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Pneumothorax is a condition in which air or gas has entered the pleural cavity, which is the space between the two layers of pleura that line the outside of the lungs and the inside of the chest wall. This collection of air can expand the normally empty pleural space, increase pleural pressure, and result in a partial or complete collapse of the lung. The air usually enters the pleural space through a hole in the lung or chest wall. Pneumothorax usually occurs in one lung although bilateral pneumothorax (BLP) is also known to occur.
Pneumothorax can develop spontaneously as a result of an injury, a thoracic procedure, or an underlying condition, especially acute respiratory distress syndrome (ARDS). Spontaneous pneumothorax is typically caused by rupture of small air- or fluid-filled sacs in the lungs called blebs or bullae. These blister-like sacs are usually located at the apex of the lung. Symptoms of spontaneous pneumothorax usually begin without warning in persons who are thought to be otherwise healthy.
Traumatic pneumothorax results from a blunt or penetrating injury to the chest. For example, trauma from a car accident or a stab wound may allow air into the pleural space, causing the lung to collapse. Pneumothorax also can occur when the lung or chest wall is damaged during a medical procedure such as CT-guided lung biopsy, tracheostomy, bronchoscopy, or placement of a central venous catheter.
In tension pneumothorax, air accumulates inside the pleural space with each inspiration, causing excessive pressure to build up. This will collapse a lung and put abnormal pressure on the heart and major blood vessels, reducing the flow of blood from the heart (cardiac output) to the rest of the body. Tension pneumothorax most commonly occurs in individuals who are receiving mechanical ventilation (treatment in which a machine "breathes" for an individual whose respiration is compromised) or who have undergone cardiopulmonary resuscitation.
An occasional complication of lung disease among ICU patients is pneumothorax.
Risk: Risk for spontaneous pneumothorax is greater in those who smoke cigarettes (9 times greater in female smokers and 22 times greater in male smokers (Tamura), or who have a family history of the condition).
A rare form of pneumothorax related to menses occurs in otherwise healthy women during menstruation. Symptoms develop within 48 hours of menstrual flow.
Individuals with underlying lung diseases such as asthma, lung cancer, tuberculosis, whooping cough (pertussis), or chronic obstructive pulmonary disease (COPD) are more susceptible to pneumothorax as are individuals with cystic fibrosis or AIDS whose pulmonary function is compromised by their disease. Incidence and Prevalence: Pneumothorax affects 9 out of 100,000 individuals a year. Individuals receiving mechanical ventilation have an incidence of 4 to 15% (Chen). Spontaneous pneumothorax occurs most commonly in tall, thin men between the ages of 20 and 40. About 20,000 new cases of spontaneous pneumothorax are diagnosed each year in the US. |
Source: Medical Disability Advisor
| History: Symptoms may include a sudden onset of sharp chest pain, shortness of breath (dyspnea), fatigue, and occasionally, a dry, hacking cough, painful breathing, and chest tightness. The degree of breathlessness is proportional to the size of the pneumothorax. Symptoms tend to be less severe in a slowly developing pneumothorax, and may actually subside as the body adjusts to the altered physiological state. Physical exam: With a small collection of air, there may be no detectable signs other than diminished breath sounds. With a large or tension pneumothorax, breath sounds are markedly depressed or absent, heart rate will be rapid, and the lack of oxygen may result in a bluish tinge to the skin (cyanosis). Additional symptoms may include nasal flaring, anxiety, stress, and abdominal pain. Tests: Characteristic chest x-rays usually show the presence of air outside the lung itself. A small pneumothorax may be overlooked on inhalation and will be obvious only on exhalation. Chest x-rays may also detect underlying lung disease. CT scanning can be used to examine critically ill individuals who have either complicated pleural spaces or pre-existing multiple chest tubes. Lung volume and capacity may be measured by pulmonary function tests when the individual is stable. Arterial blood gases (ABG) may be performed to help evaluate respiration by measuring oxygen and carbon dioxide (CO2) content in the blood. An electrocardiogram (ECG) and echocardiogram may be used to assess the effect of pneumothorax on cardiac performance. |
Source: Medical Disability Advisor
| The objective of treatment is to restore complete lung expansion by removing the air or gas from the pleural space in a manner that is least likely to result in recurrence. For this reason, the least invasive treatment is usually preferred because of the higher likelihood of pneumothorax recurring after insertion of a chest tube or even more traumatic procedures.
