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Pneumothorax, Emergency Medicine

Basics

Description

- Presence of free air in the intrapleural space - Spontaneous pneumothorax is due to atraumatic rupture of alveolus, bronchiole, or bleb. - Primary spontaneous pneumothorax (2/3 of incidences): - No underlying pulmonary pathology present - Rupture of small subpleural cyst or bleb - Primarily young, healthy patients (20 " 40 yr old) with tall, thin body habitus - Risk factors: Smoking, family history, Marfan syndrome, homocystinuria, thoracic endometriosis

- Infections: - Necrotizing bacterial pneumonia - TB - Fungal pneumonia - Pneumocystis carinii

- Severity of symptoms is generally proportional to size of the pneumothorax. - Chest pain on the ipsilateral side: - Sharp, pleuritic pain - Sudden onset - Dull ache in delayed presentations

- Tachypnea - Heart rate <120 bpm generally seen in simple spontaneous pneumothoraces - Jugular venous distention and tracheal deviation to the contralateral side may be evident in tension pneumothorax. - Cardiac and pulmonary exam: - Asymmetric decreased breath sounds - Hyperresonance to percussion of ipsilateral side

- US: - User experience required - Rapid at bedside - Lack of lung sliding and comet-tail artifact signifies pneumothorax. - M-mode confirms pneumothorax with smooth lines above and below pleural line. - With experience, sensitivity surpasses chest radiograph

- Suction: - Indicated when the Heimlich valve fails - Attach aspiration catheter to suction at 20 cm H2O. - Observe in ED for 1 hr.

- Tube thoracostomy: - Indications: - Suspicion of a tension pneumothorax - Gunshot wound to the chest - Clinical evidence of a pneumothorax following blunt chest trauma or penetrating chest trauma - Presence of a pneumothorax of any size in patient receiving positive-pressure ventilation - Pneumothorax with >30% collapse - Most cases of secondary pneumothorax - Definitive therapy after needle thoracostomy

- Possible complications: - Intercostal vessel bleeding - Inadequate drainage: - Kinked tube - Clogged tube - Communication outside of pleural cavity with leak

  • Presence of free air in the intrapleural space
  • Spontaneous pneumothorax is due to atraumatic rupture of alveolus, bronchiole, or bleb.
  • Primary spontaneous pneumothorax (2/3 of incidences):No underlying pulmonary pathology presentRupture of small subpleural cyst or blebPrimarily young, healthy patients (20 " 40 yr old) with tall, thin body habitusRisk factors: Smoking, family history, Marfan syndrome, homocystinuria, thoracic endometriosis
  • Secondary spontaneous pneumothorax from underlying pulmonary pathology (see Etiology)
  • Tension pneumothorax:Air continues to enter pleural space through bronchoalveolar disruption and becomes trapped via "ball-valve " mechanism.Intrapleural pressure increases.Venous return to right heart decreases, resulting in decrease in cardiac output.Mediastinum shifts toward uninvolved side, mechanically interfering with right atrial filling.Ventilation compromise and ventilation/perfusion mismatch result in hypoxemia

Etiology

  • Idiopathic
  • Airway disease:Chronic obstructive pulmonary disease (COPD)AsthmaCystic fibrosis
  • Infections:Necrotizing bacterial pneumoniaTBFungal pneumoniaPneumocystis carinii
  • Neoplasm
  • Interstitial lung disease:SarcoidosisIdiopathic pulmonary fibrosisLymphangiomyomatosisTuberous sclerosisPneumoconioses
  • Connective tissue diseases
  • Pulmonary infarction
  • Endometriosis
  • Blunt chest trauma
  • Penetrating trauma to neck or trunk
  • Iatrogenic:Central line placementOther vascular access procedures

Diagnosis

Signs and Symptoms

History

  • Severity of symptoms is generally proportional to size of the pneumothorax.
  • Chest pain on the ipsilateral side:Sharp, pleuritic painSudden onsetDull ache in delayed presentations
  • Shortness of breath
  • Rarely cough, asymptomatic, or generalized malaise

Physical Exam

  • Tachypnea
  • Heart rate <120 bpm generally seen in simple spontaneous pneumothoraces
  • Jugular venous distention and tracheal deviation to the contralateral side may be evident in tension pneumothorax.
  • Cardiac and pulmonary exam:Asymmetric decreased breath soundsHyperresonance to percussion of ipsilateral side
  • Tension pneumothorax:HypotensionTachycardia, heart rate >120 bpmDiaphoresisCyanosisCardiovascular collapseTracheal deviation

Essential Workup

  • Imaging is mainstay of the workup
  • DO NOT delay chest decompression if the patient is hemodynamically unstable and there is sufficient clinical evidence of pneumothorax.

