Pneumothorax

Yonas A.
May, 2016
Jan, 2019
 Introduction
• Pneumothorax is the collection of air in the pleural space—
that is, between the lung and the chest wall
• Pneumothoraces are classified as spontaneous and
nonspontaneous
– Spontaneous Pneumothorax
• Primary spontaneous pneumothorax: spontaneous pneumothorax
occurring in a patient without an immediately obvious underlying lung
disease
– PSP, which implies absence of underlying lung disease, is misleading, since most
patients undergoing surgical intervention for the prevention of recurrence have
identifiable emphysema-like changes (ELCs) such as blebs or bullae
• Secondary spontaneous pneumothorax: occurs in the presence of an
underlying lung condition
– Nonspontaneous Pneumothorax
• Either iatrogenic or due to trauma
 Classification
• Spontaneous
– Primary: No immediately apparent lung disease
• Subpleural bleb rupture
– Secondary: A complication of clinically apparent lung disease
• Nonspontaneous
– Traumatic
• Due to penetrating chest trauma
• Due to blunt chest trauma
– Iatrogenic
• Due to transthoracic or transbronchial lung biopsy
• Due to placement of central venous catheter
• Due to thoracentesis or pleural biopsy
• Due to barotrauma
 Epidemiology
• PSP typically occurs in tall, thin males between the ages of
12 and 30 years; it rarely occurs after the age of 40
– Cigarette smoking increases the risk of PSP in men by as much
as a factor of 20 in a dose-dependent fashion

• The peak incidence of SSP occurs later in life (60–65

years), paralleling the incidence of chronic lung disease in
the general population

• Most recurrences in PSP and SSP patients not being

treated to prevent recurrence are seen in the first 6
months to 2 years of follow-up
 Cont.
• Recurrence prevention is a more important
consideration in patients with SSP, given their
intrinsically limited pulmonary reserve and higher
pneumothorax-related mortality rate (3.5-fold)

• Death rarely occurs in the setting of PSP (0.09% for

men and 0.06% for women) but is more common in
patients with SSP (1%–3%) as a result of
compromise of pulmonary reserve from the
underlying lung disease
Etiology and Pathophysiology
 Primary Spontaneous Pneumothorax
• The exact pathophysiology of PSP remains unclear regarding
the exact site of the air leaks, its underlying disease process,
and its precipitating causes

• The most common cause of PSP is believed to be the rupture of

an apical subpleural bleb, but the exact precipitating event
remains unknown

• Strong etiologic association has been proposed between ELCs

and the occurrence of PSP
– Up to 80% of patients with PSP have ELCs on CT scans
– ELCs are often bilateral and located predominantly in the apical
segments of the upper and lower lobes
 Cont.
• The exact mechanism of bulla formation remains
speculative
– A plausible explanation is that degradation of elastic fibers
in the lung is induced by the smoking-related influx of
neutrophils and macrophages, causing an imbalance in the
protease–antiprotease and oxidant–antioxidant systems

