumatic pneumothorax

Traumatic pneumothorax occurs after some type of trauma or injury has happened to the
chest or lung wall. It can be a minor or significant injury. The trauma can damage chest
structures and cause air to leak into the pleural space.

Examples of injuries that can cause a traumatic pneumothorax include:

 trauma to the chest from a motor vehicle accident

 broken ribs
 a hard hit to the chest from a contact sport, such as from a football tackle
 a stab wound or bullet wound to the chest
 medical procedures that can damage the lung, such as a central line placement,
ventilator use, lung biopsies, or CPR

Changes in air pressure from scuba diving or mountain climbing can also cause a
traumatic pneumothorax. The change in altitude can result in air blisters developing on
the lungs and then rupturing, leading to the lung collapsing.

Quick treatment of a pneumothorax due to significant chest trauma is critical. The

symptoms are often severe, and they could contribute to potentially fatal complications
such as cardiac arrest, respiratory failure, shock, and death.

Nontraumatic pneumothorax

This type of pneumothorax doesn’t occur after injury. Instead, it happens spontaneously,
which is why it’s also referred to as spontaneous pneumothorax.

There are two major types of spontaneous pneumothorax: primary and secondary.
Primary spontaneous pneumothorax (PSP) occurs in people who have no known lung
disease, often affecting young males who are tall and thin. Secondary spontaneous

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pneumothorax (SSP) tends to occur in older people with known lung problems.

Some conditions that increase the risk of SSP include:

 chronic obstructive pulmonary disease (COPD), such as emphysema or chronic

bronchitis
 acute or chronic infection, such as tuberculosis or pneumonia
 lung cancer
 cystic fibrosis, a genetic lung disease that causes mucus to build up in the lungs
 asthma, a chronic obstructive airway disease that causes inflammation

Spontaneous hemopneumothorax (SHP) is a rare subtype of spontaneous pneumothorax.

It occurs when both blood and air fill the pleural cavity without any recent trauma or
history of lung disease.

Pathophysiology

A trauma occurs to the pleural space and air accumulates within the pleural space
around the lung,

This air collection puts pressure on the lung tissue

The air within the space compresses and collapses the lung

A collapsed, non-expandable lung cannot take in air and therefore cannot

participate in oxygenation and gas exchange,

Progressive pneumothorax with one way valve or no exit for air (termed as
pneumothorax) further puts pressure on heart, shifts mediastinum and may result in
life threatening condition such as decreasing cardiac output and compromising
circulation.

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Sign and Symptoms of a pneumothorax
The symptoms of a traumatic pneumothorax often appear at the time of chest trauma or
injury, or shortly afterward. The onset of symptoms for a spontaneous pneumothorax
normally occurs at rest. A sudden attack of chest pain is often the first symptom.

Other symptoms may include:

 a steady ache in the chest

 shortness of breath, or dyspnea
 breaking out in a cold sweat
 tightness in the chest
 pericarditis
 pneumonia
 pleuritis
 pulmonary embolism
 musculoskeletal injury (when referred to the shoulder) or an intra-abdominal
process (when referred to the abdomen).
 Pain can also simulate cardiac ischemia, although typically the pain of cardiac
ischemia is not pleuritic.
 turning blue, or cyanosis
 severe tachycardia, or a fast heart rate

Complications
The problems encountered when treating pneumothorax are

 Air leaks

 Failure of the lung to expand

 Re-expansion pulmonary edema

 Respiratory or cardiac arrest

 Hemopneumothorax

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  Empyema

 Pneumomediastinum

 Pneumopericardium

 Pneumoperitoneum

Air leaks are usually due to the primary defect—ie, continued leakage of air from the
lung into the pleural space—but can be due to air leaking around the chest tube insertion
site if the site is not properly sutured and sealed. Air leaks are more common in
secondary than in primary spontaneous pneumothorax. Most resolve spontaneously in < 1
week.

Failure of the lung to re-expand is usually due to one of the following:

 Persistent air leak

 Endobronchial obstruction

 Trapped lung

 Mal-positioned chest tube

Blood pleurodesis (a blood patch), endobronchial valves, thoracoscopy, or thoracotomy

should be considered if an air leak or an incompletely expanded lung persists beyond 1
week.

