Journal of the American Academy of Physician Assistants:
Quick Recertification Series

PNEUMOTHORAX

SMITH, JAMI S. MPA, PA‐C

Section Editor(s): Colomb‐Lippa, Dawn MHS, PA‐C; Klingler, Amy M. MS, PA‐C

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department editors

Jami Smith is an assistant professor and the academic coordinator of the PA program at Arcadia University, Glenside, Pennsylvania. She practices emergency medicine in the Philadelphia area.

No relationships to disclose.

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>GENERAL FEATURES

* Pneumothorax is an abnormal collection of air in the pleural space and classified as spontaneous (primary or secondary) or traumatic.

* Primary spontaneous pneumothorax usually occurs in the absence of underlying lung disease. Patients are classically described as tall men, aged 20 to 40 years, who are smokers.

* Secondary pneumothorax occurs due to lung pathology, including chronic obstructive pulmonary disease, cystic fibrosis, tuberculosis, asthma, interstitial lung disease, menstruation, and Pneumocystis jirovecii pneumonia.

* Traumatic pneumothoraces occur with blunt or penetrating trauma, including iatrogenic subclavian line placement or thoracentesis or following pleural or lung biopsy.

* Tension pneumothorax is a medical emergency and occurs in the setting of penetrating trauma, lung infection, and cardiopulmonary resuscitation or positive end expiratory pressure.

* Following spontaneous pneumothorax, 30% of patients experience a recurrence after either observation or tube thoracotomy treatment.

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>CLINICAL ASSESSMENT

* Patient will typically complain of dyspnea and may have varying degrees of pleuritic chest pain. Severity of the symptoms generally correlates to severity of the pneumothorax.

* If the pneumothorax is small (<15% of a hemithorax), patient may have normal findings on examination.

* Patients with a larger pneumothorax may have tachypnea and tachycardia. On lung examination, hyperresonance to percussion, decreased tactile fremitus, and diminished breath sounds are present on the affected side.

* In a tension pneumothorax, findings may include a displaced point of maximal impulse, tracheal deviation, mediastinal shift, and hemodynamic instability.

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>DIAGNOSIS

* A visceral pleural line on the chest radiograph is diagnostic and may be noted only on the expiratory view.

* Chest CT may demonstrate the cause of a spontaneous secondary pneumothorax.

* In a tension pneumothorax, the diagnosis should be made based on the history and physical examination; however, radiographs would reveal mediastinal shift away from the affected side with a large amount of air in the pleural space.

* Left‐sided primary pneumothorax may produce QRS axis and precordial T‐wave changes that can be misinterpreted as an MI.

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>TREATMENT

* Treatment of primary spontaneous pneumothorax depends on the size of the air collection in the pleural space.

– A small pneumothorax will typically resolve on its own.

– Supplemental oxygen therapy increases the rate of reabsorption.

– Large pneumothorax: A smallbore catheter attached to a Heimlich valve may be used, with outpatient follow‐up.

– If the pneumothorax fails to resolve, a traditional chest tube attached to water seal drainage with suction may be used.

* Secondary spontaneous pneumothorax requires standard chest tube drainage using water seal drainage with suction and admission to the hospital. The underlying cause should then be addressed.

* Since most traumatic pneumothoraces occur concomitantly with hemothorax, treatment includes a large‐bore chest tube with water seal and drainage with suction.

* In an unstable patient with a tension pneumothorax, immediate needle decompression should be performed with a 14‐ to 16‐gauge needle inserted into the second intercostal space. Ultimately, the patient should have tube thoracostomy and water seal drainage with suction.

* Recurrent spontaneous pneumothoraces may require surgical resection of blebs or pleurodesis with talc.

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>>QUESTIONS & ANSWERS<<

1. Which of the following is not an examination finding in pneumothorax?

a. Decreased tactile fremitus

b. Tachypnea

c. Decreased resonance to percussion

d. Decreased breath sounds on the affected side

Answer: c

Explanation: When air leaks into the pleural space, the lung recoils from the chest wall and the increased air creates a hyperresonant sound to percussion.

2. Which of the following is not a cause of secondary spontaneous pneumothorax?

a. Chronic obstructive pulmonary disease

b. Pneumocystis jirovecii pneumonia

c. Penetrating lung trauma

d. Cystic fibrosis

Answer: c

Explanation: Penetrating lung trauma will cause a traumatic pneumothorax or, if large enough, a tension pneumothorax with hemodynamic instability, mediastinal shift away from the affected side, and tracheal deviation.

© 2013 Lippincott Williams & Wilkins, Inc.

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