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Pneumothorax - Emergency Management

General Information

General InformationGeneral Information

Description

  • Collection of air in pleural space separating thoracic wall and lung
    • Primary spontaneous pneumothorax: occurs spontaneously without known lung pathology
    • Secondary spontaneous pneumothorax: occurs in setting of known pulmonary abnormality/pathology
    • Traumatic pneumothorax: pneumothorax that occurs secondary to traumatic injury
    • Tension pneumothorax: life-threatening complication of pneumothorax in which air accumulates and becomes trapped by one-way valve, which can compress lung and compress/displace mediastinal structures, including the heart, leading to hemodynamic instability

Anatomy

  • 12 pairs of ribs attach in a more rigid manner posteriorly to the spine than to the sternum anteriorly where cartilage provides some flexibility1
    • Ribs 11 and 12 are “floating” and only attach posteriorly
  • 3 layers of intercostal muscles connect each rib to each other, making a protective barrier1
  • The lungs are covered by the visceral and parietal pleura1
    • The potential space between these 2 pleura is the pleural cavity
    • Space contains small amount of lubricating fluid
    • Normally under negative pressure when compared to alveoli
    • There is no communication between the right and left pleural cavities

Etiology

  • Spontaneous2,3,4
  • Iatrogenic: top 5 causes are transthoracic needle aspiration, subclavian needle stick, thoracentesis, transbronchial biopsy, and pleural biopsy2,3,4
  • Traumatic2,3,4
    • Penetrating: stab wounds and gun shot wounds are most common; also impaled objects due to industrial accidents, falls, or blast injuries
    • Blunt: most commonly from motor vehicle collisions; also due to falls and assaults

Epidemiology

  • Primary spontaneous pneumothorax most common in young (20-30 years old) males2,3,4
  • Secondary spontaneous pneumothorax most common in older (60-65 years old) males with chronic obstructive pulmonary disease (COPD)2,3,4
  • Iatrogenic pneumothorax occurs in 5-7/10,000 hospital admissions2,3,4
    • Pediatric TIP: 1%-2% of neonates will experience iatrogenic pneumothorax; there is a higher incidence with neonatal respiratory distress syndrome
  • Traumatic: pneumothorax ranks second after rib fractures as most common chest trauma, occurring in up to 50% of chest trauma patients2,3,4

References

References

General References Used

  1. Gray, H. Anatomy of the Human Body. Philadelphia: Lea and Febiger; 1918.
  2. Sassoon CS, Light RW, O'Hara VS, Moritz TE. Iatrogenic pneumothorax: etiology and morbidity. Results of a Department of Veterans Affairs Cooperative Study. Respiration. 1992;59(4):215-20
  3. Davis JS, Satahoo SS, Butler FK, et al. An analysis of prehospital deaths: Who can we save? J Trauma Acute Care Surg. 2014 Aug;77(2):213-8
  4. Noppen M, De Keukeleire T. Pneumothorax. Respiration. 2008;76(2):121-7full-text
  5. Asensio JA, Mazzini FN, Vu T. Thoracic Injury. In: Peitzman AB, Rhodes M, Schwab CW, Yealy D, Fabian T, eds. The Trauma Manual: Trauma and Acute Care Surgery. 3rd ed. 2008. Pp 209-228.
  6. Kincaid EH, Meredith JW. Injuries to the Chest. In: Souba WW, Fink MP, Jurkovich GJ, et al, eds. ACS Surgery Principles and Practice. 6th ed. New York: NY. 2007.1274-1292.
  7. Brunett PH, Yarris LM, Cevik AA. Pulmonary Trauma. In: Tintinalli J, Stapczynski JS, Ma OJ, et al; The American College of Emergency Physicians. Tintinalli’s Emergency Medicine A Comprehensive Study Guide. 7th ed. New York: NY. 2011. 1744-1758.
  8. Aukema TS, Beenen LF, Hietbrink F, Leenen LP. Initial assessment of chest X-ray in thoracic trauma patients: Awareness of specific injuries. World J Radiol. 2012 Feb 28;4(2):48-52full-text
  9. Husain LF, Hagopian L, Wayman D, Baker WE, Carmody KA. Sonographic diagnosis of pneumothorax. J Emerg Trauma Shock. 2012 Jan;5(1):76-81full-text
  10. Scalea TM, Rodriguez A, Chiu WC, et al. Focused Assessment with Sonography for Trauma (FAST): results from an international consensus conference. J Trauma. 1999 Mar;46(3):466-72
  11. Wilkerson RG, Stone MB. Sensitivity of bedside ultrasound and supine anteroposterior chest radiographs for the identification of pneumothorax after blunt trauma. Acad Emerg Med. 2010 Jan;17(1):11-7full-text
  12. Volpicelli G. Sonographic diagnosis of pneumothorax. Intensive Care Med. 2011 Feb;37(2):224-32
  13. Ianniello S, Di Giacomo V, Sessa B, Miele V. First-line sonographic diagnosis of pneumothorax in major trauma: accuracy of e-FAST and comparison with multidetector computed tomography. Radiol Med. 2014 Sep;119(9):674-80
  14. Kirkpatrick AW, Ng AK, Dulchavsky SA, et al. Sonographic diagnosis of a pneumothorax inapparent on plain radiography: confirmation by computed tomography. J Trauma. 2001 Apr;50(4):750-2
  15. Baumann MH, Strange C, Heffner JE, et al; AACP Pneumothorax Consensus Group. Management of spontaneous pneumothorax: an American College of Chest Physicians Delphi consensus statement. Chest. 2001 Feb;119(2):590-602
  16. Inaba K, Branco BC, Eckstein M, et al. Optimal positioning for emergent needle thoracostomy: a cadaver-based study. J Trauma. 2011 Nov;71(5):1099-103
  17. Sanchez LD, Straszewski S, Saghir A, et al. Anterior versus lateral needle decompression of tension pneumothorax: comparison by computed tomography chest wall measurement. Acad Emerg Med. 2011 Oct;18(10):1022-6full-text
  18. Massongo M, Leroy S, Scherpereel A, et al. Outpatient management of primary spontaneous pneumothorax: a prospective study. Eur Respir J. 2014 Feb;43(2):582-90full-text

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How to cite

National Library of Medicine, or "Vancouver style" (International Committee of Medical Journal Editors):

  • DynaMed [Internet]. Ipswich (MA): EBSCO Information Services. 1995 - . Record No. T913035, Pneumothorax - Emergency Management; [updated 2018 Nov 30, cited place cited date here]. Available from https://www.dynamed.com/topics/dmp~AN~T913035. Registration and login required.

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