• The ectomorphic physique often noted in PSP patients,

characterized by the rapid increase in vertical size of
the thorax during early childhood and adolescence,
may affect intrathoracic pressure and drive subpleural
cyst formation (ELC formation)
 Cont.
• ELCs may not be the sole cause of air leak, as
suggested by the fact that air leak may occur
in the absence of ELCs or in areas distant from
ruptured ELCs
– This observation has led to the concept of “pleural
porosity” as a factor in PSP
– Pleurodesis and not bleb excision alone is the
cornerstone of preventing recurrence
Secondary Spontaneous Pneumothorax
• Airway disease • Connective tissue disease
– COPD – Wegener's granulomatosis
– Cystic fibrosis
– Rheumatoid lung
– Asthma
– Mixed CTD
• Infectious lung disease
– Tuberculosis
• Cancer
– PCP – Metastatic sarcomas to the
– Necrotizing pneumonia lung
• Interstitial lung disease – Mesothelioma
– Cryptogenic fibrosing – Lung cancer
alveolitis • Thoracic endometriosis
– Sarcoidosis
– Catamenial pneumothorax
– Histiocystosis
– Lymphangioleiomyomatosis
 Cont.
• Catamenial pneumothorax
– It is defined as a recurrent pneumothorax occurring within
72 hours of the onset of menstruation
• May also occur in the immediate premenstrual period and the
ovulatory phase
– It is part of the thoracic endometriosis syndrome, which also
includes catamenial hemothorax, catamenial hemoptysis,
and lung nodules
– It refers to the clinical and radiologic manifestations
associated with the growth of endometrial glands and
stroma in the lungs, pleural surfaces, diaphragm, and rarely
the tracheobronchial tree
– Unlike pelvic endometriosis, TES is a rare condition
 Iatrogenic pneumothorax
• Top 5 causes:
– Transthoracic needle aspiration (24%)
– Subclavian vessel puncture (22%)
– Thoracentesis (22%)
– Pleural biopsy (8%)
– Mechanical ventilation (7%)
• Barotrauma pneumothorax is defined as that occurring
in a patient receiving positive-pressure ventilation
• It can result in rapid deterioration and result in a
tension pneumothorax
Clinical Presentation, Physical
Examination, and Diagnosis
 PSP
• The typical patient with PSP is a young, tall, thin male in late adolescence or
early adulthood who experiences the sudden onset of pleuritic chest pain
and dyspnea at rest or during normal activities
– Many patients with PSP do not seek medical advice for several days

• Tachycardia is the most common physical finding, and the larger the
pneumothorax, the more likely additional findings may be present (signs of
pneumothorax)

• In instances of mild collapse, physical findings can be misleadingly normal

and a chest radiograph may confirm the suspected diagnosis

• Symptoms usually resolve within 24 hours, even if the pneumothorax

remains untreated and does not resolve
 SSP
• In contrast to the benign clinical course of PSP, SSP is a potentially life-
threatening event, because patients have associated lung disease and
limited cardiopulmonary reserve

• In patients with SSP, dyspnea may be severe and out of proportion to the
size of the pneumothorax, and hypoxemia, hypercarbia, and hypotension
may be the dominant findings

• Symptoms do not resolve spontaneously in patients with SSP

• The physical findings are often subtle and may be masked by the underlying
lung disease

• Tension pneumothorax is an uncommon complication of SP, with a

malignant course leading to death if untreated
Imaging of Pneumothorax
 Cont.
• The diagnosis of PSP is suggested by the patient's
history and confirmed by the identification of a thin,
visceral pleural line (<1 mm in width) that is found to
be displaced from the chest wall on a PA chest
radiograph obtained with the patient in an upright
position

• In the presence of adhesions between the lung and

the chest wall, the lung collapses unevenly or
partially, giving the appearance of a loculated
pneumothorax
 Cont.
• In patients suspected of having SSP secondary to COPD,
a giant bulla may appear as a pneumothorax and should
be clearly distinguished before proceeding with any
intervention
– A clue to the presence of pneumothorax is a visceral pleural
line that runs parallel to the chest wall
• Bullous lesions that abut the chest wall have a concave appearance
– If the distinction is not clear, a CT scan of the chest should be
performed to differentiate between the two conditions,
because only pneumothorax should be treated with a
drainage procedure
• The presence of thin strands of tissue within the airspace confirms
the diagnosis of bulla
 Cont.
• Additional radiographic findings in pneumothorax
may include:
– Mediastinal and subcutaneous emphysema
– Small pleural effusion
• Small fluid collections are frequently encountered if the
pneumothorax lasts longer than 24 hours
– The fluid is usually clear, and it is not necessary to analyze it
• On occasion a large effusion may represent a hemothorax
secondary to a torn vascular adhesion
 Cont.
• The ACCP does not recommend routine CT for
first-time PSP or SSP
– CT is recommended in:
• Differentiating pneumothorax from complex bullous
disease
• When the plain radiograph is obscured by surgical
emphysema
• When aberrant tube placement is suspected
 Size Estimation of the Pneumothorax
• The size of pneumothorax is an important
determinant of therapy

