Etiology

Causes of traumatic pneumothorax:[2][3][4]

Iatrogenic: (Induced by a medical procedure)
 Central venous catheterization in the subclavian or internal jugular vein
 Lung biopsy
 Barotrauma due to positive pressure ventilation
 Percutaneous tracheostomy
 Thoracentesis
 Pacemaker insertion
 Bronchoscopy
 Cardiopulmonary resuscitation
 Intercostal nerve block
Non-Iatrogenic: (Due to external trauma)
 Penetrating or blunt trauma
 Rib fracture
 Diving or flying
Causes of tension pneumothorax:
All the above causes can further cause tension pneumothorax as well as:
 Idiopathic spontaneous pneumothorax
 Open pneumothorax
 Conversion of spontaneous pneumothorax to tension
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Epidemiology
Traumatic and tension pneumothoraces are more common than spontaneous pneumothoraces. Transthoracic
needle aspiration and central venous catheters are usually the most common causes of iatrogenic
pneumothorax. The rate of iatrogenic pneumothoraces is increasing in US hospitals as intensive care
modalities have increasingly dependant on positive pressure ventilation and central venous catheters. Central
venous catheterization increases the risk of pneumothoraces when placed in the internal jugular or
subclavian. The incidence is about 1 to 13% but increases to 40% if multiple attempts are made. These
numbers are lower if procedures are done under ultrasound. Iatrogenic pneumothorax usually causes
substantial morbidity but rarely death. The incidence is 5 to 7 per 10,000 hospital admissions.
Tension pneumothoraces can develop in 1 to 2% of cases initially presenting with idiopathic spontaneous
pneumothoraces. It is difficult to determine the actual incidence of tension pneumothorax as by the time
trauma patients are transported to trauma centers, they have already received decompressive needle
thoracotomies. Patients with trauma tend to have an associated pneumothorax or tension pneumothorax 20%
of the time. In cases of severe chest trauma, there is an associated pneumothorax 50% of the time. The
incidence of traumatic pneumothorax depends on the size and mechanism of the injury. A review of military
deaths from thoracic trauma suggests that up to 5% of combat casualties with thoracic trauma have tension
pneumothorax at the time of death.[3][4][5][6][7][6]
Pathophysiology
Before understanding the pathophysiology of tension and traumatic pneumothoraces, it is essential to
understand normal lung physiology. Pleural cavity (or intrapleural) pressure is negative as compared to lung
pressure and atmospheric pressure. There is a tendency of the lung to recoil inward and the chest wall to
recoil outward. That pressure gradient between the lung and pleural space prevents the lung from collapsing.
During a pneumothorax, communication develops between the pleural space and the lung, resulting in air
movement from the lung into the pleural space. This takes away the pressure gradient that is usually present
and causes a progressive rise in the intrapleural pressure. This rise in pressure further compresses the lung
and decreases its volume. The ipsilateral lung is unable to function at its normal capacity, and ventilation is
then reduced, resulting in hypoxemia.[2][8]
Tension pneumothorax is common in ICU ventilated patients. Tension pneumothorax occurs when the air
enters into the pleural space but is not able to fully exit, similar to a one-way valve mechanism through the
disrupted pleura or tracheobronchial tree. During inspiration, a sizeable high-pressure air collection
accumulates in the intrapleural space and is not able to completely exit during expiration. This will cause the
lung to collapse on the ipsilateral side. As the pressure increases, it will cause the mediastinum to shift
towards the contralateral side, contributing further to hypoxemia. In severe cases, the increased pressure can
also compress the heart, the contralateral lung, and the vasculature leading to hemodynamic instability. This
is due to impaired cardiac filling and reduced venous return. Hypoxemia also triggers pulmonary
vasoconstriction and increases pulmonary vascular resistance. As a result, hypoxemia, acidosis, and
decreased cardiac output can lead to cardiac arrest and, ultimately, death if the tension pneumothorax is not
managed in a timely fashion.[2][8]
Traumatic pneumothorax occurs secondary to a penetrating (e.g., gunshot wounds, stab wounds) or blunt
chest trauma. Depending on the depth of a penetrating chest wound, the air will flow into the pleural space
either through the chest wall or from the visceral pleural of the tracheobronchial tree. With a blunt force
trauma, a pneumothorax can occur if a rib fracture or dislocation lacerates the visceral pleura. An alternative
mechanism is through blunt thoracic trauma, where the increased alveolar pressure can cause the alveoli to
rupture, which results in the air entering the pleural cavity.[2]

History and Physical

Patients with pneumothoraces can be either asymptomatic or symptomatic. In a small pneumothorax, many
patients may present without symptoms.
Symptomatic patients will present with sharp pleuritic pain that can radiate to the ipsilateral back or
shoulder. The severely symptomatic patients will present with shortness of breath. Upon history taking, it is
essential to note whether the patient previously had a pneumothorax as recurrence is seen in more than15%
of cases on either the ipsilateral or contralateral side.
On examination, it is essential to assess for signs of respiratory distress, including increased respiratory rate,
dyspnea, and retractions. On lung auscultation, decreased or absent breath sounds on the ipsilateral side,
reduced tactile fremitus, hyper-resonant percussion sounds, and possible asymmetrical lung expansion are
suggestive of pneumothorax. Symptoms of tension pneumothorax are more severe. With tension
pneumothorax, patients will have signs of hemodynamic instability with hypotension and tachycardia.
Cyanosis and jugular venous distension can also be present. In severe cases or if the diagnosis was missed,
patients can develop acute respiratory failure, and possibly cardiac arrest. In some instances, subcutaneous
emphysema can also be seen. The diagnosis of tension pneumothorax must be made immediately through
clinical assessment as waiting for imaging, if not readily available, may delay management and increase
mortality.[2][8][9]

