PNEUMOTHORAX

The Professional Medical Journal

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ORIGINAL PROF-3922
DOI: 10.17957/TPMJ/17.3922

PNEMOTHORAX;
INCIDENCE AND OUTCOMES OF PNEUMOTHORAX IN CRITICALLY ILL PATIENTS
1. (DA, FCPS Anaesthesia, M. Sc.
Pain Medicine),
Assistant Professor of Anesthesia,
Intensive Care Unit and Pain
Management.
Nishtar Medical College/Hospital Syed Aftab Haider1, Atqua Sultan2, Zaira Salman3, Salman Waris4, Muhammad Yousaf5
Multan.
2. (Resident FCPS Anaesthesia),
ABSTRACT… Objectives: To determine the incidence and outcomes of pneumothorax in
Nishtar Medical College/Hospital critically ill patients admitted in intensive care unit (ICU). Study Design: Retrospective study.
Multan. Setting: Intensive care unit of Nishtar Hospital Multan. Period: 1 July, 2016 to 31 Dec, 2016.
3. (Resident MS Anaesthesia), Methods: Included analysis of 300 patients. Patients of all age groups and gender were included
Nishtar Medical College/Hospital
Multan. in this analysis. We reviewed their clinical records regarding age, gender, incidence and type of
4. (DA, MCPS, FCPS Anaesthesia), pneumothorax, pneumothorax episodes and its causes. Diagnosis of pneumothorax was based
Professor of Anesthesia, on clinical examination and plain chest X-rays of patients. Results: Pneumothorax occurred only
Intensive Care Unit and Pain
Management.
in 26 (8.7%) patients. Out of these 26 patients, there were 3 (1.0%) patients in whom spontaneous
Nishtar Medical College/Hospital pneumothorax occurred and in remaining 23 (7.7%) patients pneumothorax was iatrogenic in
Multan. nature. There was significantly higher rate of mortality in patients who developed pneumothorax
5. (DA, FCPS Anaesthesia), 38.46%versus 3.2% in patients without pneumothorax (p-value <0.001). Duration of ICU stay
Associate Professor of Anesthesia,
Intensive Care Unit and Pain was also significantly prolonged in pneumothorax patients 11.4 days versus only 6.2 days
Management. in patients without pneumothorax (p-value <0.001). Patients with iatrogenic pneumothorax,
Nishtar Medical College/Hospital mortality occurred in 5 (83.3%) patients in whom pneumothorax occurred due to mechanical
Multan.
ventilation, 1 (33.3%) in patients with central venous catheter insertion, 2 (22.3%) in patients with
Correspondence Address: pericardiocentesis and 2 (40.0%) in patients with thoracentesis. Conclusion: Pneumothorax is
Dr. Syed Aftab Haider associated with a very high mortality and increased length of ICU stay. Mortality rate is higher
Postal Address: House No. 25, in pneumothorax due to mechanical ventilation (barotrauma) as compared to other procedure
Westernfort Canal View Society,
Qasim Villa, Cantt Multan. related pneumothoraxes.
[email protected]
Key words: Pneumothorax, Mechanical Ventilation, Mortality.
Article received on:
10/03/2017
Accepted for publication: Article Citation: Haider SA, Sultan A, Salman Z, Waris S, Yousaf M. Pneumothorax; Incidence
05/07/2017 and outcomes of pneumothorax in critically ill patients. Professional Med J
Received after proof reading:
08/08/2017
2017;24(8):1157-1161. DOI: 10.17957/TPMJ/17.3922

