Pneumothorax

- CME –
Mohamed Siruhan

Supervisor: Dr. Ian

Outline

• Classification of pneumothorax
• Epidemiology
• Pathophysiology and etiology
• Clinical features
• Radiological features
• Management of spontaneous pneumothorax – case based
• Recommendations on air travel and diving.
• Practice questions
Etiological Classification of pneumothorax
• Spontaneous
• Primary: Pneumothorax occurring in persons without clinically apparent lung disease
• Secondary: Pneumothorax occurring in the setting of underlying pulmonary disease
• Traumatic
• Penetrating chest injury
• Blunt chest injury
• Iatrogenic Pneumothorax
• Transthoracic needle aspiration
• Placement of catheter in subclavian or jugular vein
• Thoracentesis and pleural biopsy
• Mechanical ventilation
Etiology - Secondary spontaneous
pneumothorax
• Airway disease • Interstitial Lung Disease
• COPD • Sarcoidosis
• Idiopathic Pulmonary fibrosis
• Cystic fibrosis • Langerhans’ cell granulomatosis
• Asthma • Lymphangioleiomyomatosis
• Infectious lung diseases • Tuberous sclerosis
• Tuberculosis • Connective Tissue disease
• Rhumatoid arthritis
• Pneumocystis • Ankylosing spondylitis
pneumonia • Polymyosistis and dermatomyositis
• Necrotizing pneumonia • Scleroderma
(anaerobic, Gram negative, • Marfan’s syndrome
staphylococcus) • Ehlers–Danlos syndrome
• Cancer
• Sarcoma
• Lung cancer
• Catamenial pneumothorax – Pneumothorax related to mensturation
• Postulated to occur in the setting of endometriosis affecting the lung.
Epidemiology of pneumothorax
Incidence(/100000) Age group predisposition Recurrence Symptoms
Male female

Primary spontaneous 18-28 1.2 – 6 Age 10 -30 years Thin 16 – 52% Symptoms
Rare in >40 years Tall less
Smoking (up to 20x)
Secondary spontaneous 6.3 2 60 – 65 years COPD (26/100000) 39 – 47% Most often
HIV ( PCP) symptomatic

Catamenial 30 – 40 yrs H/O endometriosis 50% with Within 72

Hormone hours of
therapy onset of
menses
Pathophysiology of primary spontaneous
pneumothorax (PSP)
• Subpleural bullae/blebs/porosities
• 76 -100% on VATS (Video assisted thoracoscopic surgery )1
• All most all the patients undergoing thoracotomy 1
• 79- 96% of patients on contralateral lung, those who were managed by
sternotomy.1
• 89% ipsilateral bullae and blebs on CT ( compared to 20% age and smoking
matched controls)1
• Subpleural bullae formation remains speculative
• Smoking related influx of neutrophils and macrophages
• Degredation of elastic fibers
• Imbalance in the protease-antiprotease and oxidant-antioxidant systems.1

1. Spontaneous pneumothorax. Sahn SA, Heffner JE N Engl J Med. 2000;342(12):868

Pathophysiology…(PSP)
• Inflammation induced obstruction of the small airways increases
alveolar pressure, causes air leak in to interstitium
• Air moves to hilum, causing pneumomediastium.
• As pneumomediastinum causes rise in pressure and rupture of
mediastinal parietal pleura, causing pneumothorax.
Pathophysiology…..(PSP)

Hypoxemia
Increase alveolar- Low ventilation-
Reduced FVC arterial Oxygen perfusion ration ( Hypercapnia occurs
gradient in secondary spontan.
(V/Q) and Shunting
pneumothorax)
Pathophysiology in secondary spontaneous
pneumothorax

Rupture of
Alveolar pressure > Air in the interstitium
mediastinal parietal
traverses to hilum
interstitium pressure ( and cause
pleura and
pneumothorax
Alveolar rupture) pneumomediastinum
develops

Crosses to
Air from pleural cavity
Pneumothorax
ruptured alveoli via necrosed
lung (eg. PCP)
Thoracoscopic images
Subpleural blebs
Air filled spaces between the lung
parenchyma and the visceral pleura

Subpleural bullae
Air filled spaces within the lung
parenchyma itself
Thoracoscopic images……
Blebs Bullae
 • Smoking and the Increased Risk of Contracting Spontaneous
Pneumothorax Bense, M.D., FC.C.P.;* Gunar Ekiund, Ph.D., Odont. D.
and Lars-Gösta Wiman, M.D., EC.C.P1- CHEST I 92 I 6 I DECEMBER, 1987

1.Smoking and the increased risk of contracting spontaneous pneumothorax.Bense L, Eklund G, Wiman LGChest.
1987;92(6):1009.
Relative risk of spontaneous
pneumothorax for males and
females based on total population
according to daily cigarette consumption.