A small pneumothorax in a healthy adult requires no treatment, as the air will usually reabsorb in a few days. A larger pneumothorax, or a small one associated with lung disease, usually requires treatment. To treat a small pneumothorax, air can be withdrawn from the pleural cavity through a small tube and one-way valve. Treatment of a large pneumothorax usually requires hospitalization and involves removing air from the pleural space with a suction tube (tube thoracostomy) inserted through the chest wall. The chest tube may need to stay in place for several days until the leaking of air from the lung ceases. If the opening (fistula) is large and persistent, surgical repair of the fistula or surgical removal of the involved lung segment (lobectomy or segmentectomy) may be required.
Treatment of pneumothorax associated with an underlying lung disease is often more difficult and requires more definitive therapy. Because these individuals may be poor surgical candidates, the least invasive procedure possible will be used. The surgeon may insert a thin, lighted instrument (thoracoscope) between the ribs to visualize the full pleura, staple or resect a blister (bleb), remove a portion of the pleura, and to apply electrocautery, laser, or sclerotherapy (injection of an agent that results in internal scarring) to seal the pleural cavity and seal the source of the air leak. |
Source: Medical Disability Advisor
| Outcome varies from complete recovery to chronic problems depending upon underlying conditions and the cause of the pneumothorax. Once a pneumothorax has healed, there is usually no long-term effect on health. Recurrence is common, especially within the first few months following the initial pneumothorax.
When the pneumothorax or collapsed lung has been treated appropriately, the lung usually re-expands in 2 to 3 days, and total recovery can be expected in 1 to 2 weeks. Removing air from the pleural cavity is generally successful regardless of the technique used.
Spontaneous pneumothorax has about a 15% chance of recurrence, usually on the same side; chances of recurrence on the other side are significantly less (Tamura). Individuals may help avoid recurrence by discontinuing smoking and avoiding high altitudes, scuba diving, or flying in unpressurized aircraft.
Lobectomy is an involved procedure and generally successful. The eventual outcome of the surgery itself depends upon additional treatment, which is usually uneventful.
Trauma and tension pneumothorax have higher mortality when associated with underlying lung disease (Chen). |
Source: Medical Disability Advisor
| If there is continual air leakage, the pneumothorax may become progressively larger. This can result in a tension pneumothorax, a condition in which air is allowed to enter but not escape the pleural space. A tension pneumothorax is a medical emergency as it may cause a life-threatening compression of the heart. |
Source: Medical Disability Advisor
| Work restrictions and accommodations are not usually associated with this condition. However, should exertion lead to increased efforts to breathe, a pneumothorax could recur. In such cases, the individual should be restricted from strenuous and heavy work until all danger of recurrence has passed. |
Source: Medical Disability Advisor
| If an individual fails to recover within the expected maximum duration period, the reader may wish to consider the following questions to better understand the specifics of an individual's medical case. Regarding diagnosis:
- Is there a history of injury to the chest and lungs?
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Did individual have a sudden onset of sharp chest pain and shortness of breath? How severe?
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Is individual a smoker? What is the individual's sex? Is the individual tall and thin?
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Has individual undergone CPR? Is he or she on a respirator?
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Does individual have any underlying condition that places him/her at risk for developing a pneumothorax such as asthma, COPD, lung cancer, AIDS or cystic fibrosis?
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Did individual have chest x-rays that included inspiration and expiration views?
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Was the diagnosis confirmed with a chest x-ray? If so, does it show residual or recurrent pneumothorax?
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Were pulmonary function tests, arterial blood gases and ECG done later?
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Were other conditions with similar symptoms ruled out (e.g., asthma, chronic obstructive pulmonary disease and emphysema, rib fractures, heart attack, congestive heart failure and pulmonary edema, esophagitis, pulmonary embolism, aspiration pneumonia, acute respiratory distress syndrome, angina, and adult respiratory distress syndrome)?
Regarding treatment:
- Was placement of a thoracostomy tube or needle decompression warranted?
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Was a repeat chest x-ray done to monitor resolution of the pneumothorax?
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If the pneumothorax persisted or worsened despite treatment was placement of additional chest tubes tried?
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Was surgery indicated?
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Were underlying conditions addressed appropriately in the treatment plan?
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Was this episode a recurrence or the initial episode?
Regarding prognosis:
- Does individual have any underlying conditions such as chronic lung disease, asthma, AIDS, heart disease or cancer that could impact recovery and prognosis?
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Did individual experience any complications such as tension pneumothorax and/or cardiopulmonary arrest, which could impact recovery and prognosis?
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Source: Medical Disability Advisor
| Chen, K. Y., et al. "Pneumothorax in the ICU." Chest 122 2 (2002): 678-688.Tamura, M., Yasuhito Ohta, and H. Sata. "Thorascopic Appearance of Bilateral Spontaneous Pneumothorax." Chest 124 6 (2003): 2363-2371. |
Source: Medical Disability Advisor
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