INTRODUCTION pneumothorax.7Incidence of pneumothorax is

Pneumothorax is a devastating complication in lower in patients with normal lungs and it mostly
patients admitted in intensive care units and is occurs in patients with underlying lung pathology
associated with very high rate of mortality and such as adult respiratory distress syndrome,
morbidity.1,2 It is caused by accumulation of pneumonia and obstructive lung diseases such
air in extra-pulmonary spaces within the chest as asthmatic patients.8,9
cavity caused due to leakage of air from the
lungs within the chest wall.3 Pneumothorax Pneumothorax significantly adds up in morbidity
can be spontaneous or iatrogenic, which is likeprolonged mechanical ventilation, increased
the most common. Incidence of spontaneous length of hospital stayand mortality of ICU
pneumothorax varies from 4% to 15% in patients patients.10-12 The purpose of this study is to
admitted in intensive care units (ICU).4,5 In United determine the incidence of pneumothorax in
States (US) nearly 7.4-18/100,000 patients suffer critically ill patients admitted in intensive care unit
from spontaneous pneumothorax.6 (ICU) of Nishtar Hospital Multan and its impact on
their outcome.
Mechanical ventilation is one of the major
causes of pneumothorax in ICU patients. It is METHODOLOGY
responsible for 30% to 97% of all causes of This retrospective study included analysis of 300
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PNEUMOTHORAX 2

patients who were admitted in intensive care unit mechanical ventilation, central venous catheter
of Nishtar Hospital Multan. Patients of all age (CVP) was inserted in 77 (38.7%) patients,
groups and gender were included in this analysis. thoracentesis was done in 23 (11.5%) patients
We reviewed their clinical records regarding age, and pericardiocentesis was done in 15 (7.5%)
gender, incidence and type of pneumothorax, patients (Figure-1).
pneumothorax episodes and its causes.
Spontaneous pneumothorax occurred only in 26
Patients were then divided into two groups on the (8.7%) patients. Out of these 26 patients, there
basis of type of pneumothorax. Group I: included were 3 (1.0%) patients in whom spontaneous
patients with spontaneous pneumothorax, Group pneumothorax occurred and in remaining 23
II: included patients with iatrogenic pneumothorax. (7.7%) patients pneumothorax was iatrogenic
Spontaneous pneumothorax was defined as in nature. Pericardiocentesis and mechanical
rupture of visceral pleura or lung parenchyma ventilation were the commonest causes of
with no definitive cause. And occurrence of iatrogenic pneumothorax (Table-II).
pneumothorax after some medical procedure was
defined as iatrogenic pneumothorax. Diagnosis of There was significantly higher rate of mortality
pneumothorax was based on clinical examination in patients who developed pneumothorax as
and plain chest X-rays of patients. Clinical compared to the patients who did not. Mortality
symptoms of pneumothorax included; Presence rate was 38.46% in patients who developed
of chest pain associated with respiratory distress, pneumothorax as compared to only 3.2% in
tachypnea, and absence of breath sounds and patients who did not develop pneumothorax
chest movement on the affected side. This was (p-value <0.001) (Figure-2). Duration of stay of
further confirmed by PA view of plain chest X-rays. patients in ICU was also significantly prolonged
in pneumothorax patients 11 days versus only 6
Data analysis was done using SPSS v23 software days in patients without pneumothorax (p-value
for Windows. Frequency and percentages were <0.001).
used to represent incidence, causes and types
of pneumothorax. Chi-square test was used to Regarding mortality rate in pneumothorax
compare mortality between spontaneous and patients, there was no mortality in patients with
iatrogenic pneumothorax, and mortality in patients spontaneous pneumothorax. Regarding mortality
with versus without pneumothorax. Independent rate in patients with iatrogenic pneumothorax,
sample t-test was used to compare length of ICU mortality occurred in 5 (83.3%) patients in whom
stay in patients with pneumothorax and without pneumothorax occurred due to mechanical
pneumothorax. P-value <0.05 was considered ventilation, 1 (33.3%) in patients with central
significant difference. venous catheter insertion, 2 (22.3%) in patients
with pericardiocentesis and 2 (40.0%) in patients
RESULTS with thoracentesis. But this difference in mortality
Out of three hundred patients, 71.6% patients was not statistically significant (p-value 0.12).
were male. The mean age of study patients was
55.4+12.7 years. The main reasons for admission
to intensive care unit was hemodynamic instability,
pulmonary edema, severe pneumonia, and acute
exacerbation of COPD (Table-I).

