Questions on pneumothorax
Definition and classifications
- What is pneumothorax? A
- What are the types of pneumothorax? A
- What are the types of spontaneous pneumothorax? A
- What is catamenial pneumothorax? A
- What is tension pneumothorax? A
- What is hydropneumothorax? a
Etiology and Pathophysiology
- What are the causes of pneumothorax? A
- What are the causes of recurrent pneumothorax (more than twice)? a
- What are the causes of tension pneumothorax? a
- What are the causes of hydropneumothorax? a
Clinical manifestations
- What is the usual presentation of pneumothorax? A
- What are the definitive signs of pneumothorax? A
- How would you grade pneumothorax? A
- What are the signs of hydropneumothorax? a
Examinations
- What is the bedside test of hydropneumothorax? a
Investigations
- Mention one single investigation for your diagnosis. a
- What investigations do you suggest? A
- When CT scan necessary in pneumothorax? hl
- What is coin test? a
Diagnosis
- A young male presents with sudden severe rightsided chest pain and breathlessness. On examination, resonant on percussion and absent breath sound on right side. What is your diagnosis? H
- What are physical signs in bedside to differentiate lobar pneumonia and pneumothorax? h
- What are the differential dfiagnosis? A
- Why is this not giant bulla? Hl
- Why is this not pleural effusion? hl
Treatment
- How to treat pneumothorax? A
- If you are working in a remote place and a patient presents with tension pneumothorax, what measures should you take? A
- What is the most importan predictor of re-expansion pulmonary edema? Hl
- What is the rate of resolution/ reabsorption of a spontaneous primary pneumothorax? Hl
- What are the indications of surgery (open thoracotomy)? A
- How do you know that the water seal drainage is working properly or not? A
- What advice is given to the patient with water seal drainage? A
- What are the indications of chest tube or IT tube drainage? A
- How to follow-up a patient after chest tube insertion? A
- How long the lung takes to re-expand? A
- What are the possible causes of failure of re-expansion of lung? A
- How to treat recurrent pneumothorax? A
- How to treat tension pneumothorax? A
- How to manage hydropneumothorax? a
Rimikri
SOLVES
What is pneumothorax?
Pneumothorax is the presence of air in the pleural space.
* Davidson’s Principles and Practice of Medicine, 22nd Edition Page: 728
What are the types of pneumothorax?
As follows:
- Spontaneous:
- Primary and
- Secondary
- Traumatic
* Long Cases in Clinical Medicine, ABM Abdullah Page: 134
What are the types of spontaneous pneumothorax?
Three types (anatomical):
- Closed
- Communication between the lung and pleural space is sealed off.
- Intrapleural pressure is less than atmospheric pressure.
- Trapped air is slowly reabsorbed, lung reexpands in 2 to 4 weeks.
- Closed pneumothorax may be mild, moderate and large.
- Open
- Communication between the lung and pleural space persists (bronchopleural fistula).
- Intrapleural pressure and atmospheric pressure are equal throughout the respiratory cycle, which prevents re-expansion of the collapsed lung.
- Hydropneumothorax develops.
- Infection is common and empyema develops.
- Physical examination shows features of hydropneumothorax.
- Causes are:
- Rupture of emphysematous bullae
- Small pleural bleb
- Tuberculous cavity
- Lung abscess bursting into pleural cavity.
- Tension (valvular)
- There is a communication between the pleura and the lung which acts as a one-way valve allowing air to enter into the pleural space during inspiration, but does not let air escape on expiration.
- Intrapleural pressure becomes greater than the atmospheric pressure.
- It results in compression of the lung, shifting of mediastinum to the opposite side, compression of heart and the opposite lung also.
- It reduces the venous return by compressing the SVC. There is rapidly progressing breathlessness, cyanosis, shock, etc.
- It is a medical emergency, death may occur within minutes.
Note:
Normal intrapleural pressure is negative (subatmospheric), usually – 2.5 to – 6.0 mm Hg.
Figure: Types of spontaneous pneumothorax. A Closed type. B Open type. C Tension (valvular) type.
* Long Cases in Clinical Medicine, ABM Abdullah Page: 134; Figure: Davidson’s Principles and Practice of Medicine, 22nd Edition Page: 729
What is catamenial pneumothorax?
If pneumothorax develops at the time of menstruation, it is called catamenial pneumothorax.
- It is usually on the right side, occurs within 48 hours of onset of menstruation, common in 25 to 30 year old female and is due to intrapleural endometriosis.