Diagnosis Tests & Interpretation

Lab

Arterial blood gas offers little over oxygen saturation.

Imaging

  • Chest radiograph:
  • Patients unable to tolerate upright chest radiograph can be taken in decubitus position with the suspected side up:Absence of lung markings distal or peripheral to the visceral pleural white lineDisplacement of mediastinum or anterior junction lineDeep sulcus sign
  • On frontal view, larger lateral costodiaphragmatic recess than on opposite side
  • Diaphragm may be inverted on the side with deep sulcus:A rough estimate of pneumothorax size is sufficient to make clinical decisions.
  • Expiratory film:May demonstrate small pneumothorax but has not been shown to increase yield of detection
  • Chest CT:Very sensitive for small pneumothorax but has little practical advantage over chest radiograph
  • US:User experience requiredRapid at bedsideLack of lung sliding and comet-tail artifact signifies pneumothorax.M-mode confirms pneumothorax with smooth lines above and below pleural line.With experience, sensitivity surpasses chest radiograph

Diagnostic Procedures/Surgery

ECG:

  • Often necessary to rule out cardiac etiologies of chest pain
  • Nonspecific changes include T-wave inversion, left axis deviation, and decreased R-wave amplitude.

Differential Diagnosis

  • Acute abdominal processes
  • Aortic aneurysm or dissection
  • Asthma exacerbation
  • Chest wall pain
  • COPD exacerbation
  • Myocardial infarction
  • Pericarditis
  • Pleuritis
  • Pneumomediastinum
  • Pulmonary embolus

Treatment

Pre-Hospital

Unstable patients with a suspected tension pneumothorax require immediate needle thoracostomy.

Initial Stabilization/Therapy

  • Cardiac monitor
  • Pulse oximetry
  • Oxygen 100% via nonrebreather face mask
  • IV access
  • Suspected tension pneumothorax requires either immediate needle thoracostomy or tube thoracostomy.
  • Needle thoracostomy:Immediate placement indicated in unstable patients with a tension pneumothorax14G " 18G angiocatheter in the 2nd intercostal space at midclavicular line or 4th or 5th intercostal space at anterior axillary lineNOTE: The length of most standard angiocatheters is too short to penetrate the pleural cavity in moderate to large framed patients " longer, purpose-specific catheters may be required

Ed Treatment/Procedures

  • Nontraumatic pneumothorax estimated at <15% collapse and no cardiovascular or respiratory compromise:Observe with 100% oxygen support for 4 " 6 hr.Repeat chest radiograph and discharge if unchanged.
  • Simple aspiration:Indications:Simple pneumothorax with only 15 " 30% collapseIncrease in size of a small pneumothorax during observationPlacement of aspiration catheter (typically 8F) with 3-way stopcock
  • Aspirate air until resistance or 3 L of air aspirated.If the pneumothorax is no longer visible on 2 subsequent chest radiographs at 4 hr intervals, remove catheter.If a final chest radiograph is normal 2 hr after the catheter is removed, the patient may be discharged.A 2nd aspiration may be attempted if the pneumothorax does not resolve.
  • Heimlich valve:Indicated when <30% collapse after failure of aspirationAttach Heimlich valve to aspiration catheter or chest tube.
  • Suction:Indicated when the Heimlich valve failsAttach aspiration catheter to suction at 20 cm H2O.Observe in ED for 1 hr.
  • Tube thoracostomy:Indications:Suspicion of a tension pneumothoraxGunshot wound to the chestClinical evidence of a pneumothorax following blunt chest trauma or penetrating chest traumaPresence of a pneumothorax of any size in patient receiving positive-pressure ventilationPneumothorax with >30% collapseMost cases of secondary pneumothoraxDefinitive therapy after needle thoracostomyTube size:Small-caliber (7 " 14F) tube for primary spontaneous pneumothoraces20 " 28F for secondary spontaneous pneumothorax28F when there is detectable pleural fluid or an anticipated need for mechanical ventilationCheck for tube kinks by fully rotating the inserted tube.All side holes in the tube must be within the chest wall to avoid leak.Following insertion, the tube should be connected to a water-seal device.A Heimlich valve may be used instead of a water-seal device in stable patients without a pleural effusion.Re-expansion edema is a rare complication requiring supportive care.
  • Possible complications:Intercostal vessel bleedingInadequate drainage:Kinked tubeClogged tubeCommunication outside of pleural cavity with leakRe-expansion pulmonary edema:Treatment with fluid resuscitation

