Pneumothorax. Classification, Clinic, Diagnostics, Treatment of Open and Tense Pneumothorax

Question 38
PNEUMOTHORAX. CLASSIFICATION,
CLINIC, DIAGNOSTICS, TREATMENT OF
OPEN AND TENSE PNEUMOTHORAX.
CLASSIFICATION
Pneumothorax : presence of air or gas in the pleural cavity (ie, the potential
space between the visceral and parietal pleura of the lung), which can impair
oxygenation and/or ventilation.
1) Spontaneous pneumothorax: rupture of blebs and bullae → air moves into

pleural space with increasing positive pressure → ipsilateral lung is compressed
and collapses
2) Traumatic pneumothorax
Closed pneumothorax: air enters through a hole in the lung (e.g., following blunt
trauma)
Open pneumothorax: air enters through a lesion in the chest wall (e.g., following
penetrating trauma)
3) Tension pneumothorax (valvular) : caused by the damage of a pulmonary

tissue or chest wall with formation of the valve, when the air during inspiration
enters a pleural space, and during expiration, due to valve closure, does not exit.
It is the most dangerous form of pneumothorax, which results in a complete
pulmonary collapse, shift of mediastinum, inflection of major vessels and cardiac
arrest.

CLINICAL MANIFESTATION
Patients range from being asymptomatic to having features of hemodynamic compromise.
1. Sudden, severe, and/or stabbing, ipsilateral pleuritic chest pain and dyspnea
2. Reduced or absent breath sounds, hyperresonant percussion, decreased fremitus on the ipsilateral side
3. Subcutaneous emphysema
4. Additional findings in tension pneumothorax
1) Severe acute respiratory distress: cyanosis, restlessness, diaphoresis
2) Reduced chest expansion on the ipsilateral side
3) Distended neck veins and hemodynamic instability (tachycardia, hypotension, pulsus paradoxus)
4) Secondary injuries may be present (e.g., open or closed wounds).
5) Signs of tension pneumothorax in ventilated patients
Tachycardia, hypotension (obstructive shock), Distention of jugular vein, Rapid decrease in SpO2, Reduced air flow, Increased
ventilation pressure, Skin emphysema

DIAGNOSTICS (1)
1. General principles
1) The diagnosis of pneumothorax is usually confirmed by chest x-ray.
- Ultrasound is becoming an increasingly accepted modality for identifying pneumothorax and is

part of the eFAST.
- CT can provide information about the underlying cause (e.g., bullae in spontaneous
pneumothorax).
2) Tension pneumothorax is primarily a clinical diagnosis and prolonged diagnostic studies should
be avoided in favor of initiating immediate treatment.

DIAGNOSTICS (2)
2. Chest x-ray
1) Indications: all patients suspected of having pneumothorax
2) Procedure: Upright PA chest x-ray in inspiration is the modality of

choice.
3) Supportive findings of pneumothorax
- Ipsilateral pleural line with reduced/absent lung markings (i.e.,

increased transparency)
- Abrupt change in radiolucency
- Deep sulcus sign : Decreased radiodensity and deep costophrenic

angle on the ipsilateral side , The sign is a result of interpleural air that
collects basally and anteriorly in the supine position.
- Hemidiaphragm elevation on the ipsilateral side
- If pulmonary disease is present: airway or parenchymal lesions
4) Supportive findings of tension pneumothorax : Ipsilateral

diaphragmatic flattening/inversion and widened intercostal spaces ,
Mediastinal shift toward the contralateral side , Tracheal deviation
toward the contralateral side
DIAGNOSTICS
3. Ultrasound
1) Indications : Trauma (eFAST), Quick bedside assessment
2) Supportive findings: Absence of pleural sliding , Absence of B-lines , Barcode sign instead of seashore sign in M-mode ,
Combination of prominent A-lines and absent B-lines
4. Chest CT
1) Indications : Uncertain diagnosis despite chest x-ray and complex cases, In suspected underlying lung disease, to determine
the likelihood of recurrent disease, Detailed assessment of bullae, Presurgical workup
2) Findings: similar to CXR
4. Laboratory studies : Laboratory analysis is generally not indicated.
1) Arterial blood gas analysis (ABG)
Indications : SpO2 < 92% on room air, Evaluation for CO2 retention in patients with lung disease (e.g., COPD) receiving
supplemental O2
Findings: ↓ PaO2 may be present
TREATMENT
Management of pneumothorax.
1. Observation and Supplementary O2
: If the amount of pneumothorax is less than 20% in