Invasive procedures were performed in 199

(66.3%) patients whereas 101 (33.7%) patients
were kept under monitoring. Out of these
199 patients, 84 (42.3%) patients underwent Figure-1. Types of Procedures performed in Intensive
care unit.

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PNEUMOTHORAX 3

Characteristics Results DISCUSSION

Age 55.4+12.7 In this study, we evaluated the incidence of
Male gender (%) 215 (71.6) pneumothorax in patients admitted in intensive
Female gender (%) 85 (28.4) care unit, length of intensive care unit (ICU) stay
Cause of Admission to ICU (%) and mortality rate in pneumothorax patients
Hemodynamic instability 155 (51.6) and effect of invasive procedures on mortality
Pneumonia 33 (11.0) in patients with pneumothorax. In our study,
Pulmonary edema 37 (12.3) incidence of pneumothorax was 26 (8.7%), with
Pleural effusion 23 (7.6) 35 episodes of pneumothorax. In our study
Acute Exacerbation of COPD 34 (11.3) spontaneous pneumothorax occurred only
Asthmatic attack 18 (6.0) in 1.0% of total ICU admissions whereas as
Table-I. Demographic characteristics of study iatrogenic pneumothorax occurred in 23 (7.7%) of
participants. ICU= intensive care unit, COPD=
chronic obstructive pulmonary disease
all ICU admission. In the study by El-Nawawy et al.
incidence of pneumothorax in patients admitted
Pneumothorax Incidence in ICU was 10.4%.13 Incidence of spontaneous
Total Incidence 26 (8.7)
pneumothorax in their study was 0.6%. Kao et al.
Spontaneous pneumothorax (%) 3 (1.0)
found 12% incidence of pneumothorax in their
Iatrogenic pneumothorax (%) 23 (7.7)
Mechanical ventilation (%) 6 (2.0) study.14
Central venous catheter (%) 3 (1.0)
Pericardiocentesis (%) 9 (3.0) In our study, duration of ICU stay was significantly
Thoracentesis (%) 5 (1.7) prolonged in patients who developed
Table-II. Incidence of pneumothorax with respect to pneumothorax, 11 days versus only 6 days in
etiological factors. patients without pneumothorax. Mortality in our
study was also significantly high in pneumothorax
With Pneumothorax
265 patients, 38.46% versus only 3.2% in patients
Without Pneumothorax
300 without pneumothorax. Several other studies have
250
also found similar results. Zhan et al. concluded
that ICU stay in patients with pneumothorax is
200 increased on an average of 4.4 days, resulting in
150 about 18 thousands dollar extra hospital charges
per patient.15 These authors also found 6.0%
100 higher mortality rate in pneumothorax patients.
16
10 9 El-Nawawy et al. concluded that duration of
50
ICU stay is increased to 7 days in patients with
0 pneumothorax as compared to the patients
Yes No
Mortality without pneumothorax.13 In their study, mortality
rate was 59.25% in pneumothorax patients and
Figure-2. Incidence of Mortality in patients with 10.3% in patients without pneumothorax.Hsu et
pneumothorax and without pneumothorax.
al also found similar results.11
No- Mortality
Type of Procedure P-value Most of the pneumothoraxes that occur in ICU are
Mortality(%) (%)
Mechanical ventilation 1 (16.7) 5 (83.3) iatrogenic in nature. Iatrogenic pneumothorax is
Central venous catheter 2 (66.7) 1 (33.3) further divided into two groups; occurring either
0.12
Pericardiocentesis 7 (77.7) 2 (22.3) due to barotrauma or due to thoracic procedures.
Thoracentesis 3 (60.0) 2 (40.0) In our study, pneumothorax in ventilated patients
Table-III. Mortality rate of iatrogenic pneumothorax due to barotrauma was accountable for 26.0% of
according to the types of procedures. all cases of iatrogenic pneumothorax. And thoracic
procedures such as CVP insertion, thoracentesis