• The plain PA chest radiograph is a poor method

for quantifying the size of a pneumothorax,
usually underestimating its size

• There are several methods

 Cont.
• The Light index
– Volume of a pneumothorax =
100 – Average diameter of the lung3 × 100
Average diameter of hemithorax3

– The diameters are measured at the hila

 Cont.
• Cont.
% Pneumothorax = [100 – (b/a)3] x 100
 Cont.
• The Rhea method
– Volume of a pneumothorax (%) =
φat the apex + φat midpoint of the upper half of the
lung + φat midpoint of the lower half of the lung
3

– Interpleural distances are measured in centimeters

– Percent of pneumothorax is calculated using a

nomogram
 Cont.
• Cont.
 Cont.
• Collins formula
– Volume of pneumothorax as size % = 4.2 + 4.7 ×
(φat the apex + φat midpoint of the upper half of
the lung + φat midpoint of the lower half of the
lung)
 Cont.
• Cont.
% Pneumothorax = 4.2 + 4.7(A+B+C)
 Cont.
• Simple estimation
– Small pneumothorax
• ACCP
– Less than 3 cm in collapse from apex to copola (46% by the
Collins formula if the lung collapses uniformly = 9 cm)
• BTS
– A rim of air less than 2 cm in collapse between the lung and
the chest wall (32% by the Collins formula = 6 cm)
 Cont.
• Cont.

ACCP: Small pneumothorax < 3cm

BTS: Small pneumothorax <2 cm
 Cont.
• A more simplified method classifies a large
pneumothorax as complete separation of the
lung from the chest wall and a small
pneumothorax as partial separation
Complications of Spontaneous
Pneumothorax
 Pneumomediastinum
• Pneumomediastinum occurs owing to the
propagation of air from a site of injury in the
lung parenchyma into the mediastinum along
the bronchovascular bundles

• Like subcutaneous emphysema, it is of no

clinical consequence, but if it is progressive, it
may require application of suction or
additional chest drains for resolution
 Hemopneumothorax
• Occurs in 5% to 10% of cases and is more common in men than in
women

• The hemorrhage occurs from a torn vascular adhesion or a

vascular bleb that fails to tamponade

• The mean blood loss is approximately 1,012 mL, and one-third of

patients present with signs of hypovolemic shock

• Although lung reexpansion may help tamponade the bleeding

site, early surgical intervention is warranted to stop the bleeding,
evacuate the clotted hemothorax, resect the site of air leak, and
proceed with pleurectomy or pleurodesis
 Tension Pneumothorax
• It is a clinical diagnosis defined as “any pneumothorax with
cardiorespiratory compromise or collapse”

• It is more a visual than auscultatory diagnosis

• It occurs rarely in patients with PSP but is more common in

patients with SSP or in victims of trauma or patients who are
intubated (barotrauma)

• Treatment: wide bore cannulla (at least 7 cm long) then chest

tube
– A syringe filled with sterile saline attached to the cannula may help
confirm pleural penetration
 Persistent Air Leak
• It is present when there is evidence of a leak 48 hours after
chest tube insertion

• Although rare in PSP, it is more common in patients with SSP

with obstructive or fibrotic lung disease

• If there is incomplete lung reexpansion, a second tube may be

required, although the ACCP recommends against placement of
an additional chest tube to attempt to seal persistent air leaks

• After 4 days of drainage, surgery should be considered to close

the air leak and perform a pleurodesis to prevent recurrence
 Recurrence
• It is the most frequent complication of PSP and is seen in 30% of
cases

