pnm thoraxan update

8/12/2019 Pnm thoraxan Update

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REVIEW

Pneumothorax: an updateGraeme P Currie, Ratna Alluri, Gordon L Christie, Joe S Legge. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Postgrad Med J2007;83:461465. doi: 10.1136/pgmj.2007.056978

Pneumothorax is a relatively common clinical problem whichcan occur in individuals of any age. Irrespective of aetiology(primary, or secondary to antecedent lung disorders or injury),immediate management depends on the extent ofcardiorespiratory impairment, degree of symptoms and size ofpneumothorax. Guidelines have been produced which outlineappropriate strategies in the care of patients with apneumothorax, while the emergence of video-assistedthoracoscopic surgery has created a more accessible andsuccessful tool by which to prevent recurrence in selectedindividuals. This evidence based review highlights current

practices involved in the management of patients with apneumothorax.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

See end of article forauthors affiliations. . . . . . . . . . . . . . . . . . . . . . . .

Correspondence to:Dr Graeme P Currie,Department of RespiratoryMedicine, Aberdeen RoyalInfirmary, Foresterhill,

Aberdeen AB25 2ZN, UK;[email protected]

Received 3 January 2007Accepted 21 February 2007. . . . . . . . . . . . . . . . . . . . . . . .

Pneumothorax is the presence of air betweenthe parietal and visceral pleura. It is arelatively common respiratory disorder and

can occur in a variety of clinical settings and inindividuals of any age. The presentation of apneumothorax varies between minimal pleuriticchest discomfort and breathlessness to a life-threatening medical emergency with cardiore-spiratory collapse requiring immediate interven-

tion and subsequent prevention.13 This evidencebased review article outlines the causes, diagnosisand current management of a pneumothorax. Allauthors performed a comprehensive literaturesearch using Medline, Clinical Evidence,Cochrane Library and Embase up to November2006. The following key words were used in thesearch: pneumothorax, causes, diagnosis, manage-ment, pleurodesis, diving, flying, tension, surgeryand video assisted thoracoscopic surgery (VATS);we then selected and extracted articles that we feltto be of relevance to practising clinicians.

CLASSIFICATION AND PATHOGENESISPneumothorax can be categorised as primary,secondary, iatrogenic or traumatic according toaetiology. Occasionally, individuals may develop aconcomitant haemothorax due to bleeding causedby shearing of adjacent subpleural vessels whenthe lung collapses.

Primary spontaneous pneumothoraces occurmost commonly in young, tall, thin males with nopredisposing lung disease or history of thoracictrauma, although rupture of an underlying smallsubpleural bleb or bulla is thought to be responsiblein many cases (fig 1).4 5 Moreover, current cigarettesmoking greatly increases the risk of developing apneumothorax by as much as nine times, with

evidence of a doseresponse relationship.6 The exact

incidence of primary spontaneous pneumothorax isuncertain, although the yearly frequency in healthyindividuals has been reported to be approximately1828/100 000 for males and 1.26/100 000 forfemales.7 8

Secondary pneumothoraces occur when there isan underlying lung abnormality. Conditions pre-disposing to the development of a secondarypneumothorax are shown in box 1, althoughchronic obstructive pulmonary disease is the mostcommon.

An iatrogenic pneumothorax is most commonlycaused by central vein cannulation (subclavian morecommonly so than internal jugular vein), pleural tap

or biopsy, transbronchial biopsy, fine needle aspira-tion, and has occasionally been caused by acupunc-ture. Intravenous drug users who try and locatecentral veins are also at risk of developing apneumothorax in the community.9 Intubatedpatients being mechanically ventilated may developan iatrogenic pneumothorax due to high inspiratoryinflation pressures causing pulmonary barotrauma.Before the widespread use of effective chemother-apy, artificial pneumothoraces were created byclinicians treating tuberculosis in an attempt tocollapse and rest the affected lung and help healcavitating disease. Traumatic pneumothorax occursfollowing direct injury to the thorax; common

causes include penetrating chest injury or a frac-tured rib lacerating the visceral pleura.

