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Pneumothorax

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Pneumothorax, Traumatic Pneumothorax

  • See Also
  1. Blunt Chest Trauma
  2. Spontaneous Pneumothorax
  • Epidemiology
  1. Prevalence: 77 per 100,000 hospital visits in U.S. per year
  • Types
  1. Spontaneous Pneumothorax (Simple Pneumothorax)
    1. Primary Spontaneous Pneumothorax (no underlying lung disease known)
    2. Secondary Spontaneous Pneumothorax (e.g. underlying Asthma, COPD, ILD, Cystic Fibrosis)
  2. Traumatic Pneumothorax
    1. Traumatic Open Pneumothorax (communicating Pneumothorax or Sucking Chest Wound)
    2. Traumatic Closed Pneumothorax
    3. Iatrogenic Pneumothorax (from procedure, e.g. Central Line Placement)
  3. Complicated subtypes
    1. Hemothorax
    2. Tension Pneumothorax
  • Pathophysiology
  1. Air enters potential space between the visceral pleura and the parietal pleura
  2. Tension Pneumothorax may result
    1. Air accumulates in the pleural space with each breath taken
    2. Pressure compresses the lung tissue and inhibits venous return with secondary decreased Cardiac Output
  • Causes
  • Adults
  1. Blunt Chest Trauma
    1. Most common cause of sports-related Pneumothorax
    2. Consider other concurrent injuries (e.g. Pulmonary Contusion)
  2. Penetrating Chest Trauma
  3. Spontaneous Pneumothorax
  4. Iatrogenic Pneumothorax (secondary to medical procedure)
  • Risk Factors
  • Newborns (1-3% of births)
  1. Premature Infant
  2. Respiratory distress syndrome
  3. Meconium Aspiration Syndrome
  • Symptoms
  1. Dyspnea
  2. Pleuritic Chest Pain
  3. Cough
  • Signs
  1. See Spontaneous Pneumothorax (Simple Pneumothorax)
  2. See Open Pneumothorax
  3. See Tension Pneumothorax
  4. Decreased breath sounds
  5. Hyperresonance to percussion
  6. Hypoxia
  • Imaging
  1. See Pneumothorax Imaging
  2. Chest XRay
    1. Upright and end expiratory films are preferred
    2. Supine Chest XRay is unreliable and likely to yield a False Negative study
    3. Test Specificity is high (but caution with blebs)
    4. Even large pneumothoraces on CT may be missed on Chest XRay
      1. Test Sensitivity: 47%
      2. Rodriguez (2019) Ann Emerg Med 73(1):58-65 +PMID:30287121 [PubMed]
  3. Bedside Ultrasound (POCUS)
    1. See Lung Ultrasound for Pneumothorax (Sliding Lung Sign)
    2. Sliding Lung Sign evaluation is part of Extended FAST Exam
  4. Chest CT
    1. See Nexus Chest CT Decision Rule in Blunt Trauma
    2. Gold standard in Pneumothorax (but avoid delaying management for CT in most cases)
    3. Indicated where Chest XRay cannot distinguish bleb in COPD from Pneumothorax
    4. Identifies associated Traumatic Injury (e.g. multiple contiguous Rib Fractures)
  • Precautions
  1. Until a Chest Tube is placed, Tension Pneumothorax is a risk
  2. Do not perform Positive Pressure Ventilation, general Anesthesia or air transport until Pneumothorax decompression
  3. Consider Esophageal Rupture in the injured patient with a left Pneumothorax or Hemothorax without a Rib Fracture
  • Management
  1. See Trauma Evaluation
  2. See Spontaneous Pneumothorax (includes disposition and restrictions)
  3. See Tension Pneumothorax
  4. See Open Pneumothorax
  5. See Hemothorax
  6. Non-Traumatic Pneumothorax
    1. See Spontaneous Pneumothorax
  7. Traumatic Pneumothorax
    1. Chest Tube at 4-5th intercostal space at the mid-axillary line
      1. Confirm Chest Tube placement with Chest XRay
    2. Hemothorax may be treated with 28 F Chest Tube
    3. Small Caliber Chest Tube (14 F) Indications
      1. Contraindicated in Hemothorax and hemopneumothorax (use 28 F in these cases)
      2. Small Caliber Chest Tubes appear safe in uncomplicated Traumatic Pneumothorax
        1. Small Caliber Chest Tubes are as effective and significantly less painful than standard Chest Tubes
        2. Kulvatunyou (2014) Br J Surg 101(2): 17-22 [PubMed]
  • Complications
  1. Tension Pneumothorax
  • References
  1. Noppen (2003) Respiration 70(4): 431-8 [PubMed]
  2. Alshaqaq (2026) Crit Dec Emerg Med 40(3): 4-12
  3. Majoewsky (2012) EM:RAPC3 2(2): 3-4
  4. Tranchell (2013) Crit Dec Emerg Med 27(7): 11-8