- It is treated by hormone therapy to suppress ovulation (by progesterone or androgen therapy) or simply by oral contraceptive pills.
- Sometimes, surgical exploration and pleurodesis may be needed.
* Long Cases in Clinical Medicine, ABM Abdullah Page: 135
What is tension pneumothorax?
It is a valvular-type of pneumothorax, in which there is a communication between lung and pleural cavity with one-way valve, which allows air to enter during inspiration and prevents to leave during expiration.
* Long Cases in Clinical Medicine, ABM Abdullah Page: 136
What is hydropneumothorax?
When there is accumulation of fluid and air in pleural cavity, it is called hydropneumothorax.
* Long Cases in Clinical Medicine, ABM Abdullah Page: 138
What are the causes of pneumothorax?
Causes of pneumothorax/ Classification of pneumothorax:
Spontaneous
- Primary
- No evidence of overt lung disease.
- Air escapes from the lung into the pleural space through
- rupture of a small pleural bleb, or the pulmonary end of a pleural adhesion
- Secondary
- Underlying lung disease, most commonly COPD and tuberculosis.
- Also seen in asthma, lung abscess, pulmonary infarcts, bronchogenic carcinoma, and all forms of fibrotic and cystic lung disease
Traumatic
- Iatrogenic (e.g. following thoracic surgery or biopsy)
- Chest wall injury
* Davidson’s Principles and Practice of Medicine, 22nd Edition Page: 729
Note:
- In young patient, common cause is rupture of subpleural bleb
- In patient > 40 years of age, common cause is chronic bronchitis with emphysema
* Long Cases in Clinical Medicine, ABM Abdullah Page: 134
What are the causes of recurrent pneumothorax (more than twice)?
Causes are:
- Apical subpleural bleb or cyst (congenital)
- Emphysematous bullae
- Cystic fibrosis
- Others—Marfan’s syndrome, catamenial pneumothorax, Ehlers-Danlos syndrome, α1 – antitrypsin deficiency and histiocytosis X, honeycomb lung.
* Long Cases in Clinical Medicine, ABM Abdullah Page: 135
What are the causes of tension pneumothorax?
Causes of tension pneumothorax:
- Traumatic
- Mechanical ventilation at high pressure
- Rarely, spontaneous pneumothorax.
* Long Cases in Clinical Medicine, ABM Abdullah Page: 136
What are the causes of hydropneumothorax?
Its causes are:
- Iatrogenic (during aspiration of pleural fluid)
- Pulmonary tuberculosis
- Bronchopleural fistula
- Trauma (penetrating chest injury and thoracic surgery)
- Rupture of lung abscess
- Esophageal rupture
- Erosion of bronchial carcinoma.
* Long Cases in Clinical Medicine, ABM Abdullah Page: 138
What is the usual presentation of pneumothorax?
The patient usually presents with sudden onset of unilateral pleuritic chest pain and breathlessness (Most common symptoms).
* Long Cases in Clinical Medicine, ABM Abdullah Page: 133; Davidson’s Principles and Practice of Medicine, 22nd Edition Page: 729
What are the features of tension pneumothorax?
Features of tension pneumothorax:
- Severe chest pain (pain is worse with cough and relieve on sitting position)
- Severe and progressively increasing dyspnea
- Cough
- Tachypnea, tachycardia, pulsus paradoxus
- Features of shock (hypotension, central cyanosis and tachycardia)
- Raised JVP, engorged neck vein due to compression of the heart
- Shifting of mediastinum to the opposite side.
Note
Cardinal features are progressively increasing dyspnea and features of shock.
* Long Cases in Clinical Medicine, ABM Abdullah Page: 136
How would you grade pneumothorax?
According to British Thoracic Society:
- Mild—small rim of air around the lung, <20% of the radiographic volume
- Moderate—lung collapse, >20 to 50% of the radiographic volume
- Large—lung collapse, >50% of the radiographic volume
- Tension—pneumothorax with cardiorespiratory distress, features of shock.
* Long Cases in Clinical Medicine, ABM Abdullah Page: 135
What are the definitive signs of pneumothorax?
Hyper-resonance on percussion and diminished or absent breath sound.
* Long Cases in Clinical Medicine, ABM Abdullah Page: 133
What are the signs of hydropneumothorax?
In lower part, signs of pleural effusion and in upper part, signs of pneumothorax.