Tension pneumothorax can occur due to anyaetiology and is defined as any size of pneu-mothorax causing mediastinal shift and cardio-vascular collapse. In individuals with advancedlung disease, even a small pneumothorax cancause significant respiratory failure and cardiovas-cular instability.

DIAGNOSISClinical featuresIt is often possible to diagnose a pneumothoraxor include it in a list of possible diagnoseson thebasis of a consistent history and examinationfindings. Patients typically report an abrupt onsetof pleuritic pain and breathlessness. Examinationfindings may vary according to the size of thepneumothorax and presence of limited cardiore-spiratory reserve. Typical signs include reducedbreath sounds, reduced ipsilateral chest expansionand hyperresonant percussion note. Tracheal shiftaway from the affected side, tachycardia, tachyp-noea and hypotension occur in a tension pneu-mothorax. Contrary to traditional teaching, it hasbeen recently suggested that in tension, lateralis-ing signs are an inconsistent finding, althoughgeneral features such as acute onset and rapid

cardiovascular instability are universal.10

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ImagingThe postero-anterior chest radiograph shows absent lungmarkings extending from the edge of visceral pleura to chestwall, although it is possible to confuse a pneumothorax with alung bulla, edge of the scapula or artefact such as a piece ofclothing. Care should be taken in the evaluation of the chestradiograph, especially portable films taken in accident andemergency. There is generally no need to request an expiratoryfilm, although lateral views can sometimes provide additionalinformation if it is uncertain whether a pneumothorax ispresent or not.11 Mediastinal shift is usually evident inindividuals with a tension pneumothorax (fig 2). In patientsundergoing transbronchial needle biopsy, transthoracic ultra-sound has been proposed as being a useful and sensitivebedside test to detect a post-intervention pneumothorax orhydropneumothorax.12

Computed tomography (CT) imaging of the chest isoccasionally performed when diagnostic uncertainty existsfor example, in order to distinguish a pneumothorax from largebulla or when the lung field is obscured by surgicalemphysema. It is also often carried out before a contemplatedsurgical procedure, or when an underlying lung abnormalitysuch as interstitial lung disease, lymphangioleiomyomatosis or

histiocytosisis considered a possibility.

MANAGEMENTThe management of a pneumothorax depends on the severity ofsymptoms, its size, and presence of underlying lung disease.Chest radiographs are notoriously poor at assessing the volumeof pneumothorax, although recent guidelines published by theBritish Thoracic Society suggest that the size of a pneu-mothorax should be categorised according to the amount of airvisible between the lung edge and chest wall2:

N Small pneumothorax: ,2 cm rim present between the lungedge and chest wall

N Large pneumothorax: >2 cm rim present between the lungedge and chest wall.

OxygenHigh flow oxygen (.28%) should usually be given toindividuals with a pneumothorax in order to maintain adequateoxygenation (saturation .92%) to vital organs. This also lowersthe partial pressure of nitrogen, which may in turn acceleratethe rate of absorption of air from the pleural cavity and hastenlung re-expansion. However, care should be taken in indivi-duals with chronic obstructive pulmonary disease who mayretain carbon dioxide.

Primary spontaneous pneumothoraxPatients with a small spontaneous pneumothorax with fewsymptoms do not require active intervention. Most of theseindividuals do not require admission to hospital, but should begiven written instructions to return to hospital if symptomssuch as worsening breathlessness or chest pain develop. Afollow up appointment within 12 weeks for repeat chestradiograph should be arranged before discharge. In some cases,it might be appropriate to admit patients if they live remotefrom medical access or if concerns exist regarding follow upcare or attendance.

According to British Thoracic Society guidelines, sympto-matic individuals with a large primary spontaneous pneu-mothorax should initially undergo needle aspiration with

Figure 1 A lung bleb.