• Life time relative risk of first

spontaneous pneumothorax
among smokers
• 9 (Women),
• 22(men) 1.

1.Smoking and the increased risk of contracting spontaneous

pneumothorax.Bense L, Eklund G, Wiman LGChest. 1987;92(6):1009.
Clinical presentation
• Ipsiliateral pleuritic chest pain
• Acute dyspnea
• Symptoms usually resolve within 24 hours, even if the pneumothorax
remains untreated and does not resolve1
• Patients with a small pneumothorax (<15%) may have a normal physical
examination1.
• Tachycardia is the most common finding1.
• Clinical signs: decreased movement of the chest wall, a hyperresonant
percussion note, diminished fremitus, and decreased or absent breath
sounds on the affected side.
• Sever tachycardia, Hypotension, cyanosis raise suspicion for tension
pneumothorax
1. Spontaneous pneumothorax. Sahn SA, Heffner JE N Engl J Med. 2000;342(12):868
standard PA erect CXR - Radiological features
• Visceral pleural line – necessary to make a
definitive diagnosis
• Visceral pleural line parallels the curvature
of the chest wall (ie. Convex outwards)
• Pneumothorax mimic conditions do not
maintain this spatial relationship. Eg.bullae,
artifacts.
• Usually there is absence of lung markings
peripheral to pleural line.
• Pleural adhesions – lung markings may be
visible beyond the pleural line
Large Bullae
Radiological features CXR…
• Airfluid interface when present
confirms presence of pneumothorax.
• Supine CXR - Air collects anteriorly and
inferiorly
• Deep sulcus sign
• Displaces costopherenic sulcus
inferiorly
• Increased lucency of
costopherenic sulcus
• Double diaphragm sign
Luftsichel, “air crescent,” sign

• Seen in setting of left upper lobe

atelectasis
• indirect sign of overinflation
characterized by hyperexpansion of
the superior segment of lower lobe
on the left side and its insinuation
between collapse upper lobe and
mediastinum.
• Tension pneumothorax
• Shift of mobile
mediastinal structures to
the opposite side
• Inversion of
hemidiaphragm
• Flatting of heart contour
on the side under
tension.
Other modalities
• Lateral X-rays
• Expiratory films
• Supine and lateral decubitus X – rays

• Less sensitive and not recommended routinely based on current

guidelines
Imaging…
• USG
• Main value in managing supine trauma patients

• CT scan
• This can be regarded as the ‘gold standard’ – able to detect
small pneumothorax, estimate size
• Identify aberrant chest drain placement.
• To determine the best treatment for persistent air leaks or to
plan a surgical intervention. (ACCP)
Size of pneumothorax

• Apex – cupola
distance(ACCP) - 2001
• a ≥ 3cms small
• a < 3cms large

• Interpleural distance at
hilum (BTS) - 2010
• b ≥ 2cms small
• b < 2cms large
Size of pneumothorax…..
THE SPANISH SOCIETY OF PULMONOLOGY AND THORACIC SURGERY (SEPAR)

Partial Complete without lung collapse Complete with total lung collapse
CASE 1
• 34yrs/Malay/Male
• No known medical illness
• Ex-smoker 20 pack years (
stopped 4/12, now on e-
cigarettes)
• C/O Shortness of breath
and left sided pleuritic chest
pain x 3 days
O/E
• Mildly tachypnoeic RR
24/min
• Pulse: 78/min BP 147/85
mmHg SpO2 100% NP
• Lungs: Reduced air entry on
left side, hyperresonant on
percussion.
CASE 1.. 34yrs/Male/ex-smoker

