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Respirology (2004) 9, 157–164
INVITED REVIEW SERIES: PLEURAL DISEASES
Michael H. BAUMANN1 AND Marc NOPPEN2 Division of Pulmonary and Critical Care Medicine, University of Mississippi Medical Center, Jackson, Mississippi, USA and 2Interventional Endoscopy Clinic, Academic Hospital AZ-VUB, Brussels, Belgium
Pneumothorax BAUMANN MH, NOPPEN M. Respirology 2004; 9: 157–164 Abstract: Spontaneous pneumothoraces can occur without obvious underlying lung disease (primary) or in patients with known underlying lung disease (secondary). Management guidelines for spontaneous pneumothorax have been published by major professional organizations, but awareness and application among clinicians seems poor. First episodes of primary spontaneous pneumothorax can be managed with observation if the pneumothorax is small. If the pneumothorax is large or if the patient is symptomatic, manual aspiration via a small catheter or insertion of a smallbore catheter coupled to a Heimlich valve or water-seal device, should be performed. In general, deﬁnitive measures to prevent recurrence are recommended after the ﬁrst recurrence of the pneumothorax, and can be achieved by medical (e.g. talc) or surgical (video-assisted thoracic surgery) pleurodesis. Secondary pneumothoraces should be treated with chest tube drainage followed by pleurodesis after the ﬁrst episode to minimize any risk of recurrence. Traumatic pneumothoraces may be occult (not seen on an initial CXR) or non-occult. The majority are treated by placement of a chest tube. Selected patients may be treated conservatively, with approximately 10% of these patients eventually requiring chest tube placement. Iatrogenic pneumothoraces have a myriad of causes with transthoracic lung needle biopsy being most common. Transthoracic needle biopsyrelated pneumothoraces have CT ﬁndings that can predict their occurrence and the need for chest tube placement. Iatrogenic pneumothoraces, regardless of cause, may be managed by observation or small bore chest tube placement, depending upon patient stability and the size of the pneumothorax. Key words: iatrogenic, pneumothorax, spontaneous, traumatic.
Pneumothoraces are classiﬁed as spontaneous and non-spontaneous.1,2 Spontaneous pneumothoraces occur without any preceding trauma or obvious precipitating causes. Spontaneous pneumothorax that occurs in patients with no underlying lung disease is termed primary spontaneous pneumothorax (PSP), while secondary spontaneous pneumothorax (SSP) refers to those that develop in the presence of an underlying lung condition, such as COPD, cystic ﬁbrosis, or Pneumocystis carinii pneumonia. Nonspontaneous pneumothoraces are classiﬁed as traumatic and are subdivided into non-iatrogenic and iatrogenic. Non-iatrogenic pneumothoraces can
Correspondence: Michael H. Baumann, Division of Pulmonary and Critical Care Medicine, University of Mississippi Medical Center, Jackson, 2500 North State Street, MS 39216–4505, USA. Email: email@example.com
develop following direct or indirect trauma, often to the chest, unrelated to any medical procedure. Iatrogenic pneumothoraces result from medical interventions.1–3 Whatever the cause or the type of pneumothorax, tension pneumothorax may develop. Tension pneumothorax is present when intrapleural pressure exceeds atmospheric pressure throughout expiration.1,3 The patient suffering from tension pneumothorax can rapidly develop extreme dyspnoea, unilateral chest hyperinﬂation, cyanosis, and haemodynamic instability. Development of a tension pneumothorax is usually a medical emergency requiring prompt intervention by any number of chest drainage techniques to relieve the intrapleural pressure.1,3 Of note, the shift of the mediastinal structures to the contralateral side of the pneumothorax, as may be detected by CXR, is a normal phenomenon related to pleural air entry and not a deﬁnite sign of tension physiology. Tension pneumothorax should be a clinical diagnosis that should not await conﬁrmation by CXR.1,3
9 Several practical questions regarding PSP management deserve consideration: 1. especially video-assisted thoracoscopic surgery (VATS).9.g.24. as well as clinical evidence. PSP usually presents with sudden chest pain or discomfort. Does a recurrence of PSP increase the likelihood of further recurrences? Recurrence rates after a ﬁrst episode of PSP treated with an air evacuation technique vary from 16–52%. Small catheter manual aspiration19–23 in an outpatient setting. mostly young. usually in association with Pneumocystis carinii pneumonia. SSP is considered a potentially life-threatening event.24 Exceptions are patients with professional risks (e. partial pleurectomy or talc poudrage (0–10% recurrence). which should be as less invasive as possible.25 that recurrence prevention treatment should always be offered after a ﬁrst recurrence of a pneumothorax.36 After a ﬁrst recurrence.5 The incidence of SSP is comparable to that of PSP In COPD .17. In 8–20% of patients with cystic ﬁbrosis. causal role of rupture of blebs or bullae (so-called