Review Article

Pneumothorax: from definition to diagnosis and treatment

Paul Zarogoulidis1, Ioannis Kioumis1, Georgia Pitsiou1, Konstantinos Porpodis1, Sofia Lampaki1,
Antonis Papaiwannou1, Nikolaos Katsikogiannis2, Bojan Zaric3, Perin Branislav3, Nevena Secen3,
Georgios Dryllis4, Nikolaos Machairiotis5, Aggeliki Rapti6, Konstantinos Zarogoulidis1
1
Pulmonary Department, “G. Papanikolaou” General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece; 2Surgery Department,
University General Hospital of Alexandroupolis, Democritus University of Thrace, Alexandroupolis, Greece; 3Institute for Pulmonary Diseases
of Vojvodina, Clinic for Thoracic Oncology, Faculty of Medicine, University of Novi Sad, Novi Sad, Serbia; 4Hematology Department, “Laiko”
University General Hospital, Athens, Greece; 5Obstetric-Gynecology Department, “Thriassio” General Hospital of Athens, Athens, Greece;
6
Pulmonary Department, “Sotiria” Hospital for Chest Diseases, Athens, Greece
Correspondence to: Paul Zarogoulidis, MD, PhD. Pulmonary Department, “G. Papanikolaou” General Hospital, Aristotle University of Thessaloniki,
Thessaloniki, Greece. Email: [email protected].

Abstract: Pneumothorax is an urgent situation that has to be treated immediately upon diagnosis.
Pneumothorax is divided to primary and secondary. A primary pneumothorax is considered the one that
occurs without an apparent cause and in the absence of significant lung disease. On the other hand secondary
pneumothorax occurs in the presence of existing lung pathology. There is the case where an amount of air
in the chest increases markedly and a one-way valve is formed leading to a tension pneumothorax. Unless
reversed by effective treatment, this situation can progress and cause death. Pneumothorax can be caused
by physical trauma to the chest or as a complication of medical or surgical intervention (biopsy). Symptoms
typically include chest pain and shortness of breath. Diagnosis of a pneumothorax requires a chest X-ray or
computed tomography (CT) scan. Small spontaneous pneumothoraces typically resolve without treatment
and require only monitoring. In our current special issue we will present the definition, diagnosis and
treatment of pneumothorax from different experts in the field, different countries and present different
methods of treatment.

Keywords: Pneumothorax; medical thoracoscopy; spontaneous; secondary

Submitted Sep 09, 2014. Accepted for publication Sep 10, 2014.
doi: 10.3978/j.issn.2072-1439.2014.09.24
View this article at: http://dx.doi.org/10.3978/j.issn.2072-1439.2014.09.24

Primary spontaneous observed. There are several cases where a PSP is a threat for
a patient’s life, however; several patients may wait several
Spontaneous pneumothoraces are divided into two types:
days before seeking medical attention. It has been observed
primary, which occurs in the absence of known lung disease,
that it is rare for PSPs to cause tension pneumothoraces.
and secondary, which occurs in someone with underlying
lung disease. Until now the cause of primary spontaneous
pneumothorax (PSP) has not been identified, however; Secondary spontaneous
several risk factors have been identified such as; smoking, Secondary spontaneous pneumothorax occurs due to
male sex, and a family history of pneumothorax. Several underlying chest diseases. Most commonly they are
underlying mechanisms have been observed and are observed in patients with chronic obstructive pulmonary
discussed below. Moreover; a PSP tends to occur in a young disease (COPD), which accounts for approximately 70%
adult without underlying lung problems. Symptoms such of cases. Other known lung diseases that may increase the
as, chest pain and sometimes mild breathlessness are usually incidence for pneumothorax are; tuberculosis, necrotizing

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Journal of Thoracic Disease, Vol 6, Suppl 4 October 2014 S373