* Long Cases in Clinical Medicine, ABM Abdullah Page: 138
What is the bedside test of hydropneumothorax?
Succusion splash.
* Long Cases in Clinical Medicine, ABM Abdullah Page: 138
Mention one single investigation for your diagnosis.
X-ray chest P/A view.
* Long Cases in Clinical Medicine, ABM Abdullah Page: 133
What investigations do you suggest?
As follows:
- Complete blood count and ESR
- Chest X-ray P/A view
- Sometimes, CT scan of chest
- Others– to detect cause of secondary spontaneous pneumothorax.
* Long Cases in Clinical Medicine, ABM Abdullah Page: 133; Short and Long Cases in Clinical Medicine, HN Sarker Page: 25
What are the radiological findings of the X-ray?
X-ray chest PA view showing:
- Hypertranslucent area without bronchovascular markings with collapsed lung margin in right side.
- Trachea shifted to the left side
- Right low flat diaphragm
Radiological diagnosis: Right-sided pneumothorax.
X-ray chest PA view showing:
- Hypertranslucent area without bronchovascular markings with collapsed lung margin in left side.
Radiological diagnosis: Left-sided pneumothorax.
* Short Cases in Clinical Medicine, ABM Abdullah, 5th Edition Page: 544
When CT scan necessary in pneumothorax?
CT scan is necessary
- To differentiate a pneumothorax from complex bullous disease
- When surgical emphysema is present and obscure underlying structure.
* Short and Long Cases in Clinical Medicine, HN Sarker Page: 25
What is coin test?
- In this test, one coin is placed on the front or back of the chest and struck with edge of another coin.
- At the same time auscultated on the opposite side of the chest at the same level.
- There will be a metallic, bell-like sound if pneumothorax is present.
* Long Cases in Clinical Medicine, ABM Abdullah Page: 135
A young male presents with sudden severe right sided chest pain and breathlessness. On examination, resonant on percussion and absent breath sound on right side. What is your diagnosis?
Right-sided pneumothorax is the diagnosis.
* Pre-exam preparation for medicine, HN Sarker
What are physical signs in bedside to differentiate lobar pneumonia and pneumothorax?
Examination | Lobar pneumonia | Pneumothorax |
Trachea | Central | Deviated to opposite site |
Percussion note | Woody dull | Hyper-resonant |
Auscultation | Bronchial breath sound
↑ vocal resonance |
↓ or absent breath sound
↓ or absent vocal resonance |
* Pre-exam preparation for medicine, HN Sarker
What are the differential diagnosis?
As follows:
- Big pulmonary cavity
- Giant bullae.
* Long Cases in Clinical Medicine, ABM Abdullah Page: 133
Why is this not giant bulla?
In bulla, no mediastinal shifting is present, i.e. trachea and apex beat are in normal position.
* Short and Long Cases in Clinical Medicine, HN Sarker Page: 25
Why is this not pleural effusion?
In pleural effusion, percussion note is stony dull.
* Short and Long Cases in Clinical Medicine, HN Sarker Page: 25
How to treat pneumothorax?
Depends on whether it is primary or secondary, open, closed or tension or presence of symptoms.
- In primary small pneumothorax:
- Spontaneous resolution occurs.
- Follow-up at 2-week interval (repeat chest X-ray)
- Normal activity
- Avoid strenuous exercise
- In primary moderate to large with breathlessness:
- Percutaneous needle aspiration of air (2 to 5 litre. Stop, if resistance to suction is felt or patient coughs).
- In secondary pneumothorax:
- Patient with COPD, even small pneumothorax can cause respiratory failure.
- Hence, water seal drainage should be given.
- Open pneumothorax:
- Surgery (as is due to bronchopleural fistula).
- Tension pneumothorax (described below).
Advice to the patient:
- Must stop smoking
- Avoid air travel for 6 weeks after normal chest X-ray
- Diving should be permanently avoided.
* Long Cases in Clinical Medicine, ABM Abdullah Page: 137
If you are working in a remote place and a patient presents with tension pneumothorax, what measures should you take?
- Immediately I shall insert a wide bore needle (may be cannula/venflon) in the second intercostal space in midclavicular line.
- This will allow the trapped air to escape (producing an audible hiss).
- Then I shall send the patient to the nearest hospital (do not remove the cannula, tape it securely).
* Long Cases in Clinical Medicine, ABM Abdullah Page: 137
What are the indications of surgery (open thoracotomy)?