emphysema-like changes. if that is unavailable. available data show that both VATS bullectomy plus pleurodesis and medical talc poudrage without bullae treatment. there is no rationale to advise (rela.29.158 MH Baumann and M Noppen SPONTANEOUS PNEUMOTHORAX PSP occurs at a frequency of 7. cigarette smoking and an asthenic physiognomy. Smoking cessation appeared to reduce the recurrence rate in one study.10 An algorithmic approach to the treatment of PSP is shown in Fig.10 Hence.12. smoking cessation did not decrease the incidence of PSP except when patients had stopped smoking for at least 1 year before their ﬁrst pneumothorax. present in the majority of PSP patients. radiologist.19 The above-mentioned guidelines agreed that small and asymptomatic ﬁrst episodes of PSP should be observed for several hours.16 However. (the most common cause of SSP) spontaneous pneumothorax occurs in 26 cases per 100 000 population per year. randomized. however. Risk factors are male gender.33 While no large. surgeon. a spontaneous pneumothorax is known to develop.28 or air can pass through the mediastinal pleura following rupture of alveoli into the peribronchovascular interstitium.16 are successful in the majority of cases. tive) rest after a cured episode of PSP . In the case of incomplete lung expansion and/or persistent air leak. management strategies differ signiﬁcantly between these two presentations.37 These ﬁndings may be biased by the fact that a younger age at . A deﬁnitive treatment to prevent recurrence is not advocated after one single episode of PSP because the majority of patients will never have recurrences. medical or surgical thoracoscopy or.18 If management guidelines are adhered to. A large or symptomatic ﬁrst episode of PSP should be treated by an air evacuation technique.9.10 No precipitating cause(s) can usually be identiﬁed for any episode of PSP in individual patients.8 Because of the additional presence of the patient’s underlying lung disease. especially at the lung apices.4–18 cases (ageadjusted incidence) per 100 000 population per year in men and in 1. The diagnosis is made on an erect posteroanterior CXR at inspiration.14 and 2003. etc. or insertion of a small (14-Fr) percutaneous catheter attached to a Heimlich valve (outpatient setting) or to a water seal device (hospitalization). There is no need for systematic radiographs taken at expiration.15 and by the American College of Chest Physicians. emergency ward physician.2–6 cases (age-adjusted incidence) per 100 000 population per year in women. itself decreases the likelihood of PSP recurrence. Some controversy still exists around the optimal procedure to prevent recurrence of the pneumothorax. followed by discharge from hospital when the patient is stable. there are many other important reasons to advise smoking cessation in these. and the availability of therapeutic options. are equally effective.9. Most episodes occur at rest.26 Air leakage can occur elsewhere at the visceral pleura whether or not ELC are present (‘pleural porosity’). they are not always the actual site of the air leak. while PSP is virtually always a nuisance rather than a life-threatening condition.9. Should PSP patients stop smoking? Smoking cigarettes undoubtedly increases the risk of developing PSP 4 It is less clear whether quitting smoking in . the likelihood of subsequent recurrences seems to increase progressively up to 62% for a second and 83% for a third recurrence. limited thoracotomy should be performed within 3–4 days. Should patients be advised to rest or to decrease physical activity after an episode of PSP? Physical activity is not a risk factor for the occurrence of PSP 11 Hence. 3. spontaneous pneumothorax occurs at some time during their lives. therapeutic outcome appears to be improved. aircraft personnel). are . 2.13 The management of PSP is typically characterized by extensive practice variations and largely depends on the specialty of the physician-in-charge (pulmonologist.4.2 This may explain why recurrence rates of PSP seem somewhat higher after ELC treatment (e.9. There is good consensus.6 In 2–6% of HIV positive patients.). patients. however. averaging 30%. bullectomy) alone (up to 20% recurrence)29–32 as compared to pleurodesis by mechanical abrasion.34 In another study.10 Such practice variations have led to the development of management guidelines by the British Thoracic Society in 1993.27. 1.35 Nevertheless.g.7 although this high incidence has undoubtedly decreased since the advent of effective antiretroviral therapy.11 The role of atmospheric pressure or weather changes as the explanation of the often observed clustering of pneumothoraces is unclear. This is in part because of the different views on the pathophysiology of PSP especially on the . Primary spontaneous pneumothorax PSP typically occurs in young adults (peak age incidence 20–30 years). ELC) in the development of PSP Although ELC. evidence suggests that guidelines are poorly used and applied in clinical practice. prospective study has compared various recurrence prevention techniques.