Box 1: Conditions predisposing to thedevelopment of a secondary pneumothorax

N Obstructive airway disease

chronic obstructive pulmonary diseaseasthma

N Suppurative lung disease

bronchiectasiscystic fibrosis

N Malignant disease

lung cancer

N Interstitial lung disease

pulmonary fibrosisextrinsic allergic alveolitissarcoidosislymphangioleiomyomatosishistiocytosis X

N Infections

pneumonia (for example, due to Staphylococcus aureusorPneumocystis jiroveci)tuberculosis

N Miscellaneous

adult respiratory distress syndromeMarfan syndromeEhlors Danlos syndrome

catamenialrheumatoid arthritis and other connective tissue diseases

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subsequent chest radiograph and observation.2 Thereafter, ifneedle aspiration is unsuccessful, a chest drain is usuallyrequired. This is in contrast to US guidelines where simpleaspiration is not advocated and chest drain insertion isconsidered more appropriate.1 In a randomised trial of 137patients with first episode of primary spontaneous pneu-mothorax, the effects of simple aspiration versus chest draininsertion were assessed.13 Immediate success was obtained in62% assigned to undergo aspiration versus 68% having a chestdrain inserted, while the 1 week success rates were similar in

both group (88% vs 89%, respectively). Recurrence rates at 1and 2 years were 22% and 31%, respectively, for patients whohad simple aspiration, and 24% and 25%, respectively, forpatients who had a chest drain insertion. In another study of 91patients with primary spontaneous pneumothorax who under-went needle aspiration, recurrence occurred in 18% over thesubsequent year.14

Current guidelines do not generally advocate that a surgicalprocedure to prevent recurrence after the first spontaneousepisode is undertaken.1 2 However, it is important to informpatients that the recurrence rate for primary pneumothorax ismore than 20% after the first episode13 and even greater afterthe second episode and tends to be more likely in women, tallmen and smokers.15 It is conceivable that given the relatively

high recurrence rate, perhaps in the future, greater numbers ofindividuals with first episode of spontaneous primary pneu-mothorax will proceed to have surgical intervention. Furtherrandomised controlled studies, incorporating patient prefer-ence, cost and short and long term outcomes, are required toestablish whether such an approach is merited.

Secondary pneumothoraxPatients with a small secondary pneumothorax with fewsymptoms require overnight observation. Individuals who aresymptomatic from a larger pneumothorax require chest draininsertion, as needle aspiration is less likely to be successful,especially in older patients.16 17 Since many of these patientsexperience a further pneumothorax, it is advisable that an

attempt is made to prevent recurrence with pleurodesis.

Tension pneumothoraxTension pneumothorax is a medical emergency and cliniciansshould follow the ABC in terms of immediate management. Ina life-threatening situation, treatment may be necessary with-out a chest radiograph. A plastic cannula (Venflon) should beplaced in the mid-clavicular line in the second intercostal spaceand once the pleural space has been entered, a release of airshould be heard when the internal needle is removed (fig 3).The cannula should be left in place until a chest drain isinserted and bubbling.

Chest drainsSince most hospital doctors will be expected to insert a chestdrain at some point in their career, it is imperative that the safetechnique of doing so and subsequent management is taught byan experienced operator.18 However, unnecessary and avoidableproblems such as drain misplacement and inadequate attach-ment to the skin are frequently encountered. Indeed, in a recentsurvey of 55 junior doctors, 45% failed to identify correctly asafe position for insertion.19 Other problems encounteredinclude bleeding, infection and empyema, damage to theneurovascular bundle, myocardium, mediastinal contents andlung parenchyma, surgical emphysema, and chest tube kinkingand blockage.

Chest drains are most easily inserted using the Seldingertechnique (tube over wire) in the safe trianglesuch as inthe mid-axillary line in the fifth intercostal spacewith thepatient sitting at 45 (fig 4). This minimises risk of injury toadjacent thoracic structures. The drain should be connected toan underwater seal and seen to be bubbling following insertion.In the treatment of a straightforward pneumothorax, a largebore chest drain is not usually required and a 1014 calibreFrench gauge is adequate. In individuals who may have cervicalspine instabilityespecially those involved in significantantecedent thoracic traumathe chest drain should be placedwith the patient lying supine. Drains should not be securedusing a purse-string suture as this has a poor cosmeticoutcome and may be painful; a suture placed in the skin and

then wrapped several times around the drain is usuallyadequate. Suction should not generally be applied to a chestdrain within 48 h of insertion in order to avoid the possibility ofre-expansion pulmonary oedema.20 A chest radiograph shouldbe arranged following insertion to check tube placement,although drains positioned either apically or basally caneffectively drain a pneumothorax.

