Subjective presentation and main complaints
The onset of the pathology is always acute. At the moment of the visceral pleura rupture, the patient experiences a sudden attack of sharp chest pain on the affected side. If the process is accompanied by the development of mediastinal emphysema, the pain syndrome may mimic the clinical picture of myocardial infarction, which requires careful differential diagnosis.
The second leading symptom is dyspnea. Its appearance is explained by compression atelectasis—an acute collapse of the lung tissue under the pressure of air accumulated in the pleural cavity. The severity of dyspnea directly depends on two factors: the volume of the collapsed lung and the rate of increase in intrapleural pressure. Respiratory distress is most pronounced in tension (valvular) pneumothorax. With progressive respiratory failure and associated hemodynamic shifts, the patient develops acrocyanosis.
Objective examination of the patient
On external examination, the patient's forced posture and pronounced dyspnea are noteworthy. Examination of the cardiovascular system reveals a rapid but weak pulse, indicating hemodynamic decompensation.
Local examination of the chest reveals characteristic asymmetry:
- The affected hemithorax bulges and noticeably lags behind the healthy side during respiration.
- The intercostal spaces on the side of the pneumothorax are widened.
- In the open traumatic variant of the pathology, subcutaneous emphysema is observed, and air is sucked into the wound with a whistling sound while foamy blood with bubbles is noisily discharged.
Physical examination
The methods of percussion and auscultation serve as the basis for the clinical recognition of air accumulation in the pleural cavity.
The key percussion sign is a hyperresonant sound over the affected area. Auscultation determines the most important symptom—breath sounds are not transmitted (there is either a sharp weakening or a complete absence of breathing). This allows pneumothorax to be reliably differentiated from other bronchopulmonary syndromes.
| Abnormal | Percussion note | Auscultatory findings |
|---|---|---|
| Pneumothorax | Hyperresonant sound | Absence of breath sounds |
| Hemothorax | Dullness (diminished sound) | Absence of breath sounds |
Hemodynamic effects
The accumulation of air in the pleural cavity inevitably leads to the displacement of mediastinal organs. This causes severe disorders in the cardiovascular system: tachycardia develops, and the pulse becomes rapid and weak. The displacement of the great vessels and the heart provokes a sharp drop in blood pressure, up to collapse. Such hemodynamic shifts are particularly characteristic of tension (valvular) pneumothorax, in which the patient's condition is assessed as extremely severe.
Class and exam questions
Why does dyspnea occur in pneumothorax?
Dyspnea is caused by compression atelectasis—an acute collapse of lung tissue due to the accumulation of air in the pleural cavity.
How to distinguish pneumothorax from hemothorax using physical examination methods?
In both pathologies, breath sounds are absent, however, in pneumothorax, percussion reveals a hyperresonant sound, whereas in hemothorax, a dull sound (muffled resonance) is detected.
What happens to blood pressure in tension pneumothorax?
Due to the displacement of mediastinal organs, there is a sharp drop in blood pressure up to the development of collapse.
What else to study on this topic
- Radiological findings: visceral pleural line sign and mediastinal shift
- CT diagnostic criteria for air accumulation in the pleural cavity
- Changes in blood gas composition in acute respiratory failure
- Mechanism of development of mediastinal emphysema
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