34 4.42.Pneumothorax PSP 159 yes Signs of tension no Immediate needle decompression followed by CTD and further treatment PTX size < 20 %† or < 3 cm apex-cupula.10 The diagnosis can usually be made on an erect posteroanterior CXR.44 Because of the underlying lung disease. although CT is sometimes necessary to differentiate pneumothoraces from large thin-walled bullae. Should PSP patients be allowed to dive? Intrapulmonary (e. recurrence rates are higher in SSP varying from 40 to 80% .43 Secondary spontaneous pneumothorax While PSP is almost always a benign disorder without the need for immediate intervention.40 impose a recurrence prevention treatment after a ﬁrst episode of PSP in aviation personnel. a volume of gas will expand with decreasing ambient pressures).g. Should PSP patients be allowed to ﬂy? Because of the repetitive changes in ambient pressure during airline travel (cabin pressures are lowered to around 550 mmHg during ﬂight). blebs. common underlying disorder. mechanical) † 20% by Light Index (reference 1) Figure 1 An algorithmic approach to the treatment of primary spontaneous pneumothorax. electrocoagulation. depending upon the underlying cause. Potential passengers who have had a PSP may theoretically board commercial aircraft once all air is evacuated from the pleural space.38 However.2 Virtually every lung disease has been reported to be associated with SSP but COPD is by far the most . CTD: chest tube drainage. military regulations.g. *After informed consent (see text). although some data suggest that safe air travel can only be guaranteed after a 2-week waiting period. substantiated. emphysema. A history of PSP or .39 as well as international ﬂight regulations. and asymptomatic PTX size > 20 % or > 3 cm apex-cupula. divers and others) * * Staple bleb/bullectomy. pilots. the documented presence of emphysema. ligation PSP: primary spontaneous pneumothorax. or symptomatic observation ± oxygen supplements follow-up 1st episode 2nd or more * Air evacuation treatment Recurrence prevention treatment Simple manual aspiration Small bore CTD at waterseal or attached to Heimlich Thoracoscopy (medical or surgical) CTD with chemical pleurodesis if thoracoscopy refused or contraindicated Success at 1 attempt Unsuccessful at 1st attempt No ELC’s or no air leak found at ELC’s persistent air leak (> 4 days) Visible air leak at ELC success Talcage or mechanical pleurodesis ELC treatment ** + pleurodesis (talcage. bullae) or intrapleural (e. 5. ﬂight attendants) theoretically may have an increased risk of developing PSP although this has not been . blebs or bullae are considered contraindications for diving. frequent ﬂyers (e. SSP is a potentially life-threatening event because of compromised respiratory reserves due to the underlying lung disease. or in certain patient groups (aircraft personnel. the ﬁrst occurrence of PSP is an independent risk factor for future recurrences.g.41 Safety regulations impose a waiting period of 3 weeks after a treated pneumothorax event. pneumothorax) air will expand during ascent from a dive (Boyle’s law).10 In contrast to PSP dyspnoea is usually more severe . and sometimes even life-threatening in the SSP patient.g.2. ELC's: emphysema-like changes Reproduced with permission from reference number 9. because development of a pneumothorax immediately prior to or early in ﬂight is more dangerous (according to Boyle’s law.40 Patients with pneumothoraces can be transported by air as long as an open connection between the pleural space and the ambient atmosphere is present (e. chest tube coupled to a water seal device or to a Heimlich valve). Patients with .