• Recurrence is defined as a pneumothorax that appears in the

ipsilateral side >7 days after a pneumothorax has resolved

• Most recurrences are seen during the first 6 months to 2 years of

follow-up

• A contralateral pneumothorax may occur in up to 25% to 40% of

cases

• After a second PSP, the risk of a subsequent event increases to >60%

Treatment
 Introduction
• The management of pneumothorax centers on
evacuating air from the pleural space and preventing
recurrences

• The best treatment remains unknown and continues

to be debated

• Management options range from observation, simple

aspiration, small-bore catheter insertion, and tube
thoracostomy to VATS and thoracotomy with bleb
excision and pleurodesis
 Cont.
• Selection of an approach depends on:
– Size of the pneumothorax
– Severity of symptoms
– Whether there is an open (persistent air leak) or
closed (no air leak) pneumothorax
– Whether the pneumo- thorax is primary,
secondary, or recurrent
 Treatment Options
• Conservative (address the pneumothorax only)
– Observation
– Needle aspiration
– Catheter drainage of pneumothorax (CASP)
– Tube thoracostomy

• Intermediate (address the pleura only)

– Tube thoracostomy with instillation of sclerosing agent
– Medical thoracoscopy with talc poudrage

• Invasive (address the blebs and the pleura)

– VATS blebectomy, pleurectomy, pleural abrasion, sclerosing agent
– Minithoracotomy blebectomy, pleurectomy, pleural abrasion, sclerosing
agent
Algorithm/First episode of PSP

CASP: Catheter aspiration of pneumothorax

Algorithm/First episode of SSP
 Oxygen and Observation
• For clinically stable PSP patients with small
penumothoraces (<2 cm) and preferably in the
hospital setting

• Absorption of air in the pleural space is

accelerated three- to fourfold by breathing an
oxygen-rich mixture, thus increasing the gradient
for nitrogen absorption
– Patients with spontaneus pneumothorax admitted for
care should receive high-flow (10 L/min) oxygen
 Needle Aspiration
• The ACCP recommends a chest tube or pleural catheter as the
preferred intervention for PSP and reserves simple aspiration for
stable PSP patients with small pneumothoraces that have failed
observation

• BTS guidelines embrace simple aspiration as the first line treatment

for all first episodes of PSP requiring intervention

• The success rate of drainage in PSP for simple aspiration is 75%,

while it is 80% for indwelling catheters and 85% for large-bore tubes
– The high success rate of needle aspiration suggests that the initial pleural
tear has already sealed by the time of presentation in the great majority of
cases of PSP
 Cont.
• With the exception of hemopneumothorax, there is now little
justification for using large-bore tubes (>24 Fr) for initial drainage of
either PSP or SSP

• Simple aspiration is probably inappropriate for most episodes of SSP,

given the greater need to prevent recurrence and the potential for
ongoing air leaks

• 3 reasons why simple aspiration should be considered as the first-line

intervention in PSP
– It is a simple procedure that can be performed in the emegency room and
requires minimal training
– Hospital admission is often unnecessary; even in patients with major or
complete collapse, it is successful in over 60% of cases
– It can usually predict both the existence and size of an air leak
 Technique of Simple Aspiration
• The catheter is placed utilizing the Seldinger
technique
– It is performed with a 16 to 18-gauge plastic cannula
inserted over a needle through the second intercostal
space in the midclavicular line
– For easy aspiration, the cannula can be fitted to an
automated three-way stopcock attached to a large syringe

• The catheter can be removed if the pneumo- thorax

is closed, or it may be left in place and easily
connected to a one-way valve or water seal if the
 Contraindications
• C/Is
– Bilateral pneumothoraces
– Multiple recurrent pneumothoraces
– Concurrent pleural effusion or hemothorax

