Table of Contents · 11 sections
In a nutshell. Pneumothorax is the accumulation of air in the pleural cavity with lung collapse. Types: spontaneous (primary/secondary), traumatic, iatrogenic, tension (valvular — life-threatening). Diagnosis: clinical presentation + X-ray/US. Tension: emergency needle decompression in the 2nd intercostal space along the midclavicular line or 5th intercostal space along the anterior axillary line. Followed by — Bülau tube thoracostomy.
1. Definition and classification
Pneumothorax (PT) is the presence of air in the pleural cavity, leading to partial or complete lung collapse and impaired gas exchange. Normally, the pleural pressure is negative (–5 cm H₂O), which keeps the lung expanded.
By mechanism
- Primary spontaneous — without apparent lung disease, in young, tall, asthenic individuals (rupture of subpleural blebs).
- Secondary spontaneous — associated with COPD, cystic fibrosis, lymphangioleiomyomatosis, HIV-related Pneumocystis pneumonia, lung cancer.
- Traumatic — resulting from rib fractures, penetrating injuries.
- Iatrogenic — following subclavian vein puncture, lung biopsy, mechanical ventilation with barotrauma.
By extent and severity
- Limited (localized to one area), extensive, total.
- Closed — the pleural defect has sealed.
- Open — free communication with the atmosphere through the wound tract.
- Tension (valvular) — air enters during inspiration and cannot escape during expiration, pressure builds up.
2. Pathophysiology
Air in the pleural cavity leads to lung collapse and a decrease in the gas exchange surface area. Hypoxemia and respiratory failure develop. In tension PT among all types — progressive mediastinal shift to the contralateral side → compression of the vena cava → ↓ venous return → obstructive shock.
3. Clinical presentation
- Sudden dyspnea, pleuritic chest pain on the affected side.
- Dry cough.
- Tachycardia, tachypnea.
- Decreased breath sounds and vocal fremitus on the affected side.
- Hyperresonance on percussion.
- In tension PT: pronounced cyanosis, hypotension, tachycardia, distended neck veins, tracheal deviation to the contralateral side — clinical diagnosis without waiting for radiography.
4. Diagnosis
Radiography
- Visceral pleural line, beyond which pulmonary markings are absent.
- Mediastinal shift (in tension PT — toward the unaffected side).
- Downward displacement of the diaphragmatic dome on the side of the PT.
- To assess size — measuring the distance from the chest wall to the visceral pleura at the level of the lung root.
Pleural ultrasound
- Absence of "lung sliding" — higher sensitivity than radiography in supine patients.
- Lung point — a specific sign of PT.
CT
- Gold standard for assessing volume and identifying underlying blebs/cysts.
- Indications: recurrent PT, equivocal radiograph, surgical planning.
5. Assessing PT size
| Size | Criteria (BTS 2010) |
|---|---|
| Small | < 2 cm from the chest wall at the root level |
| Large | ≥ 2 cm |
According to ACCP, the distance from the lung apex to the pleural dome is used: < 3 cm — small, ≥ 3 cm — large.
6. Management
Tension pneumothorax — emergency care
- Immediate needle decompression (14G needle) in the 2nd intercostal space along the midclavicular line or 5th intercostal space along the anterior axillary line (close to the superior border of the rib below to avoid injuring the intercostal neurovascular bundle).
- Following decompression — placement of a standard chest tube (28–32 Fr) using the Bülau technique in the 5th intercostal space.
- Oxygenation, monitoring.
Primary spontaneous
- Small without dyspnea — observation + oxygen therapy (accelerates air resorption 3–4 fold), follow-up radiography in 6–24 hours.
- Large or with dyspnea — needle aspiration; if ineffective (or recurrent PT) — chest tube insertion.
Secondary spontaneous
- Always chest tube insertion: the risk of rapid decompensation is higher.
- Consideration of surgical intervention for recurrences.
Traumatic and iatrogenic
- Small iatrogenic — observation.
- All traumatic — pleural cavity drainage.
7. Pleural drainage
- Site: 5th intercostal space at the anterior axillary line (safe triangle).
- Size: 20–28 Fr for adults.
- Connection to a Būlau system or active suction (−10 to −20 cm H₂O).
- Drain removal — after complete lung expansion + absence of air leak for 24 hours.
8. Surgical treatment
- Indications: second episode on the same side, first episode on the contralateral side, persistent air leak > 5–7 days, bilateral PT, high-risk occupations (pilots, divers).
- Method of choice — VATS (video-assisted thoracoscopic surgery) with bullectomy and mechanical/chemical pleurodesis (pleurectomy, talc).
9. Complications
- Recurrence (30–50% after the first episode).
- Hemothorax (in case of vascular injury).
- Re-expansion pulmonary edema upon rapid lung re-expansion.
- Empyema, infection at the drain site.
10. Recurrence prevention
- Smoking cessation (strong risk factor).
- Pleurodesis in case of recurrence.
- Avoid diving without prior evaluation and surgery.
11. FAQ
Can tension PT be diagnosed clinically?
Yes, and it must be. Wasting time on an X-ray means losing the patient. Clinical signs (hypotension + decreased breath sounds + tympany + tracheal deviation) are an indication for immediate decompression.
Why is the puncture performed over the upper border of the rib?
The intercostal neurovascular bundle runs along the lower border of the overlying rib. Puncturing near the upper border of the underlying rib is safe.
What are the dangers of an open pneumothorax?
With each inspiration, air is sucked into the pleural cavity → paradoxical respiration, mediastinal flutter → hemodynamic instability. First aid — an occlusive "valve" dressing (sealed on three sides).
When is active pleurodesis indicated?
For recurrent spontaneous PT, bilateral PT, in patients with high-risk occupations. Methods: surgical pleurectomy, chemical (talc, doxycycline).
How long does it take for the lung to re-expand?
With a small PT on oxygen support — 1–3 days; with drainage of a large one — hours/days depending on the source of the leak.
See also: Pneumonia · COPD · Wounds · Acute abdomen · Surgery catalog · Clinical scales