16 The British Thoracic Society .52. no professional society guidelines exist for the care of patients with a non-spontaneous pneumothorax. one not seen on an initial CXR but found later with additional imaging. partial pleurectomy.51 potentially prompting chest drainage independent of the presence of pleural air. therefore in centres where thoracoscopy is readily available.53 The study did not deﬁne whether the 1. patients with SSP should undergo immediate thoracoscopy. Due to the preference of the study institution’s surgeons. did not require a chest tube when managed conservatively. hormonal menstruation suppression treatment may be indicated. 329 (41%) were treated conservatively (observation alone) and 29 (8. All patients were treated in hospital and only four patients had gun shot wound-related pneumothoraces. Large or symptomatic pneumothoraces should always be treated with a chest tube (coupled to a Heimlich valve or water seal device). With these restrictions.15. and seen on four or more contiguous slices. Non-iatrogenic traumatic pneumothorax Annually. In very large and/or unstable pneumothoraces. A speciﬁc type of SSP is catamenial pneumothorax. more than 50 000 trauma-related pneumothoraces (non-iatrogenic traumatic pneumotho- races) occur in the USA.52–54 A failure rate of 7–9% has been reported for conservative (observational) management of non-occult traumatic pneumothoraces. Pneumothorax ranks second only to rib fracture as the most common sign of chest injury and can be seen in 40–50% of chest trauma patients.5-cm distance was from the chest apex to lung or other reference point.16 Recurrence prevention after the ﬁrst episode of SSP is recommended by most. and to those with limited respiratory reserve. not extending to the mid coronal line.160 SSP usually require immediate and effective therapy to treat the presenting episode of pneumothorax. particularly in patients who may require positive pressure ventilation. and upon successful lung re-expansion. prior placement of a small bore chest tube is probably recommended. early (within 3–5 days) thoracoscopic intervention is recommended. guidelines15 recommend evacuation of the pneumothorax by manual aspiration in young (< 50 years) asymptomatic patients with a small pneumothorax. Information is limited but several publications provide helpful information to guide the care of these patients.47 Because recurrences are frequent.48 Utilizing a CT-directed size classiﬁcation of the pneumothorax.48. provided a systematic approach to the conservative management of occult non-iatrogenic traumatic pneumothoraces.47 and should therefore be systematically searched for in menstruating women with pneumothoraces. However.46 A recent prospective study suggests that catamenial pneumothorax may be more common than previously thought. The American College of Chest Physicians guidelines16 also recommend hospitalization in all cases. diaphragmatic abnormalities related to endometriosis are often found during thoracoscopy. with chest trauma contributing directly to 25% of these deaths and signiﬁcantly to an additional 50%. and maintaining a high suspicion may be required to successfully diagnose a traumatic pneumothorax.53 The largest of these studies limited chest tube placement in 804 traumatic pneumothorax patients to those with: lung collapse of > 1. However.45 In case of a persistent air leak. chest tubes were placed in all patients with anterolateral pneumothoraces. and a largebore chest tube is recommended when a large air leak is suspected or when positive pressure ventilation is required.49. Small pneumothoraces may be observed or treated with a small bore chest tube.50 early detection is critical. Anterolateral pneumothoraces were pleural air collections extending at least to the mid coronal line. Anterior pneumothoraces were air collections located anteriorly.16. 24 of 27 patients (89%) with a minuscule or anterior pneumothorax.49 Minuscule pneumothoraces were deﬁned as air collections £ 1-cm thick and seen in no more than four contiguous 10-mm thick slices. Occult traumatic pneumothoraces may also be treated conservatively in selected patients. If general anaesthesia and positive pressure ventilation are used.5 cm by CXR. recurrence prevention treatment is indicated after a ﬁrst event of catamenial pneumothorax.8%) required chest tube placement due to pneumothorax enlargement. and most authors also recommend immediate deﬁnitive therapy for recurrence prevention after the ﬁrst episode of SSP 10. all mechanically ventilated patients with an anterior pneumothorax received a chest tube. Also. talc slurry. Wolfman et al.) through a chest tube. A thoracoscopic approach (medical or surgical) with an effective pleurodesis technique (pleural abrasion.49 Con- .16 Ideally. a 24-h period of inpatient observation. smaller but bilateral pneumothoraces.52 Nearly 20% of traumatic pneumothorax patients have an accompanying haemothorax. up to 38% of occult pneumothoraces may progress with the application of positive pressure ventilation.50 Up to 51% of trauma patients that present have an occult pneumothorax. insertion of a moderate-sized chest tube is advocated. or talc poudrage) is preferred over instillation of a sclerosant (tetracycline. etc. > 1-cm thick.48–50 Blunt trauma to the abdomen may also precipitate a traumatic pneumothorax.48. Of the 804 patients. requirement for mechanical ventilation.51 Given the likelihood of progression with mechanical ventilation.49 Early incorporation of a routine CT of the chest in all chest and multitrauma patients. In most cases. chest tube placement may not be required in all traumatic pneumothoraces regardless of an occult or non-occult presentation. In addition. MH Baumann and M Noppen NON-SPONTANEOUS PNEUMOTHORAX As opposed to patients with a spontaneous pneumothorax.48. occurring within 24–72 h after the onset of menstruation. Traumatic pneumothoraces are usually managed with placement of a chest tube.