As follows:
- Failure of the lung to re-expand after 5 days of tube thoracotomy
- Recurrence (usually on third recurrence)
- Bilateral pneumothorax.
* Long Cases in Clinical Medicine, ABM Abdullah Page: 135
How do you know that the water seal drainage is working properly or not?
As follows:
- Bubbling of air in water
- During expiration or coughing, more bubbling occurs
- During inspiration, water column ascends within the tube, which remains under water.
* Long Cases in Clinical Medicine, ABM Abdullah Page: 136
What advice is given to the patient with water seal drainage?
Never raise the bottle above the chest wall. The bottle must be kept below the level of thorax. The patient is also advised to inflate air pillows or balloons which will help in the expansion of collapsed lung.
* Long Cases in Clinical Medicine, ABM Abdullah Page: 136
What are the indications of chest tube or IT tube drainage?
As follows:
- Tension pneumothorax
- Large second spontaneous pneumothorax if > 50 years
- Malignant pleural effusion
- Empyema thoracis or complicated parapneumonic effusion
- Hydropneumothorax
- Traumatic hemopneumothorax
- Postoperatively as for example thoracotomy, esophagectomy, cardiothoracic surgery.
* Long Cases in Clinical Medicine, ABM Abdullah Page: 136
How to follow-up a patient after chest tube insertion?
As follows:
- Bubbling—whether it disappears or persistent (indicates leaking)
- Blockage of the tube by clot or kinking
- Malposition
- Retrograde flow back into the chest.
* Long Cases in Clinical Medicine, ABM Abdullah Page: 137
What is the most important predictor of re-expansion pulmonary edema?
Delayed treatment; the greater the length of time the lung has remained collapsed, the greater the risk of re-expansion pulmonary edema.
* Short and Long Cases in Clinical Medicine, HN Sarker Page: 26
What is the rate of resolution/ reabsorption of a spontaneous primary pneumothorax?
The rate of absorption is 1.22–1.8% of the volume of hemithorax per day.
* Short and Long Cases in Clinical Medicine, HN Sarker Page: 26
How long the lung takes to re-expand?
Air is absorbed at the rate of 1.25% of the total radiographic volume/day. So, if there is 50% lung collapse, it will take 40 days to expand.
* Long Cases in Clinical Medicine, ABM Abdullah Page: 137
What are the possible causes of failure of re-expansion of lung?
As follows:
- Water seal drainage is not working properly or may be blocked.
- Presence of bronchopleural fistula.
- A major bronchus may be obstructed.
- Lung is completely fibrosed with permanent damage.
* Long Cases in Clinical Medicine, ABM Abdullah Page: 137
How to treat recurrent pneumothorax?
Treatment:
- Chemical pleurodesis. Done by injecting tetracycline (500 mg), kaolin or talc into the pleural cavity through intercostal tube.
- Surgical pleurodesis. Done by parietal pleurectomy or pleural abrasion during thoracotomy or thoracoscopy. Indications are:
- All patients after a second pneumothorax
- Considered after first episode of secondary pneumothorax, if there is low respiratory reserve
- Patient who plan to continue activity, where pneumothorax would be particularly dangerous (e.g. flying or diving) should undergo definitive treatment after first episode of primary spontaneous pneumothorax.
Note
Pleurodesis is avoided in patient with cystic fibrosis, as lung transplantation may be required and pleurodesis may make this condition technically not feasible.
* Long Cases in Clinical Medicine, ABM Abdullah Page: 135
How to treat tension pneumothorax?
Treatment:
- Immediate insertion of wide bore needle in second intercostal space in midclavicular line, with the patient is sitting position.
- Intrathoracic tube is inserted in fourth, fifth or sixth intercostal space in midaxillary line, and the tip of the tube should be advanced in apical direction. It is connected to a underwater seal or oneway Heimlich valve.
- The patient should be kept propped up with oxygen inhalation.
- Morphine 5 to 10 mg subcutaneously.
- If bubbling ceases, repeat chest X-ray. If the lung re-expands, tube may be removed after 24 hours.
- Tube should be removed during expiration or Valsalva maneuver (the tube need not be clamped before removing).
- If no response or continued bubbling for 5 to 7 days, surgical treatment may be necessary.
* Long Cases in Clinical Medicine, ABM Abdullah Page: 136
How to manage hydropneumothorax?
Management:
Water seal drainage and treatment of primary cause.
* Long Cases in Clinical Medicine, ABM Abdullah Page: 138