CXR – on presentation CXR – post left chest tube

CASE 1.. 34yrs/Male/ex-smoker

CXR – post chest tube removal D4 CXR – Post chest tube reinsertion
CASE 1.. 34yrs/Male/ex-smoker

CT – pre op

CXR – Post op (VATS)

Management and Outcome
• Diagnosis:
• Primary spontaneous pneumothorax
• Management
• Chest Tube insertion
• Gumco suction D2
• Chest tube removal on D4 and reinsertion due to recurrence ( persistant air
leak)
• VATS ( Video assisted thoracosopic surgery)
• Outcome
• Discharged well on D2 post op.
• Lung fully expanded and asymptomatic.
Management issues……..controversies and pitfalls
• General measures ?
• Use of High flow oxygen?
• Will you aspirate or insert chest tube?
• Admit or Discharge?
• Apply suction after Chest tube?
• Will you clamp the chest tube, prior to its removal?
• When will surgical referral needed?
• Surgical options available?
• Chemical pleurodesis as an alternative to surgery?
General measures
• Adequate analgesia – for pneumothorax and to cover for chest drain etc.

• Bed rest - There is no evidence that confining the patient to bed favors air
absorption or lung expansion (ACCP)

• Supplemental oxygen:- (Grade B recommendation)

• Spontaneous rate of reabsorption 1.25% to 1.8% (50-75 mL) of the total volume/24
hours
• Supplemental oxygen increases the rate of absorption by a factor of 41
• It reduces partial pressure of nitrogen in the pleural capillaries. And enhances the
reabsorption of air in the pleural cavity.

1.British Medical Journal, 1971, 4, 86-8 T. C. NORTHFIELD

General measures…..
• High Flow Oxygen (for example, 10 L/min), is recommended
• Caution in COPD - risk of hypercapnia

• Cessation of smoking.
 Oxygen therapy for
spontaneous pneumothorax1.
• Group 1 – (12 males, Room air)
• Group 2 - 10 patients received Air and
oxygen(16 litres/min) alternatively
• 9- 38 hours of oxygen alternate with room air.
• FiO2 not measured but estimated to be higher
than 50 -60% and unlikely to be 100%
• Oxygen therapy resulted in a 4 fold
increase in the mean rate of
absorption(P<0.01).
• Pneumothorax < 30% ( 2.2 fold) (P<0.01).
• Pneumothorax >30% ( 5.2 fold) (P<0.01).

1.British Medical Journal, 1971, 4, 86-8 T. C. NORTHFIELD

Oxygen therapy for spontaneous pneumothorax1

• The calculated time for full re-expansion with

daily oxygen therapy ranged from 3 -8 days,
with a mean of 5 days.

1.British Medical Journal, 1971, 4, 86-8 T. C. NORTHFIELD

Light’s index
 ACCP 2001 BTS 2010
Drainage Yes • Majority need drainage
• Minimally symtptomatic - conservative.
Admission • Most patients need admission Admission required
• Selected patients may be discharged with small bore
catheter and Heimlich valve if lung has expanded
Method of drainage • Under water seal • Needle (14-16 G) aspiration (NA) ( One
• Heimlich valve attempt)
• If failed NA small bore chest drain(<14)
Applying suction • If lung fails to reexpand quickly (good consesnsus) • When persistant air leak is suspected
• Immediately after under water seal ( some (48hrs)
consensus) • Addition of suction too early may cause
Reexpansion Pulmonary oedema)
• Not routinely recommended
• low pressure High Volume ( -10 to – 20
cmH2O)
Size of chest tube • Chest tube 16 – 24 F Needle (14 – 16 G)
• Chest tube 24 – 28 F ( Positive pressure ventilation / Chest Tube ( <14 F)
large air leak) Small bore catheter
• Small bore catheter
 ACCP 2001 BTS 2010
Chest Tube removal • Staged manner
- Confirm no persisting leak ( No more bubbling)
- CXR – Confirm resolution
- Stop any suction if applied
• Regardless of clamping, CXR is recommended after 5
– 12 hrs post last evidence of air leak (62% panel
members)
Chest Tube clamping • 53% of panel members would never clamp a chest
tube
• Remaining panel members would clamp after 4hrs of
last evidence of air leak,
Surgical opinion • Observe for 4 days • 3-5 days of persisting air leak
• After 4 days, need to evaluate for surgery
Preferred Surgical • Thoracoscopy is the preferred management • Open thoracotomy and pleurectomy
methods • If Unfit or refuse for surgery chemical pleurodesis (recurrence 1%)
• VATS with pleurectomy and pleural
abrasion is better tolerated (recurrenc
5%)
Agent for pleurodesis • Doxycycline, Talc slurry • Tetracycline, Talc
CASE 2
• 78yrs/Chinese/male • O/E:
• ex-smoker (80 pack years) • Tachypnoeic
• Pulse 110/min
• COPD stage III • BP: 200/70mmHg
• recent hospitalization for CAP and
• RR: 30 /min
AECOPD
• Lungs; reduced air entry bilateral,
• IHD – 50% LAD ( angiogram) bilateral rhonchi and prolonged
• Presented with History of cough, expiratory phase.
chest pain and hemoptysis x 2/7
• ABG: pH 7.4 pco2: 35 Hco3: 27.6
pO2:67
CASE 2… – 78/Male BGx: COPD stage III