mortality.60 Arguably.55 Signiﬁcant time delays between an instigating event and discovery of a resulting iatrogenic pneumothorax compound the problem of the many potential causes.5 cm size < 1. and in one series. after central line placement. Adapted from reference number 3 versely. Clinicians must be vigilant for their occurrence even when the potential inciting interventions are at body sites remote from the chest.5 cm size Minuscule/ anterior Anterolateral Chest tube Chest tube Clinically stable Hospital observation Clinically unstable Chest tube Clinically stable Hospital observation Clinically unstable Chest tube Strongly consider chest tube placement in all mechanically ventilated patients Figure 2 Treatment of non-iatrogenic traumatic pneumothorax. and positive pressure ventilation (7%). underlying lung disease. 2).57–59 A patient’s clinical presentation may vary considerably based upon the inciting mechanism. more than one in 10 patients managed conservatively. placement of a chest tube in occult and non-occult traumatic pneumothorax patients is a reasonable initial approach in the majority of patients. pleural biopsy (8%). However. P = 0.3 Iatrogenic traumatic pneumothorax Ever increasing utilization of invasive diagnostic and therapeutic interventions undoubtedly inﬂates the already signiﬁcant incidence of iatrogenic pneumothoraces.56 Iatrogenic pneumothoraces may have considerable associated costs including possible morbidity. preoperative lung function may predict iatrogenic pneumothorax rates but studies vary considerably. transthoracic needle lung biopsy has associated variables that may predict the risk of pneumothorax. and the presence or absence of mechanical ventilation. a larger bore tube (28–36-Fr) should be considered.01) and smaller lung lesions (£ 2 cm. have a delayed (8– 96-h) CXR diagnosis. The institution of positive pressure ventilation should prompt strong consideration for chest tube placement in all non-iatrogenic traumatic pneumothorax patients. respectively). and the potential for a signiﬁcant air leak if the patient is mechanically ventilated.59 The most common of these.3 The exact incidence rate of iatrogenic pneumothoraces is unknown. noted that CT evidence of emphysema in the lung lobe of the biopsy (P = 0. Cox et al. prolonged hospitalization in 8% of affected patients.60 Additionally. Given the potential need to drain both blood and air. traversing aerated lung en route to the target lesion increased the rate of pneumothorax occurrence compared with biopsy of a juxtapleural lesion (pneumothorax rate approximately 50% vs 15%.3 Adopting the degree of collapse from . thoracentesis (20%).61–65 Treatment of iatrogenic pneumothoraces should focus upon the least invasive intervention appropriate to the patient’s underlying lung health and clinical circumstances.3 The six most common causes of iatrogenic pneumothorax among 535 Veterans Administration patients were transthoracic needle lung biopsy (24%).Pneumothorax 161 Non-Occult Pneumothorax Occult Pneumothorax CT size classification > 1.001) correlated with the occurrence of pneumothorax. eventually required a chest tube. Up to 4% of patients with an iatrogenic pneumothorax. carefully selected patients may be closely monitored without chest tube placement. needle size and lesion location did not correlate with pneumothorax rate. transbronchial lung biopsy (10%). In summary (Fig. approximately 10% of these patients eventually require a chest tube. The number of needle passes. subclavian vein catheterization (22%).
