Pneumothorax

A condition in which air enters the pleural cavity, either from the respiratory passages or alveoli and through the visceral pleura  for example by rupture of a bleb or a bullus after a cough or spontanteously, or through the chest wall in association with chest trauma. (MVA, stabbing, shooting etc).

Diagnosis -  spontaneous pneumothorax  ie one not associated with trauma. it has been divided in the past into primary and secondary, with only the latter being considered due to lung disease, but there may well be no true primary cases. Some young adults may have no obvious chest disease even after investigation but one suspects most of these would have more than one bleb or bullum on the lungs, and most are smokers. The patient may have no symptoms but usually has some dyspnoea (shortness of breath) and may have pleuritic chest pain, (chest wall pain on breathing or coughing. The patient is usually a smoker and usually suffers from chronic obstructive pulmonary disease. The pneumothorax is usually small and apical. It is suspected by the sudden onset, usually during activity such as vigorous coughing, vomiting, sport etc and confirmed either by physical examination (decreased respiratory incursion on one side,  possibly decreased breath sounds especially at the apex on that side, and slight mediastinal deviation to the other side) or by radiology - always required.  A film taken up-right in both inspiration and expiration will usually show partial collapse of the lung with a peripheral air shadow outside the pleural line.  An additional film taken with the patient lying on the "normal" side may be necessary in some cases. Traumatic pneumothorax is diagnosed similarly except that the diagnosis is usually more obvious from the nature of the trauma. Tension pneumothorax (as to which see) must be diagnosed and treated very urgently if suspected. Traumatic pneumothorax  requires treatment of the trauma in addition to that directed to the pneumothorax as above. Flail chest (a whole part of the chest moving paradoxically with respiration due to multiple rib fractures with two along each rib) is usually accompanied by pneumothorax but the flail chest dominates the assessment and treatment of that dreaded condition.

Treatment is not always required but aspiration or thoracostomy usually through an upper intercostal space is indicated if there is marked dyspnoea and a small pneumothorax, or if the pneumothorax is large - say if a third or more of the half-chest is air. Simple aspiration is required but referral to an appropriate specialist must follow as the cause of the underlying chest condition (very occasionally none is found) must be elucidated and proper treatment initiated.

The main "complication" of spontaneous pneumothorax is recurrence - perhaps 50% get a second or later episode, often quite quickly. For that reason some centres call in a thoracoscopist routinely to offer thoracic inspection, which usually reveals more blebs or bulli. Air may enter tissues for example in the mediastinum or the neck or upper chest in either form of pneumothorax. ("Tissue emphysema") Many centres still use an underwater drain after aspiration of any but the smallest "spontaneous" pneumothorax, mainly to prevent very early recurrence. The drain can be taken out as soon as the bubbles stop. DrRic 21:12, 25 March 2008 (UTC)