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PNEUMOTHORAX 4

and pericardiocentesis were responsible for care unit. Clin Chest Med. 1999;20(2):317-27.
remaining 74.0% pneumothorax cases and
5. De Latorre FJ, Klamburg J, Leon C, Soler M, Rius J.
pericardiocentesis was the most common Incidence of pneumothorax and pneumomediastinum
procedure responsible for pneumothorax. In the in patients with aspiration pneumonia requiring
study of Chen et al. thoracic procedures were ventilatory support. Chest. 1977;72(2):141-4.
responsible for 58.0% cases for pneumothorax.16
6. Marx J, Walls R, Hockberger R. Rosen’s emergency
In their study thoracentesis was highly associated
medicine-concepts and clinical practice: Elsevier
with pneumothorax and pericardiocentesis was Health Sciences; 2013.
responsible for 10.0% cases of pneumothorax.
Despairs et al in a singlecenter study found 28.0% 7. de Lassence A, Timsit J-F, Tafflet M, Azoulay E, Jamali
incidence of pneumothorax after thoracentesis.17 S, Vincent F, et al. Pneumothorax in the intensive
care unit incidence, risk Factors, and outcome.
Some studies have reported that incidence of Anesthesiology. 2006;104(1):5-13.
pneumothorax after thoracentesis is reduced
to only 3.0% if thoracentesis is done under 8. Petersen GW, Baier H. Incidence of pulmonary
ultrasonography guidance.18,19 barotrauma in a medical ICU. CritCare Med.
1983;11(2):67-9.

In our study, mortality rate of mechanically 9. Pierson D. Complications associated with mechanical
ventilated patients after pneumothorax was ventilation. Crit Care Clin. 1990;6(3):711-24.
83.3%. Hsu et al found 77.4% mortality rate in
these patients.11 da Silva et also found a very high 10. Esteban A, Anzueto A, Frutos F, Alía I, Brochard L,
Stewart TE, et al. Characteristics and outcomes in
mortality rate in mechanically ventilated children adult patients receiving mechanical ventilation:
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11. Hsu C-W, Sun S-F. Iatrogenic pneumothorax related
on mechanical ventilation and in other patients
to mechanical ventilation. World JCrit Care Med.
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The main limitation of our study is its small sample 12. da Silva PSL, de Aguiar VE, Fonseca MCM. Iatrogenic
size and furthermore this study is conducted only pneumothorax in mechanically ventilated children:
Incidence, risk factors and other outcomes. Heart
in a single center. We recommend that a large Lung: J Acute Crit Care. 2015;44(3):238-42.
scale study should be conducted in our country
to get the exact estimations of spontaneous and 13. El-Nawawy AA, Al-Halawany AS, Antonios MA, Newegy
iatrogenic pneumothorax in patients admitted to RG. Prevalence and risk factors of pneumothorax
among patients admitted to a Pediatric Intensive
intensive care units.
Care Unit. Indian J Crit Care Med. 2016;20(8):453-58.
Copyright© 05 July, 2017.
14. Kao H-K, Wang J-H, Sung C-S, Huang Y-C, Lien T-C.
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“Those who follow the crowd usually

get lost in it.”
Unknown

AUTHORSHIP AND CONTRIBUTION DECLARATION

Sr. # Author-s Full Name Contribution to the paper Author=s Signature
1 Syed Aftab Haider
Conceived, designed the
methodology
2 Atqua Sultan Did data collection and helped in
statistical analysis
3 Zaira Salman Did data collection and manuscript
writing
4 Salman Waris Supervised the research project and
gave final approval for publication
5 Muhammad Yousaf Supervised the research project and
gave final approval for publication

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