CXR on previous admission 1 month ago CXR current

CASE2.. 78yrs/Male BGx COPD stage III -
Discussion
• Diagnosis
• Acute Management
• Surgical management – to prevent recurrence
• Medical management – to prevent recurrence
Management and outcome!
• Left side Chest Tube insertion
• Suction
• Chest tube removal on Day 6 after
full expansion confirmed on CXR

• Plan for pleurodesis after CT scan

as patient unfit for surgery

• Outcome: Patient died on Day 8

Cause of death: Acute
coronary Syndrome
CASE 3
• 19 years / Male
• No known medical illness
• Non-smoker
• Acute onset Shortness of
breath and Right sided chest
pain for 2 days
• O/E:
HR: 130/min BP 140/80mm Hg
Tachpnoeic RR: 40/minute
Lungs: Reduced breath sound on
Right side with Hyperresonance
on percussion
Chest X-Ray on arrival CXR post chest tube – 6hrs
• Diagnosis:
• Tension
Pneumotho
Chest – X-ray rax
• Management
• Emergency
Chest tube
insertion
• Outcome
• Discharged
Tension pneumothorax
• Pathophysiology
• One-way valve system at the breach permitting air to enter the pleural cavity
during inspiration but preventing egress of air during expiration

• Increase in the intrapleural pressure such that it exceeds atmospheric

pressure for much of the respiratory cycle.

• Impaired venous return and reduced cardiac output results in the typical
features of hypoxemia and hemodynamic compromise
Management
• Insert Needle at 2nd intercostal space
anteriorly, at mid clavicular line,

• Observe for egress of air

• Insert Chest drain, keep the needle

until chest drain secured and
connected to underwater drainage
system.
CASE 4
• A 38-year-old female smoker
• Background Hx Pelvic
endometriosis
• Intermittent recurrent Right
sided chest pain. Usually occur
by Day 2 of menstruation
• Admitted on Day 2 of menses.
With shortness of breath and
Right sided chest pain.
CASE4 38yrs/Female Bgx.Pneumothorax…
• VATS on the fifth day of menstruation
showed numerous brownish oval lesions
scattered on the diaphragm – endometrial
implants
DIAGNOSIS: CATAMENIAL PNEUMOTHORAX