pneumonia, pneumonocystis carini, lung cancer, sarcoma tube. Treatment also depends on the physician that is going
involving the lung, sarcoidosis, endometriosis, cystic to handle the patient; pulmonary physicians usually perform
fibrosis, acute severe asthma, idiopathic pulmonary fibrosis, medical thoracoscopy (minimally invasive) one port, while
Rheumatoid arthritis, ankylosing spondylitis, polymyositis thoracic surgeons use a surgery suite and two ports. In some
and dermatomyositis, systemic sclerosis, Marfan’s syndrome cases patient preference is requested.
and Ehlers-Danlos syndrome, histiocytosis X and In traumatic pneumothorax, chest tubes are usually
lymphangioleiomyomatosis (LAM). Secondary spontaneous inserted and these patients are handled by thoracic surgeons
pneumothoraces (SSPs), by definition, occurs in individuals as other chest organs might be affected. If mechanical
with significant underlying lung disease. The following ventilation is required, the risk of tension pneumothorax
symptoms are usually observed; hypoxemia and hypercapnia is greatly increased and the insertion of a chest tube is
in more severe cases. The sudden onset of breathlessness mandatory. Any open chest wound should be covered with
in patients with known underlying lung diseases such as; an airtight seal, as it carries a high risk of leading to tension
COPD, cystic fibrosis, or other serious lung diseases should pneumothorax.
therefore prompt investigations to identify the possibility of Tension pneumothorax is usually treated with urgent
a pneumothorax. needle decompression. There are several cases where
“silent lung” is observed and needle decompression may
be required before transport to the hospital upon the site
Traumatic pneumothorax
of the accident, and can be performed by an emergency
Traumatic pneumothorax occurs when the chest wall medical technician or other trained professional. The
is pierced, such as when a stab wound or gunshot needle or cannula is left in place until a chest tube can be
wound allows air to enter the pleural space. Traumatic inserted. If tension pneumothorax leads to cardiac arrest,
pneumothoraces have been found to occur in up to needle decompression is performed as part of resuscitation
half of all cases of chest trauma, with only rib fractures as it may restore cardiac output.
being more common in this group. The pneumothorax
can be occult in half of these cases, but may enlarge—
Conservative
particularly if mechanical ventilation is required. This type
of pneumothorax has also been observed to patients already Small spontaneous pneumothoraces do not always require
receiving mechanical ventilation for some other reason. treatment, as they are unlikely to proceed to respiratory
failure or tension pneumothorax, and generally resolve
spontaneously. A case by case evaluation is needed and
Mechanism
careful follow up of these patients. This approach is most
The thoracic cavity contains the lungs, heart, and appropriate if the estimated size of the pneumothorax is
numerous major blood vessels. On each side of the cavity, small (defined as <50% of the volume of the hemithorax),
a pleural membrane covers the surface of lung (visceral there is no breathlessness, and there is no underlying lung
pleura) and also lines the inside of the chest wall (parietal disease. A 24-hour observation is optional for these patients
pleura). Between the two layers there is a small amount of or clear instructions are given to return to hospital if there
lubricating serous fluid. The lungs are fully inflated within are worsening symptoms. Follow up as outpatients require
the cavity because the pressure inside the airways is higher repeated X-rays to confirm improvement. Secondary
than the pressure inside the pleural space. Pneumothorax pneumothoraces are only treated conservatively if the size
can only develop if air is allowed to enter, through damage is very small (1 cm or less air rim) and there are limited
to the chest wall or damage to the lung itself, or occasionally symptoms. Oxygen given at a high flow rate may accelerate
because microorganisms in the pleural space produce gas. resorption as much as fourfold.

Treatment Aspiration

The treatment of pneumothorax depends on a number of In view of a large PSP (>50%), or in a PSP associated
factors, and may vary from discharge with early follow-up with breathlessness, guidelines recommend that reducing
to immediate needle decompression or insertion of a chest the size by aspiration is equally effective as the insertion

© Pioneer Bioscience Publishing Company. All rights reserved. www.jthoracdis.com J Thorac Dis 2014;6(S4):S372-S376
S374 Zarogoulidis et al. Pneumothorax: an up-to-date presentation

