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Quick Recertification Series

JA M I S. S M I T H, M PA , PA-C

PNEUMOTHORAX to percussion, decreased tactile fremi- >>QUESTIONS & ANSWERS<<
tus, and diminished breath sounds are
›GENERAL FEATURES present on the affected side. 1. Which of the following is not an ex-
• Pneumothorax is an abnormal • In a tension pneumothorax, findings amination finding in pneumothorax?
collection of air in the pleural space may include a displaced point of a. Decreased tactile fremitus
and classified as spontaneous (pri- maximal impulse, tracheal devia- b. Tachypnea
mary or secondary) or traumatic. tion, mediastinal shift, and hemody- c. Decreased resonance to percussion
• Primary spontaneous pneumotho- namic instability. d. Decreased breath sounds on the
affected side
rax usually occurs in the absence of
underlying lung disease. Patients are ›DIAGNOSIS Answer: c
classically described as tall men, aged • A visceral pleural line on the chest Explanation: When air leaks into the
20 to 40 years, who are smokers. radiograph is diagnostic and may be pleural space, the lung recoils from
• Secondary pneumothorax occurs due noted only on the expiratory view. the chest wall and the increased air
to lung pathology, including chronic • Chest CT may demonstrate the creates a hyperresonant sound to
obstructive pulmonary disease, cystic cause of a spontaneous secondary percussion.
fibrosis, tuberculosis, asthma, intersti- pneumothorax.
tial lung disease, menstruation, and • In a tension pneumothorax, the 2. Which of the following is not a
Pneumocystis jirovecii pneumonia. diagnosis should be made based cause of secondary spontaneous
• Traumatic pneumothoraces occur on the history and physical ex- pneumothorax?
with blunt or penetrating trauma, amination; however, radiographs a. Chronic obstructive pulmonary
including iatrogenic subclavian line would reveal mediastinal shift disease
b. Pneumocystis jirovecii pneumonia
placement or thoracentesis or fol- away from the affected side with c. Penetrating lung trauma
lowing pleural or lung biopsy. a large amount of air in the d. Cystic fibrosis
• Tension pneumothorax is a medical pleural space.
emergency and occurs in the setting • Left-sided primary pneumothorax Answer: c
of penetrating trauma, lung infection, may produce QRS axis and pre- Explanation: Penetrating lung trauma
and cardiopulmonary resuscitation cordial T-wave changes that can be will cause a traumatic pneumothorax
or positive end expiratory pressure. misinterpreted as an MI. or, if large enough, a tension pneu-
mothorax with hemodynamic instabil-
• Following spontaneous pneumotho-
ity, mediastinal shift away from the
rax, 30% of patients experience a ›TREATMENT affected side, and tracheal deviation.
recurrence after either observation • Treatment of primary spontaneous
or tube thoracotomy treatment. pneumothorax depends on the size of
the air collection in the pleural space. • Since most traumatic pneumotho-
›CLINICAL ASSESSMENT – A small pneumothorax will typi- races occur concomitantly with
• Patient will typically complain of cally resolve on its own. hemothorax, treatment includes a
dyspnea and may have varying de- – Supplemental oxygen therapy large-bore chest tube with water seal
grees of pleuritic chest pain. Severity increases the rate of reabsorption. and drainage with suction.
of the symptoms generally correlates – Large pneumothorax: A small- • In an unstable patient with a tension
to severity of the pneumothorax. bore catheter attached to a pneumothorax, immediate needle
• If the pneumothorax is small (<15% Heimlich valve may be used, with decompression should be performed
of a hemithorax), patient may have outpatient follow-up. with a 14- to 16-gauge needle
normal findings on examination. – If the pneumothorax fails to inserted into the second intercostal
• Patients with a larger pneumothorax resolve, a traditional chest tube space. Ultimately, the patient should
may have tachypnea and tachycardia. attached to water seal drainage have tube thoracostomy and water
On lung examination, hyperresonance with suction may be used. seal drainage with suction.
• Secondary spontaneous pneumo- • Recurrent spontaneous pneumothora-
thorax requires standard chest tube ces may require surgical resection of
Jami Smith is an assistant professor and the ac-
ademic coordinator of the PA program at Arcadia
drainage using water seal drainage blebs or pleurodesis with talc. JAAPA
University, Glenside, Pennsylvania. She practices with suction and admission to the
emergency medicine in the Philadelphia area. hospital. The underlying cause Dawn Colomb-Lippa, MHS, PA-C;
No relationships to disclose. should then be addressed. Amy M. Klingler, MS, PA-C, department editors • MAY 2013 • 26(5) • JAAPA 59