Overview
Definition
The presence of air or gas in the pleural cavity, leading to partial or complete collapse of the lung.
Epidemiology
Primary spontaneous mostly in tall, thin young men. Secondary spontaneous in patients with underlying lung disease (COPD).
Etiology & Risk Factors
- Primary Spontaneous: Rupture of a subpleural apical bleb
- Secondary Spontaneous: COPD/Emphysema, Cystic Fibrosis, Marfan Syndrome
- Traumatic: Penetrating or blunt chest trauma, iatrogenic (central line placement, mechanical ventilation barotrauma)
Clinical Symptoms
- Sudden-onset, unilateral pleuritic chest pain
- Dyspnea
- Decreased breath sounds and hyperresonance to percussion on the affected side
Clinical Approach
Diagnosis
- Chest X-ray (Upright, PA view): Visible visceral pleural edge with absent lung markings peripherally
- Bedside Ultrasound: Absence of 'lung sliding', presence of a 'lung point'
- Tension Pneumothorax is a CLINICAL diagnosis, do not wait for imaging if suspected
Management
- Small (< 2-3 cm) / Asymptomatic: Observation and supplemental oxygen (accelerates nitrogen resorption)
- Large / Symptomatic: Needle aspiration or small-bore chest tube (tube thoracostomy)
- Tension Pneumothorax: IMMEDIATE needle decompression (2nd intercostal space mid-clavicular line, or 5th ICS mid-axillary line) followed by chest tube
- Recurrent: VATS with pleurodesis
Complications
- Tension Pneumothorax (causing obstructive shock and death)
- Pneumomediastinum
- Re-expansion pulmonary edema (if drained too rapidly)