• In these situations, a small-bore catheter or

chest tube is indicated
Small-Bore (8.5–14 Fr) Chest Drains
• These catheters can be easily introduced utilizing the Seldinger
technique (the second intercostal space midclavicular line or
within the “safe triangle”)

• After placement of the catheter, the patient may be discharged

to home with instructions to return for follow-up in 48 hours for
a chest radiograph and reassessment of the air leak
– If the air leak has resolved, the catheter is removed
– If there is a persistent air leak or pneumothorax, the patient is
admitted for application of suction (CASP) and daily chest radiographs
• If, after 2 days of suction (4 days from time of insertion), there is a persistent
air leak, VATS and pleurodesis is proposed

• They may be as effective as large bore chest tubes in first

 Tube Thoracostomy (14-28Fr)
• Recommendations
– ACCP: Clinically stable or unstable PSP patients with large pneumothoraces
– BTS: Only if initial aspiration or CASP is unsuccessful in controlling the patient's
symptoms
• General indications:
– Large PSP
– SSP
– Bilateral pneumothoraces
– Comcomitant hydro- or hemopneumothorax
– Respiratory symptoms out of proportion to the size of the pneumothorax
– Contralateral pneumonectomy
– Traumatic pneumothorax
– Intubated patients on mechanical ventilation (barotrauma)
• Chest tube malposition is the most common complication and should be
diagnosed promptly, by CT scan if necessary, to prevent additional
complications such as persistent or tension pneumothorax or progressive
subcutanoeus emphysema
 Cont.
• There is no evidence to support the routine initial use of
suction in the treatment of spontaneous pneumothorax or
in sealing air leaks or reducing hospital stay
– This has been implicated in some cases of reexpansion
pulmonary edema

• After placing a chest tube for a PSP, the ACCP and BTS
recommend a one-way valve, water seal with subsequent
suction if the lung fails to reexpand after 48 hours for
persistent air leak (defined as continued air bubbling 48
hours after insertion), or failure of the lung to reexpand
 Reexpansion pulmonary edema
• It is probably related to increased permeability of
capillaries damaged during pneumothorax
– Becomes manifested as edema during reexpansion owing to
further mechanical stresses applied to the already “leaky”
capillaries

• Clinically, these patients manifest with coughing and

dyspnea or chest tightness during or after evacuation of
the pneumothorax

• Incidence may be up to 15% and is higher in those with

larger pneumothoraces
 Cont.
• In most cases RPE does not progress beyond a
radiographic phenomenon
– But the outcome may be fatal in up to 20% of cases

• As opposed to drainage of pleural effusions, where

adjustments can be made to the rate of evacuation
of the fluid by clamping the chest tube (following
drainage of 1,500 mL), little control is exerted over
the rate of reexpansion of the lung in pneumothorax
if an open method is used for chest tube insertion
 Chest Tube Removal
• May be considered after a pneumothorax-related
air leak has resolved
– No clinical evidence of an air leak and radiograph
showing lung reexpansion

• The debate on clamping the chest tube before

removal hasn’t been settled yet

• Tubes can be safely removed during either

inspiration or exhalation
 Persistent Air Leak
• Defined as continued bubbling after 48 hours of drain
insertion

• Most air leaks in patients with PSP seal within the first 24
to 48 hours of tube drainage, and only 3% to 15% of
patients have a persistent air leak for more than 7 days
– However, up to 40% of patients with SSP may have a
persistent air leak

• Prolonging the duration of drainage for more than 7 days

results in only minimal additional pulmonary healing
 Cont.
• The ACCP guidelines suggest observation of an air leak for 4
days for PSP and 5 days for SSP before a definitive intervention
– Resolution, however, may occur in patients with SSP
• This justifies early surgery in the former group and delayed observation in
the latter, particularly when the underlying lung disease makes surgery risky