Medication

  • Local anesthetic:1% lidocaine with epinephrine 1:100,000Max. dose: 7 mg/kg " 500 mg
  • Consider procedural sedation in stable awake patients
  • No indication for antibiotics in a clean procedure

Follow-Up

Disposition

Admission Criteria

  • Tension pneumothorax
  • Chest tube required

Discharge Criteria

  • <15% collapse, no expansion while in the ED or successful aspiration with catheter removed:Discharge with follow-up in 24 hr and 1 wk for chest radiograph to assure re-expansion.
  • Reliable patients with the thoracic vent and successful aspiration or secured catheter and Heimlich valve:Discharge with 24 and 48 hr follow-up.At 48 hr follow-up:Clamp catheter, observe for 2 hr, and repeat chest radiograph.Remove thoracic vent or catheter if no re-expansion.Observe for 2 hr and repeat chest radiograph.If no re-expansion, discharge with 24 hr and 1 wk follow-up.
  • Discharge instruction should include prompt return for new onset of chest pain or dyspnea.
  • Patients without re-expansion at 1 wk require a cardiothoracic surgery consult.

Followup Recommendations

Pulmonary medicine and/or chest surgery

Pearls and Pitfalls

  • Delay in chest decompression in the unstable patient leading to rapid hemodynamic compromise
  • Avoid poor tube placement involving kinks or improper depth, which may necessitate repeating the procedure.
  • Avoid placement of catheter or tube too low on the lateral chest wall, which may lead to iatrogenic abdominal injuries.
  • Failure to detect associated mediastinal or lower neck injuries
  • If pneumomediastinum is detected, evaluate for esophageal pathology

Additional Reading

  • Baumann MH, Strange C, Heffner JE, et al. Management of spontaneous pneumothorax: An American College of Chest Physicians Delphi consensus statement. Chest. 2001;119:590 " 602.
  • Gaudio M, Hafner JW. Simple aspiration compared to chest tube insertion in the management of primary spontaneous pneumothorax. Ann Emerg Med. 2009;54:458 " 460.
  • Hassani B, Foote J, Borgundvaag B. Outpatient management of primary spontaneous pneumothorax in the emergency department of a community hospital using a small-bore catheter and a Heimlich valve. Acad Emerg Med. 2009;16:513 " 518.
  • Soldati G, Testa A, Sher S, et al. Occult traumatic pneumothorax: Diagnostic accuracy of lung ultrasonography in the emergency department. Chest. 2008;133:204 " 211.
  • MacDuff A, Arnold A, Harvey J, et al. Management of spontaneous pneumothorax: British Thoracic Society Pleural Disease Guideline 2010. Thorax. 2010;65(suppl 2):ii18 " ii31.
  • Zehtabchi S, Rios Cl. Management of emergency department patients with primary spontaneous pneumothorax: Needle aspiration or tube thoracostomy? Ann Emerg Med. 2008;51:91 " 100.

See Also (Topic, Algorithm, Electronic Media Element)

Codes

ICD9

  • 512.0 Spontaneous tension pneumothorax
  • 512.81 Primary spontaneous pneumothorax
  • 512.89 Other pneumothorax
  • 512.1 Iatrogenic pneumothorax
  • 512.82 Secondary spontaneous pneumothorax
  • 860.0 Traumatic pneumothorax without mention of open wound into thorax
  • 860.1 Traumatic pneumothorax with open wound into thorax

ICD10

  • J93.0 Spontaneous tension pneumothorax
  • J93.9 Pneumothorax, unspecified
  • J93.11 Primary spontaneous pneumothorax
  • J95.811 Postprocedural pneumothorax
  • J93.12 Secondary spontaneous pneumothorax
  • S27.0XXA Traumatic pneumothorax, initial encounter

SNOMED

  • 36118008 Pneumothorax (disorder)
  • 328561000119107 Primary spontaneous pneumothorax (disorder)
  • 233645004 Tension pneumothorax (disorder)
  • 441536000 Iatrogenic pneumothorax (disorder)
  • 22897006 Traumatic pneumothorax with open wound into thorax (disorder)
  • 328571000119101 Secondary spontaneous pneumothorax (disorder)
  • 3903005 Traumatic pneumothorax without open wound into thorax (disorder)