Chest drains should be removed (preferably during expira-tion or when performing a Valsalva manoeuvre) providing thelung has re-expanded on the chest radiograph and there is noevidence of air leak for around at least 24 h. However, in astudy of 69 trauma patients (102 chest drains), a similar (8% vs6%, p = 1.0) number of pneumothoraces occurred following

Figure 2 Chest radiograph showing a tension pneumothorax.

Figure 3 In patients with a tension pneumothorax, a plastic cannula(Venflon) should be inserted into the second intercostal space in the mid-clavicular line. Informed consent was obtained for publication of this figure.

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removal during end-inspiration and end-expiration, respec-tively.21 Debate continues as to whether drains should beclamped and a subsequent chest radiograph arranged beforeremoval,19 although doing so avoids the unnecessary trouble ofre-inserting a further chest drain if the lung collapses. Ifclamped, it is preferable to do so in a ward where nursing and

medical staff are experienced in chest drain management andare aware that it should be unclamped if the patient becomessymptomatic. However, chest drains should never be clampedin patients where bubbling persists.

REFERRAL TO A THORACIC SURGEONThe basic principle behind surgical intervention lies in remov-ing pleural bullae or suturing apical perforations, in addition toperforming a pleurodesis, pleural abrasion or pleurectomy toprevent recurrence. Video assisted thoracoscopic surgery(VATS) has facilitated a less invasive means by which to accessthe pleural space, especially in more elderly patients withcomorbidities.3 Some patients with poor performance statusmay not be fit for a surgical procedure (for example, those with

advanced chronic obstructive pulmonary disease) and achemical pleurodesis with talc (magnesium silicate) slurry ispreferable. Ward based pleurodesis with talc is usually welltolerated, although it can be associated with pleural pain, mildfever or occasionally empyema; a rare complication is adultrespiratory distress syndrome.2 The success rate of ward basedtalc slurry pleurodesis is between 8090% and for surgicalintervention (VATS stapling, pleurectomy or instillation of talc)is at least 95%.2225 In one study of 861 cases of primaryspontaneous pneumothorax, VATS talc pleurodesis with orwithout stapling of bullae was safe and resulted in a recurrencerate of only 1.7% over a 52 month follow up period. 26 In thesame study, recurrence was significantly associated (p = 0.037)with smoking. Other data have indicated that thoracoscopic

pleural argon beam coagulation may have a role to play in the

treatment of primary spontaneous pneumothorax, althoughfurther studies are required to investigate this.27

Referral to a thoracic surgeon should be considered in patientswho have a first spontaneous pneumothorax and an at-riskprofession (such as aircraft pilot or diver). Other indications forconsideration of a definitive surgical procedure to reduce chanceof recurrence include second ipsilateral pneumothorax, bilateralpneumothorax, concomitant haemothorax or first contralateralpneumothorax. Individuals who have a persistent air leak (abubbling chest drain) after 5 days of chest intubation should also

be referred for surgical consideration.2

PNEUMOTHORAX IN SPECIAL CONDITIONSFlyingAs pressure falls during ascent in aircraft, an inverselyproportional rise in gas volume occurs (Boyles law). Thiscauses expansion of air within gas filled bodily chambers suchas in an undrained pneumothorax. Airline passengers with aclosed pneumothorax may therefore experience difficulties dueto gas expansion during ascent, and can develop a tensionpneumothorax. As a consequence, individuals with anuntreated pneumothorax must not fly in commercial aircraft.Providing 1 week (or 2 weeks in the case of a traumaticpneumothorax or thoracic surgery) has elapsed after resolution

of a pneumothorax and the chest radiograph is normal,individuals may be permitted to fly (http://www.brit-thoraci-c.org.uk/c2/uploads/FlightPCsummary04.pdf). Some indivi-duals with a longstanding pneumothorax have flown withoutcomplication but only with careful pre-flight assessment,including CT imaging and exposure to a hypoxic hypobaricenvironment in a decompression chamber.28

