Complications of pneumothorax

Classification of combined pleural syndromes

In addition to isolated air accumulation, the pathological process is often complicated by the addition of fluid media or the spread of gas beyond the pleura. The following conditions are distinguished:

• Pneumomediastinum (mediastinal emphysema) is the penetration of air into the mediastinal tissue. It is often accompanied by the development of subcutaneous emphysema. A typical cause is the barotrauma mechanism during prolonged paroxysmal coughing, when forced exhalations increase intra-alveolar pressure up to the rupture of the visceral pleura.
• Hydropneumothorax is the simultaneous presence of gas and fluid in the pleural cavity.
• Pyopneumothorax is the accumulation of air and purulent masses. A classic scenario of development is the rupture of an emptied lung abscess or a destructive tuberculous cavity into the pleura.
• Hemopneumothorax is a combination of gas and blood. It most commonly occurs in penetrating chest wounds (open traumatic pneumothorax). Specific signs of such injury include noisy discharge of foamy blood and air bubbles from the wound, and a whistling suction of air. When the contents become infected, hemopneumothorax rapidly transforms into hemopyothorax.

Iatrogenic complications are also worth noting: for example, during surgical mobilization of the esophagus, tension of the interpleural ligament can provoke a rupture of the mediastinal pleura, leading to severe bilateral pneumothorax.

Tension (valvular) pneumothorax as a critical complication

The most dangerous variant of airway sealing failure is the formation of a tension (valvular) pneumothorax. A peculiar valve made of damaged soft tissues forms in the area of the lung tissue or chest wall defect.

The pathogenesis of this condition lies in the fact that air is freely sucked into the pleural cavity during inspiration, but upon expiration, the tissue valve snaps shut, completely blocking the exit of gas outward. With each respiratory cycle, intrapleural pressure steadily increases.

The consequence of this is progressive compression (collapse) of the affected lung and a pronounced shift of the mediastinal organs toward the healthy side. Clinically, this manifests as a rapid increase in acute respiratory and cardiovascular failure. The condition is regarded as extremely severe and requires immediate emergency drainage to relieve pressure.

Pain syndrome and risks of diagnostic errors

The complicated course of pneumothorax is always accompanied by pronounced pain syndrome, which can cause fatal diagnostic errors.

With the development of mediastinal emphysema, the character of chest pain can reliably mimic the clinical presentation of acute myocardial infarction. The erroneous interpretation of pleural pain as cardiac (ischemic) leads to two serious problems:

1. Prescription of unjustified cardiac interventions.
2. Catastrophic delay in diagnosing the true life-threatening pulmonary pathology (including pneumothorax itself or pulmonary embolism).

Surgical tactics and treatment methods

Relief of complications requires active surgical tactics. The basic and strictly mandatory intervention for pneumothorax, pyopneumothorax, and pleural empyema is pleural cavity drainage (recommendation confidence level C, evidence reliability level 5).

Depending on the severity of the condition, the degree of lung collapse (total or partial), and the etiology, various methods are used:

• Basic manipulations: pleural cavity puncture, thoracentesis, drainage tube placement, as well as pleurodesis to artificially create adhesions and prevent recurrences.
• Minimally invasive technologies: temporary endoscopic occlusion of the damaged bronchus to stop air inflow.
• High-tech (major) surgeries: in case of massive destruction of lung tissue (e.g., against the background of complicated tuberculosis), removal of the entire lung (pneumonectomy), surgical occlusion of the main bronchus or pulmonary artery, as well as thoracomyoplasty may be required.

Class and exam questions

What else to study on this topic

• Etiology of spontaneous pneumothorax: from bullous emphysema to rare thoracic endometriosis.
• Mechanisms of development of open and closed traumatic pneumothorax.
• The effect of a pronounced adhesive process in silicosis on the probability of lung collapse.
• Artificial (therapeutic) pneumothorax as a method of collapsotherapy in tuberculosis.
• Iatrogenic causes of pleural damage during central venous catheterization and mechanical ventilation.

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