SHM's Clinical Quick Talks-Management of Spontaneous Pneumothorax

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Pneumothorax is defined as air within the pleural space and can be caused by trauma, medical procedures, or can occur spontaneously. There are two types of spontaneous pneumothorax: primary and secondary. Primary spontaneous pneumothorax is the rupture of a small alveolar bleb and is more common in males, tall and slim individuals, and those with genetic conditions or a smoking history. Secondary spontaneous pneumothorax occurs when large bullae rupture in patients with underlying lung disease such as COPD or emphysema. Symptoms of pneumothorax include sudden dyspnea, pleuritic chest pain, and decreased breath sounds on the affected side.<br /><br />The diagnosis of pneumothorax can be made using a chest radiograph, which shows a loss of pleural markings between the collapsed lung and the chest wall. A CT chest is the most sensitive test, especially useful in patients with bullous emphysema. Point of care ultrasound can also be used to confirm the presence of a pneumothorax. <br /><br />Stable spontaneous pneumothorax can be managed with observation, low flow oxygen, or the placement of a pigtail chest tube. Resolution of pneumothorax is determined by repeat chest x-ray and clinical status. Definitive treatment includes pleurodesis, a procedure that causes inflammation and fibrosis to obliterate the pleural space. The type of pleurodesis performed depends on the surgical risk of complications for each patient.<br /><br />Clinical pearls to note include the fact that primary spontaneous pneumothorax occurs in patients with no underlying lung disease, while secondary spontaneous pneumothorax occurs in patients with lung disease. The best initial test is a chest x-ray, while a CT chest is the most sensitive. Most primary spontaneous pneumothoraxes can be observed if they are small and the patient is stable, while secondary spontaneous pneumothorax usually requires the placement of a chest tube.<br /><br />Sources: UpToDate, British Thoracic Society pleural disease guideline 2010, N Engl J Med. 2020 Jan 30;382(5):405-415. doi: 10.1056/NEJMoa1910775. PMID: 31995686

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Jachrise Sibblis

Keywords

Pneumothorax

pleural space

spontaneous pneumothorax

primary spontaneous pneumothorax

secondary spontaneous pneumothorax

alveolar bleb

bullae rupture

chest radiograph

CT chest

pleurodesis