one side of the chest (based on volume) and is
asymptomatic, Absorbed naturally after 1-2 weeks,
When 100% oxygen is inhaled, it is absorbed 4 times
faster
2. Thoracentesis (Simple needle aspiration)
: Penetrate the 2nd ICS, anterior at midclavicularline

using a 16 gauge needle
Primary spontaneous pneumothorax (15-50% level),

Iatrogenic pneumothorax (PCNB, etc., if it occurs at the
same time. The size should also be small)
TREATMENT (2)
3. Closed tube thoracostomy (Chest tube insertion) and suction drainage: Chest tube drainage
(CTD)
- Severe symptomatic, Primary pneumothorax, but very large, over 50%, Traumatic pneumothorax
- Cases that occurred during mechanical ventilation during iatrogenic pneumothorax (caused by
positive pressure), other large cases
- Tension pneumothorax; Urgent needle thoracostomy was performed quickly first, followed by
CTD.
- If there is a lesion in the opposite lung, In case of gradually increasing pneumothorax on f/u
Chest X-ray, In case of secondary pneumothorax caused by lung lesion
Procdure : Most commonly in the 4th–5th intercostal space (nipple line), between the anterior and
midaxillary line (safe triangle ), The chest drainage system may be used with or without suction,
Always check CXR after the procedure is complete.
TREATMENT (3)
4. Surgical management: Bleb stapling/resection & Pleurodesis
: Chronic, recurrent, Persistent air leak, Bilateral pneumothorax, Distinctive bullae/cyst

on X-ray, Collapse > 75%, Climbers, divers, pilots, etc.
Procedure :Video-assisted thoracoscopic surgery (VATS), Thoracotomy if necessary
THANK YOU

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Question 38

1) Spontaneous pneumothorax: rupture of blebs and bullae → air moves into

3) Tension pneumothorax (valvular) : caused by the damage of a pulmonary

4. Additional findings in tension pneumothorax

1) Severe acute respiratory distress: cyanosis, restlessness, diaphoresis

2) Reduced chest expansion on the ipsilateral side

4) Secondary injuries may be present (e.g., open or closed wounds).

5) Signs of tension pneumothorax in ventilated patients

1) The diagnosis of pneumothorax is usually confirmed by chest x-ray.

- Ultrasound is becoming an increasingly accepted modality for identifying pneumothorax and is

1) Indications: all patients suspected of having pneumothorax

2) Procedure: Upright PA chest x-ray in inspiration is the modality of

3) Supportive findings of pneumothorax

- Ipsilateral pleural line with reduced/absent lung markings (i.e.,

- Abrupt change in radiolucency

- Deep sulcus sign : Decreased radiodensity and deep costophrenic

- Hemidiaphragm elevation on the ipsilateral side

- If pulmonary disease is present: airway or parenchymal lesions

4) Supportive findings of tension pneumothorax : Ipsilateral

1) Indications : Trauma (eFAST), Quick bedside assessment

2) Findings: similar to CXR

4. Laboratory studies : Laboratory analysis is generally not indicated.

1) Arterial blood gas analysis (ABG)

Findings: ↓ PaO2 may be present

1. Observation and Supplementary O2

: If the amount of pneumothorax is less than 20% in

2. Thoracentesis (Simple needle aspiration)

: Penetrate the 2nd ICS, anterior at midclavicularline

Primary spontaneous pneumothorax (15-50% level),

: Chronic, recurrent, Persistent air leak, Bilateral pneumothorax, Distinctive bullae/cyst

Procedure :Video-assisted thoracoscopic surgery (VATS), Thoracotomy if necessary

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