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Causes and symptoms
- Spontaneous pneumothorax. Simple spontaneous pneumothorax is caused by a rupture of a small air sac or fluid-filled sac in the lung. It may be related to activity in otherwise healthy people or may occur during scuba diving or flying at high altitudes. Complicated spontaneous pneumothorax, also generally caused by rupture of a small sac in the lung, occurs in people with lung diseases. The symptoms of complicated spontaneous pneumothorax tend to be worse than those of simple pneumothorax, due to the underlying lung disease. Spontaneous pneumothorax is characterized by dull, sharp, or stabbing chest pain that begins suddenly and becomes worse with deep breathing or coughing. Other symptoms are shortness of breath, rapid breathing, abnormal breathing movement (that is, little chest wall movement when breathing), and cough.
- Tension pneumothorax. Following trauma, air may enter the chest cavity. A penetrating chest wound allows outside air to enter the chest, causing the lung to collapse. Certain medical procedures performed in the chest cavity, such as thoracentesis, also may cause a lung to collapse. Tension pneumothorax may be the immediate result of an injury; the delayed complication of a hidden injury, such as a fractured rib, that punctures the lung; or the result of lung damage from asthma, chronic bronchitis, or emphysema. Symptoms of tension pneumothorax tend to be severe with sudden onset. There is marked anxiety, distended neck veins, weak pulse, decreased breath sounds on the affected side, and a shift of the mediastinum to the opposite side.
A small spontaneous pneumothorax may require no specific treatment beyond rest and administration of oxygen for relief of dyspnea. Chest x-rays should be obtained. The patient usually is more comfortable if allowed to sit up. A larger spontaneous pneumothorax may require a more aggressive approach such as aspiration to allow for reexpansion of the lung. If air continues to leak from the defect in the lung surface a continuous closed-drainage apparatus is set up (see chest tube). As soon as the lung lesion heals and the lung is reexpanded, the patient is allowed to resume usual daily activities. Guidelines for the treatment of spontaneous pneumothorax have been published by the American College of Chest Physicians and are available on their web site at http://www.chestnet.org.
pneumothoraxLung collapse Pulmology The presence of air in the pleural space, which may be 1º–seen in tall, thin, young ♂, characterized by subpleural apical blebs, 2º–asthma, COPD, PCP, trauma, TB, iatrogenic–due to thoracentesis, subclavian line placement, PEEP, bronchoscopy Clinical Pleural pain, dyspnea, ↓ breath sounds, percussion hyperresonance, ↓ tactile fremitus Management Small blebs may heal spontaneously, larger pneumothoraces require chest tube drainage, pleurodesis. See Spontaneous pneumothorax.
pneumothorax(noo?mo-thor'aks?, nu? ) (-thor'a-sez?) plural.pneumothoracesplural.pneumothoraxes [ pneum- + thorax]
The onset is sudden, usually with a severe sharp pain in the side of the chest, and dyspnea. The physical signs are those of a distended unilateral chest, increased resonance, decrease in or absence of breath sounds, and, if fluid is present, a splashing sound on succussion (shaking) of the patient. Patients often report chest pain is worsened by coughing, deep breathing, or movement.
Chest x-rays confirm the diagnosis, revealing air in the pleural space, often identified as a line seen outlining a partially collapsed lung. A shift of the mediastinum toward one side of the chest or the other may be seen in tension pneumothorax. See: tension pneumothorax
Treatment varies according to type and amount of lung collapse. Traumatic or iatrogenic pneumothorax requires chest tube insertion to closed (water-sealed) chest drainage for lung re-expansion. Surgical repair also may be required. Spontaneous pneumothorax may be treated conservatively with bedrest if there is no sign of increased pleural pressure, less than 15% lung collapse, no dyspnea or other indication of physiological compromise. If the patient's condition worsens or if more than 15% of the lung is collapsed, a thoracostomy tube may be placed anteriorly in the second intercostal space and attached to a Heimlich flutter valve or chest-drainage unit. If fluid is present in the pleural space, a thoracostomy tube is placed in the fourth, fifth, or sixth intercostal space more posteriorly to drain it.
The patient's vital signs, chest expansion, oximetry and/or blood gases are monitored and oxygen administered to prevent hypoxia. The purpose and process for placing a chest tube are explained to the patient to allay anxiety and foster cooperation with the procedure. After the surgeon prepares and drapes the patient in sterile fashion, and administers local anesthesia, a small incision is made. A thoracostomy tube is attached to a water-sealed drainage device. The patient is placed in the semi-Fowler position to promote drainage, comfort, and ease of breathing. Vital signs and ventilatory status are monitored. Once the tube is placed, deep breathing (incentive spirometry) and coughing are encouraged (at least hourly) to promote lung expansion, with prescribed analgesics provided to control pain and discomfort (due in part to the tube itself). Ambulation is encouraged to facilitate full inspiration and enhance lung expansion. The thoracostomy tube site is kept sealed, generally by using a purse-string suture and occlusive dressing. Care is taken to avoid tension on the tubing, and all connections also are sealed to avoid air leaks. If the tube is accidentally dislodged, an occlusive (petroleum gauze) dressing is placed over the opening immediately to prevent lung collapse. When chest x-ray demonstrates adequate lung re-expansion that remains stable without suction, the thoracostomy tube is carefully removed, and the incision is covered with an occlusive dressing. The importance of follow-up examination, x-ray, and any needed care is explained prior to discharge. Patients who smoke are urged to stop smoking and exercise is increased gradually as determined by follow-up evaluation.
Scattered adhesions may afford only a partial collapse. Effusion may occur in about one third of the cases. Hazards include pain, infection, and respiratory distress.
Although some patients with pneumothorax have few symptoms, most people who come to clinical attention report the sudden onset of left- or right-sided chest pain, often accompanied by shortness of breath. Breath sounds may be absent on the affected side, or the lung percussion note on that side may reveal increased resonance.
The patient is assessed for evidence of respiratory failure or the need for immediate intervention. The development of tension pneumothorax is a medical emergency; if it is not promptly relieved, the patient will experience inadequate cardiac output and hypoxemia (and may die). To prevent rapid decompensation, a large-bore needle is inserted emergently into the pleural space at the second intercostal space, mid-clavicular line (needle decompression, needle thoracotomy). This temporizing procedure must be followed by thoracostomy tube placement and water-sealed chest drainage unit.