J. Textbook of Pleural Diseases. . Spontaneous pneumothorax. Minnesota: 1950–74. 92: 1009–12. 3). P < 0. Wiman L-G. Melton LJ. Baumann MH. 464–74. 1989. Noppen M. Pneumothorax in patients with acquired immunodeﬁciency syndrome. an iatrogenic pneumothorax ≥ 3 cm (from chest apex to lung) or > 15% in size by CXR should be considered for drainage using a smaller bore chest tube (£ 16-Fr). N. Thorac. Small iatrogenic pneumothoraces from other causes in clinically stable patients may be carefully observed.3 Appropriately selected patients with an iatrogenic pneumothorax may be safely managed with placement of a chest tube and subsequent outpatient follow up. Transthoracic needle lung biopsy is one of the most common causes of iatrogenic pneumothorax. Smoking and the increased risk of contracting spontaneous pneumothorax. Am. Surg. strongly consider chest tube placement in all mechanically ventilated patients MH Baumann and M Noppen Pneumothorax < 3 cm or < 15% size Pneumothorax ≥ 3 cm or > 15% size Clinically stable Observation (if transthoracic lung biopsy related pneumothorax and no CT evidence of emphysema. REFERENCES 1 Light RW. Lee YCG (eds).68–70 Any patient with an iatrogenic pneumothorax on mechanical ventilation should be strongly considered for placement of a chest tube in lieu of observation. Incidence of spontaneous pneumothorax in Olmsted County. 342: 868–74. Respir. 3rd Hepper NGG. Associated CT ﬁndings can predict the likelihood of a pneumothorax occurrence and the need for chest tube placement. regardless of pneumothorax size. J. 4th edn. Dines DE. Clagett OT. 2 Sahn SA. Brevig JK. regardless of stability) Small-bore chest tube Small-bore chest tube Consider outpatient management in selected patients Adapted from reference number 3 Figure 3 Treatment pneumothorax. seems a reasonable treatment approach. Cox et al. of iatrogenic the spontaneous pneumothorax literature16. Dis 1979. London. Heffner JE. Baltimore. Respiration 2003. Proc. Mayo Clin. Bense L. Pleural Diseases. Spontaneous pneumothorax in emphysema.3 Simple aspiration of the pneumothorax is possible but given the myriad of commercially available small bore chest tubes that can be attached to a Heimlich valve or similar oneway valve.66 as an indicator of treatment choice. 3 Baumann MH. Aspiration can be attempted with a small bore tube. Iatrogenic traumatic pneumothoraces may be caused by a myriad of diagnostic and therapeutic interventions and have a delayed presentation (Fig. Spector ML. however.162 Focus on least invasive intervention appropriate to patient’s condition. In: 4 5 6 7 8 9 Light RW. versus prompt placement of a chest tube in patients with CT evidence of emphysema. Ann. Chest 1987. observation is reasonable) Clinically unstable or symptomatic (or if transthoracic lung biopsy related pneumothorax and CT evidence of emphysema. in effect converting simple aspiration to placement of a small bore chest tube. Cardiovasc. Willams and Wilkins. clinical instability. Eklund G. Offord KP. Yeoh CB. the device may be left in place.01) need for chest tube placement in patients sustaining a needle lung biopsy-related pneumothorax. 47: 204–7. Surg. 2001. Pathogenesis and treatment of primary spontaneous pneumothorax: an overview. 120: 1379–82. Pneumothorax in cystic ﬁbrosis: a 26-year experience. The need for drainage can be predicted after transthoracic needle lung biopsy. 1970. Rev. and if unsuccessful. 2003. 2000. Med. 70: 431–8. Payne WS. Byrnes TA.67 use of these devices offers greater versatility. signiﬁcant symptoms. or a larger pneumothorax should prompt placement of a small bore chest drain.60 Careful observation of patients with an iatrogenic pneumothorax < 15% or < 3 cm in size and no CT evidence of emphysema. Arnold. 1989. Engl. noted that the presence of CT evidence of emphysema predicted a threefold higher (27% with emphysema vs 9% without. Non-Spontaneous Pneumothorax. 98: 546–50. 45: 481–7. Thorac. Stern RC.
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