• Patients with PSP and persistent air leaks are offered VATS
exploration and recurrence prevention
– Chemical pleurodesis with intrapleural instillation of a sclerosing
agent (talc or doxycycline) through a chest drain has a low rate of
success among patients with persistent air leaks and is
recommended only for those in whom surgery is contraindicated or
who refuse an operative procedure
 Prevention of Recurrence and
Treatment of Persistent Air Leaks
 Introduction
• Most patients with PSP can be treated with
observation, simple aspiration, or a small-bore
catheter and flutter valve
– These modalities, however, do not offer recurrence
prevention

• Attempts to prevent recurrence during the first

episode of PSP are not recommended, as 50% to
70% of these patients will not have a recurrence
Accepted Indications for Operative Intervention
for Spontaneous Pneumothorax
• Persistent air leak >4–5 days or failure to completely
reexpand the lung
• Ipsilateral recurrence
• First contralateral pneumothorax
• Bilateral spontaneous pneumothorax
• Tension pneumothorax
• Spontaneous hemopneumothorax
• Contralateral pneumonectomy
• Lifestyle and profession at risk: professional drivers, flying
personnel, spending time in remote areas with no access to
medical care
 Chemical Pleurodesis
• Chemical pleurodesis leads to an aseptic inflammation with
adhesions and ultimately to pleural symphysis
• There is no global consensus on the best agent for pleurodesis
– Most popular are doxycycline and talc, but talc is the most effective
and comparable to mechanical abrasion
– Recurrence rates with tetracycline are unacceptably high (10%–20%)
• Recurrence rates after surgical talc poudrage either by VATS or
minithoracotomy is far less than after medical pleurodesis by
pleuroscopy (medical thoracoscopy) or through the chest tubes
• Because the success of pleurodesis depends on the pleural
inflammatory response, NSAIDs should be avoided for pain
management when pleurodesis is performed
• Of concern is the need for surgical intervention following talc
 Cont.
• Talc
– High effectiveness in patients with pneumothorax and
malignant pleural effusions with a success rate of 90%
– It can be delivered as poudrage (5 g of talc) through VATS
or pleuroscopy (medical thoracoscopy) or as slurry (5 g in
100 mL of normal saline) through the chest tube
• Lidocaine (100 to 200 mg) mixed with the sclerosing solution plus
IV sedation and analgesia is recommended to reduce the
procedure-related pain and discomfort
– Complications include fever, acute pneumonitis, and rarely
ARDS
• Particularly if >10 g is used
 Cont.
• Doxycycline
– Used in a dose of 1,000 mg, given either through
the chest tube or at the time of thoracoscopy
• It should be mixed with lidocaine and premedication
with IV sedation and parenteral analgesics is also
recommended
– Respiratory failure has also been reported following
doxycycline pleurodesis
 Cont.
• Other Agents
– Iodopovidone (64%–96%)
– Silver nitrate (75%–90%)
– Bleomycin
– Erythromycin (animal studies)
– Face talc (96%)
– Quinacrine (64%–100%)
– Autologous blood patch
 Surgical Options
• Reported rates of success for surgical
approaches in preventing recurrence range
from 95% to 100%

• The success rate of thoracoscopy is generally

slightly less than that with limited (4-8cm)
thoracotomy (95% Vs 99%)
 Cont.
• The goal of surgical treatment is to locate and
excise the offending bleb(s) and promote mild
adhesion formation

• Pleural symphysis can be accomplished by a

combination of pleurectomy, pleural abrasion,
and chemical irritation
– Best: apical pleurectomy with abrasion (with a dry
gauze) of the upper half pleura and chemical
irritation of the whole cavity
 Cont.
• Preferred options
– Parietal pleural abrasion limited to the upper half of the
hemithorax and intraoperative removal of ELCs for PSP
– Parietal pleurectomy or parietal pleural abrasion limited to
the upper half of the hemithorax plus bullectomy for SSP

• Lateral thoracotomy and complete parietal pleurectomy

are no longer recommended

• Most patients are discharged by the third postoperative

day
The End!