of a chest tube. In order to perform this procedure Pleurodesis and surgery

administration of local anesthetic is necessary and inserting
Pleurodesis is considered the final solution it is a procedure
a needle connected to a three-way tap; up to 2.5 liters of
that permanently obliterates the pleural space and attaches
air (in adults). Upon follow up if there has been significant
the lung to the chest wall. The surgical thoracotomy with
reduction in the size of the pneumothorax on subsequent
identification of any source of air leakage and stapling of
X-ray, the remainder of the treatment can be conservative.
blebs—followed by pleurectomy of the outer pleural layer
It has been observed that when compared to tube drainage,
and pleural abrasion of the inner layer is considered most
first-line aspiration in PSP reduces the number of people
effective. During the healing process, the lung adheres to
requiring hospital admission significantly, without
the chest wall, effectively obliterating the pleural space.
increasing the risk of complications. The same technique
Recurrence rates are approximately 1%. Post-thoracotomy
could be also considered in secondary pneumothorax of
pain is usually observed.
moderate size (air rim 1-2 cm) without breathlessness,
A less invasive approach is thoracoscopy, usually in the
however; ongoing observation in hospital is required even
form of a procedure called video-assisted thoracoscopic
after a successful procedure.
surgery (VATS). The results of VATS are considered less
effective than thoracotomy, however; smaller scars in the
Chest tube skin. VATS offers a shorter in-hospital stays, less need
A chest tube (or intercostal drain) is the most definitive for postoperative pain control, and a reduced risk of lung
initial treatment of a pneumothorax. Chest tube is typically problems after surgery. VATS may also be used to achieve
inserted in an area under the axilla (armpit) called the chemical pleurodesis; this involves insufflation of talc.
“safe triangle”, where damage to internal organs can be Insufflation of talc induces an inflammation of the pleura
avoided. Local anesthetic is applied. Usually there are two surfaces. If a chest tube is already in place, various agents
types of tubes used. In spontaneous pneumothorax, small- may be instilled through the tube to achieve chemical
bore (smaller than 14 F, 4.7 mm diameter) tubes may be pleurodesis, such as talc, tetracycline, minocycline or
inserted by the Seldinger technique. Larger tubes do not doxycycline. Results of chemical pleurodesis tend to be
have an advantage. It has been observed that for traumatic worse than when using surgical approaches, talc pleurodesis
pneumothorax, larger tubes (28 F, 9.3 mm) are used. has been found to have the best results.
Chest tubes are required in PSPs that have not responded
to needle aspiration, in large SSPs (>50%), and in cases of Aftercare
tension pneumothorax. The method indicates that they
are connected to a one-way valve system that allows air If pneumothorax occurs in a smoker, it may be advisable
to escape, but not to re-enter, the chest. Several times it for someone to remain off work for up to a week after a
includes a bottle with water that functions like a water spontaneous pneumothorax (1-10). For those who have
seal, or a Heimlich valve. Moreover; they are not usually undergone pleurodesis it may take up to two to three weeks
connected to a negative pressure circuit, due to the fact that off work to recover. Air travel is discouraged for up to
this would result in rapid re-expansion of the lung and a seven days after complete resolution of a pneumothorax if
risk of pulmonary edema. The tube is left in place until no recurrence does not occur. Underwater diving is considered
air is seen to escape from it for a period of time (no more unsafe after an episode of pneumothorax unless a preventative
than 2 days), and X-rays confirm re-expansion of the lung. procedure has been performed (11-20). Currently
If after 2-4 days there is still evidence of an air leak, various professional guidelines suggest that pleurectomy should be
options are available. If air leak persists then, surgery may performed on both lungs and that lung function tests and CT
be required, especially in SSP. scan normalize before diving is resumed. Aircraft pilots may
Chest tubes are also used as first-line treatment when also require assessment for surgery (12,21-28).
pneumothorax occurs in people with AIDS, usually due to
underlying pneumocystis pneumonia (PCP), due to the fact
Summary
that this condition is associated with prolonged air leakage.
Furthermore, when bilateral pneumothorax occurs common In conclusion, treatment depends on the training of the
in people with PCP, surgery is often required. pulmonary physician who handles such a patient, if the

© Pioneer Bioscience Publishing Company. All rights reserved. www.jthoracdis.com J Thorac Dis 2014;6(S4):S372-S376
Journal of Thoracic Disease, Vol 6, Suppl 4 October 2014 S375

medical thoracoscopy can be applied then it could be Thorac Dis 2014;6 Suppl 1:S108-15.
the first option. In the case where medical thoracoscopy 12. Visouli AN, Darwiche K, Mpakas A, et al. Catamenial
is available or medical thoracoscopy has not provided pneumothorax: a rare entity? Report of 5 cases and review
previously a solution for a patient then a thoracic surgeon of the literature. J Thorac Dis 2012;4 Suppl 1:17-31.
or an experienced general surgeon should take over to 13. Zarogoulidis P, Chatzaki E, Hohenforst-Schmidt W, et al.
provide a solution for the patient. Management of malignant pleural effusion by suicide gene
therapy in advanced stage lung cancer: a case series and
literature review. Cancer Gene Ther 2012;19:593-600.
Acknowledgements
14. Papaioannou M, Pitsiou G, Manika K, et al. COPD
Disclosure: The authors declare no conflict of interest. Assessment Test: A Simple Tool to Evaluate Disease Severity
and Response to Treatment. COPD 2014;11:489-95.
15. Boskovic T, Stanic J, Pena-Karan S, et al. Pneumothorax
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Cite this article as: Zarogoulidis P, Kioumis I, Pitsiou G,

Porpodis K, Lampaki S, Papaiwannou A, Katsikogiannis N,
Zaric B, Branislav P, Secen N, Dryllis G, Machairiotis N, Rapti
A, Zarogoulidis K. Pneumothorax: from definition to diagnosis
and treatment. J Thorac Dis 2014;6(S4):S372-S376. doi:
10.3978/j.issn.2072-1439.2014.09.24

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