Original Editor - The Open Physio project. Show
Top Contributors - Abbey Wright, Siobhán Cullen, Admin, SULEIMAN USMAN, Eugenie Lamprecht, Kim Jackson, Nikhil Benhur Abburi, Shreya Pavaskar, Rachael Lowe, WikiSysop, Karen Wilson, Vidya Acharya and Claire Knott Definition[edit | edit source]Left pneumothorax. This X-ray is used on clinicalcases.org to illustrate a fictional case history of tension pneumothorax. Note the large, well-demarcated area devoid of lung markings, the tracheal deviation and movement of the heart away from the affected side. A pneumothorax can be defined as air in the pleural cavity[1]. This occurs when there is a breach of the lung surface or chest wall which allows air to enter the pleural cavity and consequently cause the lung to collapse. Types of Pneumothorax[edit | edit source]Various causes of pneumothoraces exist and each pneumothorax is classified according to its cause[2][3]. Primary Pneumothorax[edit | edit source]Also referred to as a spontaneous pneumothorax or primary spontaneous pneumothorax. It is characterized by having no clear cause or no known underlying lung pathology. There may be contributing factors, such as cigarette smoke, family history, the rupture of the bulla (small air-filled sacs in the lung tissue) but these will not cause pneumothorax itself. Secondary Pneumothorax[edit | edit source]Also referred to as a non-spontaneous or complicated pneumothorax. It occurs as a result of an underlying lung pathology such as COPD, Asthma, Tuberculosis, Cystic Fibrosis or Whooping Cough. Tension or Non-tension Pneumothorax[edit | edit source]A pneumothorax can further be classified as tension or non-tension pneumothorax.[4] A tension pneumothorax is caused by excessive pressure build up around the lung due to a breach in the lung surface which will admit air into the pleural cavity during inspiration but will not allow any air to escape during expiration. The breach acts as a one-way valve. This leads to lung collapse. The removal of the air is through the surgical incision by inserting an underwater drain in the pleural cavity. This excessive pressure can also prevent the heart from pumping effectively which may lead to shock. A non-tension pneumothorax is not considered as severe as there is no ongoing accumulation of air and therefore there is no increased pressure on the organs and the chest. Traumatic Pneumothorax[edit | edit source]Other causes of a pneumothorax can be trauma or incorrect medical care. A traumatic pneumothorax is caused by trauma to the lungs. Some of the causes are the following: Stab wound, gunshot, or injury from a motor vehicle accident or any other trauma to the lungs.[4] A pneumothorax which develops as a result of a medical procedure or incorrect medical care i.e. accidental puncture to the lung during surgery is termed as an iatrogenic pneumothorax.[4] Causes and Risk Factors[edit | edit source]The cause of primary spontaneous pneumothorax is unknown (idiopathic), but established risk factors include[2][5]:
Secondary spontaneous pneumothorax occurs in the setting of a variety of lung diseases. The most common is a chronic obstructive pulmonary disease (COPD), which accounts for approximately 70% of cases[5]. Known lung diseases that may significantly increase the risk for pneumothorax are:
Other traumatic factors may also lead to pneumothorax and eventually lung collapse[4]:
Signs and Symptoms[edit | edit source]
Epidemiology[edit | edit source]Primary spontaneous pneumothorax occurs most often in people between age 18 - 40 and Secondary spontaneous pneumothoraces occur more frequently after age 60 years. Prevalence of a pneumothorax in a newborn is a potentially serious problem and it occurs in about 1-2% of all births.[2] The overall person consulting rate for pneumothorax (primary and secondary combined) in the GPRD was 24.0/100 000 each year for men and 9.8/100 000 each year for women. Hospital admissions for pneumothorax as a primary diagnosis occurred at an overall incidence of 16.7/100 000 per year and 5.8/100 000 per year for men and women, respectively. Mortality rates were 1.26/million per year for men and 0.62/million per year for women.[2] Pathology[edit | edit source]The pleural cavity is the region between the chest wall and the lungs. If the air enters the pleural cavity, either from the outside (open pneumothorax) or from the lung (closed pneumothorax), the lung collapses and it becomes difficult for the person to breath. Tissue can form a one way-valve which allows air to enter the pleural cavity, but not to escape, overpressure can build up with each breath (tension pneumothorax). This leads to severe shortness of breath, deviation of the heart and compression on the vena cava leading to shock.