Re-expansion pulmonary edema occurs when the lung is rapidly expanded, as occurs
when a chest tube is connected to negative pressure after the lung has been collapsed for
> 2 days. Treatment is supportive, with oxygen, diuretics, and cardiopulmonary support
as needed.

Diagnosing pneumothorax
Diagnosis is based on the presence of air in the space around the lungs. A stethoscope
may pick up changes in lungs sounds, but detecting a small pneumothorax can be
difficult. Some imaging tests may be hard to interpret due to the air’s position between
the chest wall and lung.

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Imaging tests commonly used to diagnose pneumothorax include:

 an upright posteroanterior chest radiograph

 a CT scan
 a thoracic ultrasound

Treatment of pneumothorax
Treatment will depend on the severity of the condition. It will also depend on whether
patient has experienced pneumothorax before and what symptoms he/she is experiencing.
Both surgical and nonsurgical treatments are available.

Treatment options can include close observation combined with the insertion of chest
tubes, or more invasive surgical procedures to resolve and prevent further collapse of the
lung. Oxygen may be administered.

Observation

Observation or “watchful waiting” is typically recommended for those with a small PSP
and who aren’t short of breath. In this case, doctor will monitor the condition on a regular
basis as the air absorbs from the pleural space. Frequent X-rays will be taken to check if
the lung has fully expanded again. Doctor will likely instruct the patient to avoid air
travel until the pneumothorax as completely resolved.

Routine physical activity hasn’t been shown to worsen or delay healing of a

pneumothorax. However, it’s often advised that intense physical activity or high-contact
sports be delayed until the lung is fully healed and the pneumothorax is gone.

A pneumothorax can cause oxygen levels to drop in some people. This condition is called
hypoxemia. If this is the case, the doctor will order oxygen supplementation along with
activity limitations.

Draining excess air

Needle aspiration and chest tube insertion are two procedures designed to remove excess
air from the pleural space in the chest. These can be done at the bedside without requiring
general anesthesia.

Needle aspiration may be less uncomfortable than placement of a chest tube, but it’s also
more likely to need to be repeated.

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For a chest tube insertion, doctor will insert a hollowed tube between ribs of patient. This
allows air to drain and the lung to re-inflate. The chest tube may remain in place for
several days if a large pneumothorax exists.

Pleurodesis

Pleurodesis is a more invasive form of treatment for a pneumothorax. This procedure is

commonly recommended for individuals who’ve had repeated episodes of pneumothorax.

During pleurodesis, doctor irritates the pleural space so that air and fluid can no longer
accumulate. The term “pleura” refers to the membrane surrounding each lung.
Pleurodesis is performed to make the lungs’ membranes stick to the chest cavity. Once
the pleura adheres to the chest wall, the pleural space no longer expands, and this
prevents formation of a future pneumothorax.

Mechanical pleurodesis is performed manually. During surgery, surgeon brushes the

pleura to cause inflammation. Chemical pleurodesis is another form of treatment. The
doctor will deliver chemical irritants to the pleura through a chest tube. The irritation and
inflammation cause the lung pleura and chest wall lining to stick together.

Surgery

Surgical treatment for pneumothorax is required in certain situations. Patient may need
surgery if he/she have had a repeated spontaneous pneumothorax. A large amount of air
trapped in the chest cavity or other lung conditions may also warrant surgical repair.

There are several types of surgery for pneumothorax. One option is a thoracotomy. A
thoracotomy is surgery to open your chest. During this procedure, a surgeon makes an
incision in the chest wall between your ribs, usually to operate on your lungs. Through
this incision, the surgeon can remove part or all of a lung.

Another option is thoracoscopy, also known as video-assisted thoracoscopic surgery

(VATS). The surgeon inserts a tiny camera through the chest wall to help them see inside
the chest. A thoracoscopy can help the surgeon decide on the treatment for the
pneumothorax. The possibilities include sewing blisters closed, closing air leaks, or
removing the collapsed portion of the lung, which is called a lobectomy.

Pharmacological management

1. Local Anesthetics

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Lidocaine
Mechanism of Action
Local anesthetics prevent generation/conduction of nerve impulses by reducing sodium
permeability and increasing action potential threshold; inhibits depolarization, which
results in blockade of conduction.