Evaluation
Initial assessment to determine whether the patient is stable or unstable dictates further evaluation. If the
patient is hemodynamically unstable and in acute respiratory failure, bedside ultrasound should be
performed to confirm the diagnosis if it is available for immediate use. Concurrently, patients should be
stabilized, and a complete assessment of airway, breathing, and circulation should be performed. Emergent
needle decompression or chest tube thoracotomy must be performed immediately if the diagnosis is highly
suspected.
When a patient is hemodynamically stable, radiographic evaluation is recommended. The initial assessment
is with a chest radiograph (CXR) to confirm the diagnosis.
CXR can demonstrate one or more of the following:
 A thin line representing the edge of the visceral pleura
 Effacement of lung markings distally to this line
 Complete ipsilateral lung collapse
 Mediastinum shift away from the pneumothorax in tension pneumothorax
 Subcutaneous emphysema
 Tracheal deviation to the contralateral side of tension pneumothorax
 Flattening of the hemidiaphragm on the ipsilateral side (tension pneumothorax)
If the diagnosis is unclear on X-ray, then a chest computed tomography can be done. It is the most reliable
imaging study for the diagnosis of pneumothorax, but it is not recommended for routine use.
Ultrasound is about 94% sensitive and 100% specific with a skilled operator. This can be used as a bedside
technique to detect pneumothorax, which may be useful in unstable patients. Ultrasound findings include the
absence of lung sliding and the presence of a lung point.[2][10][11][12][13][14]

Treatment / Management
Tension and traumatic pneumothoraces are usually managed in the emergency department or the intensive
care unit. Management strategies depend on the hemodynamic stability of the patient. In any patient
presenting with chest trauma, airway, breathing, and circulation should be assessed. Penetrating chest
wounds must be covered with an airtight occlusive bandage and a clean plastic sheeting. Administration of
100% supplemental oxygen can help reduce the size of the pneumothorax by decreasing the alveolar
nitrogen partial pressure. This creates a diffusion gradient for nitrogen, thus accelerating the resolution of
the pneumothorax. Without oxygen, only 1.25% of the air is absorbed in 24 hours. Positive pressure
ventilation should be avoided initially, as it will contribute to increasing the size of the tension
pneumothorax. Patients can be placed on positive pressure ventilation after a chest tube is placed.[2][15][16]
If the patient is hemodynamically unstable and clinical suspicion is high for pneumothorax, then immediate
needle decompression must be performed without delay. Needle decompression is done at the second
intercostal space in the midclavicular line above the rib with an angio-catheter. It results in re-expansion of
the collapsed lung. However, the risk of lung re-expanding quickly increases the risk of pulmonary
edema. Following needle decompression, a chest tube is usually placed, and an immediate CXR is done to
assess the resolution of the pneumothorax.
Assessment of pneumothorax resolution is usually done with serial chest X-rays. When the patient has
improved, the lung has fully expanded, and no air leaks are visible, the chest tube is ready to be removed.
Chest tubes are usually managed by experienced nurses, respiratory therapists, surgeons, and ICU
physicians. In 90% of the cases, a chest tube is sufficient; however, there are certain cases where surgical
interventions are required, and that can either be video-assisted thoracoscopic surgery (VATS) or
thoracotomy.[17][18][19][20]
Patients that require surgical intervention are usually patients with bilateral pneumothoraces, recurrent
ipsilateral pneumothoraces, first presentation in patients with high-risk professions like pilots and drivers,
and patients who have persistent air leak (for more than seven days). During video-assisted thoracic surgery
(VATS), pneumothorax is treated with pleurodesis. There are two types of pleurodesis: mechanical or
chemical. With mechanical pleurodesis, there is a less than 5% chance of recurrence of pneumothorax. Some
options are abrasive scratchpad, dry gauze, or stripping of parietal pleura. Chemical pleurodesis options
include talc, minocycline, doxycycline, or tetracycline. Chemical pleurodesis is an alternative if the patient
cannot tolerate mechanical pleurodesis. Recent studies have shown that pleurodesis can decrease the rate of
recurrence.[21][18][22]
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Differential Diagnosis
Differential diagnoses of pneumothorax include:
 Pulmonary embolism
 Acute coronary syndrome
 Acute aortic dissection
 Myocardial infarction
 Pneumonia
 Acute pericarditis
 Rib fracture
 Diaphragmatic injuries
 Esophageal spasm
 Costochondritis
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Prognosis
Tension and traumatic pneumothoraces must be treated immediately to avoid further associated morbidity
and mortality. Delay in diagnosis and management is associated with a poor prognosis. Tension
pneumothorax arises from many causes and rapidly progresses to respiratory insufficiency, cardiovascular
collapse, and ultimately death if not recognized and treated. In uncomplicated pneumothoraces, recurrence
can happen within six months to three years. Recurrences are more common in smokers, COPD, and
patients with AIDS.[23][24]
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Complications
Pneumothorax, especially tension pneumothorax is fatal; complications that can occur due to pneumothorax
and due to tube thoracostomy are as follow:
 Respiratory failure or arrest
 Cardiac arrest
 Pneumopericardium
 Pneumoperitoneum
 Hemothorax
 Bronchopulmonary fistula
  Damage to the neurovascular bundle during tube thoracostomy
 Pain and skin infection at the site of tube thoracotomy
 Empyema
 Pyopneumothorax
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Consultations
The diagnosis and management of traumatic and iatrogenic pneumothoraces require multidisciplinary
coordination and teamwork. Following specialties should be on board while managing such patients
 Thoracic surgeon
 Pulmonologist
 Interventional radiologist
 Intensivist