[6] There is a loss of intrapleural negative pressure that can result in a lung collapse. Due to this there is a decrease in vital capacity as well as a decrease in PaO2 which is the main consequence of a pneumothorax. The decrease in PaO2 results from various factors i.e low ventilation-perfusion ratios, anatomic shunts and alveolar hypoventilation. Most patients that suffer from a pneumothorax also have an increase in alveolar-arterial oxygen tension.[6] [7] Diagnosis[edit | edit source]Initially a complete medical and physical examination needs to be conducted. Auscultation[edit | edit source]On examination of the chest with a stethoscope, it will be noted that there is either decreased or absent breath sounds over the area of the affected lung, which may indicate that the lung is not inflated in that particular area[8]. There is hyper resonance (higher pitched sounds than normal) with percussion of the chest wall which is suggestive of pneumothorax diagnosis. Imaging[edit | edit source]Chest x- rays will then be used to confirm the diagnosis of the pneumothorax.[9] In a supine chest x-ray, a deep sulcus sign is diagnostic and this is characterised by a low lateral costophrenic angle on the affected side[8]. Also, the presence of air outside normal lung airways and movement or shifting of the organs away from the air leak in the thoracic cavity will be indicative of the presence of a pneumothorax. Ultra sound scan can also provide diagnostic assistance[9]. Diagram showing a neonate with a right tension pneumothorax. Note the tracheal deviation to the left. Prognosis[edit | edit source]Up to 50% of patients who suffer from a pneumothorax will have another or a recurring pneumothorax. However, there are no long-term complications after successful treatment. Medical and Surgical Management[edit | edit source]Pneumothorax is a medical emergency that needs to be addressed rapidly once diagnosed[10]. The main aim is to relieve the pressure on the lung and allow it to expand. It is of vital importance to try and prevent the recurrence of pneumothorax. Treatment may be determined by the severity of symptoms and indicators:
Treatment[edit | edit source]There are a variety of treatment options for a spontaneous pneumothorax. It has been shown that intervention has similar results to conservative management of pneumothorax including less days spent in hospital[11][12]:
[15] Recurrent pneumothorax treatment[edit | edit source]For patients with recurrent pneumothorax after surgical intervention, there are several options[16]. For patients with a total or near-total lung collapse, repeat surgical intervention is recommended. Options include:
Physiotherapy Management[edit | edit source]Indications for Physiotherapy[edit | edit source]
Goals for Physiotherapy[edit | edit source]1.To improve ventilation and increase PaO2 levels
2. To assist in sputum removal[18]
3. To reduce work of breathing
4. Improve exercise tolerance
Physiotherapy outcome evaluation includes[edit | edit source]
References[edit | edit source]
Is a pneumothorax air in the pleural space?A pneumothorax is a collection of air outside the lung but within the pleural cavity. It occurs when air accumulates between the parietal and visceral pleura inside the chest. The air accumulation can apply pressure on the lung and make it collapse.
What is pneumothorax caused by?It can occur due to abnormal air sacs in the lungs that break apart and release air. Secondary spontaneous pneumothorax: Several lung diseases may cause a collapsed lung. These include chronic obstructive pulmonary disease (COPD), cystic fibrosis and emphysema.
What does pneumothorax mean?(NOO-moh-THOR-ax) An abnormal collection of air in the space between the thin layer of tissue that covers the lungs and the chest cavity. This can cause all or part of the lung to collapse. A pneumothorax may be caused by a chest injury, certain medical procedures, lung disease, or other damage to lung tissue.
What is the accumulation of air in the pleural space?Pneumothorax: Accumulation of air within the pleural cavity between the outside of the lung and the inside of the rib cage.
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