Uses
Local anesthetic agents are used for analgesia for thoracentesis and chest tube
placement.This drug acts by decreasing the permeability to sodium ions in
neuronal membranes, resulting in the inhibition of depolarization, and blocking
the transmission of nerve impulses.

Adverse affect
 Arrhythmias
 Bradycardia
 Edema
 Hypotension
 Heart block
 Confusion
 Drowsiness
 Dizziness
 Difficulty swallowing
 Nausea
 Vomiting
 Muscle twitching/ tremors

2. Opiate Analgesics

a. Fentanyl citrate (sublimaze)

Mechanism of Action

Narcotic agonist-analgesic of opiate receptors; inhibits ascending pain pathways, thus

altering response to pain; increases pain threshold;
produces analgesia, respiratory depression, and sedation.

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Indications
Opiate analgesic agents are used for pain control. Most analgesics have sedating
properties, which are beneficial for patients with painful skin lesions.
These drugs are important in the initial placement of thoracostomy tubes and for
controlling pain after the procedure.

Adverse Effects

 Asthenia
 Constipation
 Dry mouth
 Nausea
 Somnolence
 Sweating
 Vomiting
 Abdominal pain
 Anorexia
 Anxiety
 Fatigue
 Hallucinations

3. Benzodiazepines

a. midazolam 
Brand and Other Names: Seizalam, Versed (DSC)

Mechanism of Action

Binds receptors at several sites within the CNS, including the limbic system and reticular
formation; effects may be mediated through GABA receptor system; increase in neuronal
membrane permeability to chloride ions enhances the inhibitory effects of GABA; the

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 shift in chloride ions causes hyperpolarization (less excitability) and stabilization of the
neuronal membrane.

Indication

Benzodiazepines are used for conscious sedation. These agents are useful for
premedication before pleurodesis/sclerotherapy or placement of a thoracostomy tube.

Adverse Effects

 Decreased respiratory rate

 Apnea
 Drowsiness
 Seizure-like activity
 Nausea/vomiting
 Cough
 Pain at injection site

Nursing Interventions and Rationales

 Auscultate Breath Sounds

Breath sounds may be diminished or absent over the hemo/pneumo. A thorough
assessment can identify the problem before it progresses. This will also help to determine
if the lung has appropriately reinflated after intervention.

 
 Assess respiratory status (rate)

Patients may have rapid, shallow breathing due to collapsed lung

 
 Assess chest expansion
 Chest expansion may be asymmetrical due to collapsed lung. This is especially
prominent in a tension pneumothorax which is a medical emergency.

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 Assess hemodynamics and VS
 Tension pneumothorax can cause a significant decrease in cardiac output and is a
medical emergency. Early intervention is key to good outcomes.

 
 Place in high-fowler’s position or position of comfort. Good-lung down
positioning.
 High-fowler’s position can improve respiratory effort and improve oxygenation. Good
lung down positioning helps to improve perfusion to good lung and promote reinflation
of bad lung.

 
 Assess oxygenation and provide supplemental O2 as appropriate
 

Collapsed lung cannot participate in oxygenation or gas exchange, therefore

supplemental oxygen is typically required.

 
 Administer analgesics
 Pain can cause patients to breathe too shallow – putting them at risk for atelectasis. Pain
relief can encourage deeper breathing.

 
 Educate patient on chest expansion exercises (IS, TCDB)
 Rapid, shallow breathing, plus a collapsed lung, means a high risk for atelectasis and
pneumonia. Deep breathing exercises like Incentive Spirometry and Turn, Cough, Deep
Breathe, can help re-inflate the lungs.

 
 Prepare patient for Chest Tube Insertion or Thoracentesis. Provide appropriate
post-procedure care.
 Chest tubes are placed to remove the air or blood from the pleural space. A thoracentesis
is performed to drain fluid or blood from the pleural space. Both procedures will allow
for re inflation of the lung. Check facility policy for post-procedure monitoring. Review
Chest Tube Management and Thoracentesis lesson for more details.

 
References

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 Pneumothorax overview available from
https://emedicine.medscape.com/article/424547-overview by Brian J Daley,

 Pharmacological management available from

https://emedicine.medscape.com/article/424547-medication by Brian J Daley

 Pneumothorax available from https://en.wikipedia.org/wiki/Pneumothorax

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