Overview #
Definitions
A pneumothorax refers to gas in the pleural space. This can be classified by aetiology [1]:
- Primary spontaneous pneumothorax: no precipitating event, no pre-existing lung disease
- Secondary spontaneous pneumothorax: complication of pre-existing lung disease such as COPD
- Traumatic pneumothorax: due to blunt or penetrating trauma
The severity of pneumothorax can also be classified:
- Simple
- Tension: air accumulates progressively in the pleural cavity with haemodynamic compromise [2]
Prioritisation
URGENT: A tension pneumothorax can progress to cardiac arrest and death within minutes [2]
Triage #
Emergency requiring immediate attention. If tension pneumothorax is suspected, immediate escalation is required.
Causes #
Risk factors: [1]
Primary spontaneous pneumothorax
- Tall thin males between 10 to 30 years old
- Smoking
- Marfan syndrome
Secondary spontaneous pneumothorax
- COPD
- Cystic fibrosis
- Lung malignancy
Differentials: [3]
- Acute pulmonary embolism
- Pleuritis
- Pneumonia
- Myocardial ischaemia or infarction
- Pericarditis
- Musculoskeletal pain
Clinical features #
History:
- Sudden onset
- Typically unilateral chest pain, often pleuritic
- Dyspnoea
- Recent exercise, air travel, scuba diving or illicit drug use
- Recent invasive procedure or trauma to chest, neck, gut or abdomen
Examination:
- Increased work of breathing
- Decreased chest expansion
- Decreased breath sounds
- Hyperresonance to percussion
- Contralateral tracheal deviation: Indicates tension pneumothorax
Look out for vitals as a guide to the severity:
- Hypoxia
- Tachycardia
- Tachypnoea
- Hypotension
Investigations #
Initial investigations [3]
| Investigation | Significance |
| Chest x-ray [4] | Visceral pleural edge – sharp white lineAbsent lung markingsRadiolucent compared to normal lungMediastinal shift – indicates tension pneumothorax |
| ECG | Rule out acute coronary syndrome |
| COVID 19 swab | To confirm COVID 19 status |
Further investigations to consider
| Investigation | Indication |
| Troponin | Rule out acute coronary syndrome |
| D-dimer | Rule out pulmonary embolism |
| ABG | Pneumothorax typically causes acute respiratory alkalosis |
| CT chest * | If uncertain after CXR findings |
* Consult with senior before ordering
Classification #
Consider size [5]:
- Small pneumothorax – visible rim < 2cm between lung margin and chest wall
- Large pneumothorax – visible rim ≥ 2cm between lung margin and chest wall
Consider clinical features:
- Asymptomatic
- Symptomatic
Consider severity:
- Simple
- Tension
- Bilateral
Management #
Management – symptomatic pneumothorax
!! URGENT – notify senior clinician immediately !!
Initial management:
- COVID 19 status should be confirmed – if unsure, manage as presumed COVID 19 positive.
- DRSABCD
- MET call – if signs of shock
- Code blue – if airway compromise (eg. tension pneumothorax)
- Analgesia
- Refer to respiratory, cardiothoracics or trauma team as appropriate
Further management (requiring senior clinician):
- Observation
- Supplemental oxygen
- Needle aspiration or chest drain insertion
Management – small asymptomatic pneumothorax #
Management
- COVID 19 status should be confirmed – if unsure, manage as presumed COVID 19 positive.
- Analgesia if required
- Consider conservative management (including supplemental oxygen) after discussion with senior
- Repeat CXR after 4 hours
Diagnosis #
Clinical diagnosis or imaging features (see investigations section)
References #
- Lee YC. Pneumothorax in adults: Epidemiology and etiology. In: Broaddus V, ed. by. UpToDate [Internet]. Waltham, MA: UpToDate Inc.; 2020 [cited 31 August 2021]. Available from: https://www.uptodate.com
- Qureshi P, Gaillard F. Tension pneumothorax [Internet]. Radiopaedia.org. 2021 [cited 31 August 2021]. Available from: https://radiopaedia.org/articles/tension-pneumothorax?lang=us
- Lee YC. Clinical presentation and diagnosis of pneumothorax. In: Broaddus V, ed. by. UpToDate [Internet]. Waltham, MA: UpToDate Inc.; 2020 [cited 31 August 2021]. Available from: https://www.uptodate.com
- Luhar M, Gorrochategui M. Pneumothorax [Internet]. Radiopaedia.org. 2021 [cited 31 August 2021]. Available from: https://radiopaedia.org/articles/pneumothorax
- MacDuff A, Arnold A, Harvey JManagement of spontaneous pneumothorax: British Thoracic Society pleural disease guideline 2010Thorax 2010;65:ii18-ii31.
Contributors
Reviewing Consultant/Senior Registrar
Dr Norine Ma
Dr Asha Bonney