• Talc poudrage was applied, and treatment

with a GNRH analogue was started, 6 month
follow up patient asymptomatic

Christoph M. Kronauer, 'Catamenial Pneumothorax', New England

Journal of Medicine, 355 (2006), e9.
CASE 5
• 34 yrs / Indonesian / Female • O/E
• G4 P2 L1 [21 weeks pregnant] • Mildy tachpneoic, RR 24/min
• BGHx:
• PDA under cardio follow up detected
• Speaking in full sentences
2006 during 3rd pregnancy • Pulse: 88/min
• ECHO: PDA 0.47cm, Left to Right shunt,
No evidence of Pulm. HTN • BP: 130/70 mmHg
• Detected to have ? Lung disease in • sPO2: 97% Room air
2008 not worked up.
• Presented with Shortness of breath
• Lungs: Reduced air entry on
for 10/7 and cough x 3/7 the right side with
hyperresonant on right side
BASELINE - 2008 On presentation
CASE 5. 34yrs/Indonesian
• Diagnosis
• Secondary spontaneous pneumothorax
• Community Acquired Pneumonia
• To work up for underlying Chronic Lung
Disease – TRO TB
• Treatment
• Chest drain in ED
• High flow oxygen
• Monitoring in HDW
• Fetal well being monitoring.
• Gumco suction 5cm H2o from day 2
• Subcutaneous emphysema -
• Persisting air leak
• Discharged on Day 10 with pneumostat
Day 8 admission
• Early review in Clinic Day 16
CASE 5. 34yrs/Indonesian / 24 weeks pregnant–
second presentation
• Shortness of breath x 1/7
• After dressing change and
dislodged Chest drain

• O/E
• Mildly tachypneoic
• HR: 90/min BP: 130/80mmHg
• SpO2: 96% (NP 3Lt)
• Lungs: Reduced air entry right
side. With hyperresonance
Managment
• Chest drain with Gumco suction
(5cmH2O)
• No evidence of Air leak on Day 4
• Persisting Pneumothorax on Day 5
• CT scan once delivery and definitive
surgical management.
Air travel advice – BTS (September 2011)1

1. Managing passengers with stable respiratory disease planning air travel: British Thoracic Society recommendations
British Thoracic Society Air Travel Working GroupSeptember 2011 Volume 66 Supplement 1
International Air Transport Association (IATA) –
2013 1

Spontaneous pneumothorax
7 days after full inflation
non-surgical means

traumatic pneumothorax 14 days after full inflation

6 days or less after full inflation ( If general condition is adequate, early transportation with ―Heimlich
Assessment by doctor with type drain and a doctor or nurse escort is acceptable
aviation medicine experience)

Allow if ≥ 11 days and uncomplicated recovery

Chest surgery like – pleurectomy,
If ≤ 10 days , need assessment by doctor with aviation medicine
lobectomy, open lung biopsy
experience
1.Medical Manual ISBN 978-92-9252-195-0 © 2013 International Air Transport Association. Montreal—Geneva
 Recommendation on diving-BTS 2003 guideline1
• Barotrauma: is caused by compression or expansion of gas filled
spaces during descent or ascent, respectively
• Expansion of the lungs during ascent may cause lung rupture leading to
pneumothorax, pneumomediastinum, and arterial gas embolism.

Lung bullae or cysts increase risk of barotrauma and are contraindications to diving.1
Previous spontaneous pneumothorax is a contraindication unless treated by bilateral surgical
thoracotomy and pleurectomy and associated with normal lung function and thoracic CT scan
performed after surgery.1

Previous traumatic pneumothorax may not be a contraindication if healed and associated with
normal lung function, including flow-volume loop and thoracic CT scan1
1.British Thoracic Society guidelines on respiratory aspects of fitness for diving British Thoracic Society Fitness to Dive
Group, a Subgroup of the British Thoracic Society Standards of Care Committee Thorax 2003;58:3–13
Practice question
• Q1 – 38 y/o male presented with
difficulty in breathing. 5 days duration.
Intermittent chest discomfort. No fever
or productive cough . He smokes for 10
pack years. He was seen in the local
klinik kesihatan which the attending
doctor thought was a tension
pneumothorax. Inserted a urgent needle
decompression. He was subsequently
refer to ED because of worsening SOB
with no repeated CXR.
What is your action plan
ABCDE - > oxygen - > urgent CXR, gases. -> manage as per 2
pneumothorax.
What could have occur
? Iatrogenic pneumothorax
• Question 2 – 38 year old man admitted with intermittent fever for 1
months duration & progressive worsening in effort tolerance.
• CXR showed
• Q3 – 40 year old co-pilot came to ED
complaining worsening shortness of
breath 2 days duration. Deny
symptoms of infection. (pls get a cxr
showing very small pneumothorax)

How are you going to manage him ?

Answer – counsel & refer to CTC
• 24 year old young man came with
sudden onset of shortness of
breath. He is a active young man
who leads his football team in the
school & national level
• Does he need a chest drainage ? Or
surgical intervention in view of his
possible professional involvement in
football ?