DivingThe development of a pneumothorax at depth is associatedwith potentially fatal consequences, since during ascent, thevolume of gas within a closed pneumothorax will expand, inturn leading to a tension pneumothorax. Current guidelinessuggest that a previous spontaneous pneumothorax is a

contraindication to underwater diving unless treated bybilateral surgical pleurectomy in association with normal lungfunction and CT scan following surgery. A previous traumaticpneumothorax may not be an absolute contraindicationproviding it has healed and subsequent lung function and CTthorax scan are normal.29

Cystic fibrosisPatients with cystic fibrosis who develop a pneumothoraxshould generally be managed in a manner similar to thosewithout the disease, although needle aspiration is usually lesssuccessful. It may take longer for the lung to expand andconcomitant infectionoften with Pseudomonas aeruginosashould be treated aggressively with intravenous antibiotics.Consideration should be given to prevention of subsequentpneumothorax by either surgical intervention or talc pleurod-esis in order to prevent recurrence (which tends to be highwithout intervention).

HIV infectionPrevious data have shown that infection with tuberculosis or

Pneumocystis jiroveci (previously carinii) can predispose to thedevelopment of a pneumothorax in patients with HIV infec-tion.30 Indeed, in an HIV infected individual, P jiroveci infectionshould be considered as the most likely aetiological factor. 31

CONCLUSIONPneumothorax is a relatively common respiratory diagnosis andit is important that it is managed promptly and in anappropriate manner. Immediate management is largely deter-

Figure 4 The safe triangle is the area bordered by the anterior borderof the latissimus dorsi, the lateral border of the pectoralis major muscle, aline superior to the horizontal level of the nipple, and apex below the axilla.Informed consent was obtained for publication of this figure.

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mined by the extent of cardiorespiratory compromise, degree ofsymptoms and size of pneumothorax and may involveobservation alone, needle aspiration or chest drain insertion.Since recurrence rates are relatively high, selected individualsshould be considered for definitive surgical treatment (usuallyby VATS) or instillation of talc slurry in less fit individuals.

Junior doctors are frequently given responsibility to insertchest drains but should ideally receive a period of training andsupervision before this. Indeed, with increased availability ofclinical skills laboratories this procedure should form a core

element of postgraduate training. This has the ultimate aim ofreducing complications at insertion and subsequent aftercare ofchest drains, which are not infrequently encountered inaccident and emergency, and acute medical receiving andrespiratory wards.

Authors affiliations. . . . . . . . . . . . . . . . . . . . . . .

Graeme P Currie, Ratna Alluri, Gordon L Christie, Joe S Legge,Department of Respiratory Medicine, Aberdeen Royal Infirmary,

Aberdeen, UK

Competing interests and acknowledgements: none.

Informed consent was obtained for publication of figs 3 and 4

REFERENCES1 Baumann MH, Strange C, Heffner JE,et al. Management of spontaneous

pneumothorax: an American College of Chest Physicians Delphi consensusstatement.Chest2001;119:590602.

2 Henry M, Arnold T, Harvey J. BTS guidelines for the management of spontaneouspneumothorax.Thorax2003;58(Suppl II):ii3952.

3 Ng CS, Lee TW, Wan S, Yim AP. Video assisted thoracic surgery in themanagement of spontaneous pneumothorax: the current status. Postgrad Med J2006;82:17985.

4 Lesur O, Delorme N, Fromaget JM,et al. Computed tomography in the etiologicassessment of idiopathic spontaneous pneumothorax.Chest1990;98:3417.

5 Donahue DM, Wright CD, Viale G, et al.Resection of pulmonary blebs andpleurodesis for spontaneous pneumothorax. Chest1993;104:17679.

6 Bense L, Eklund G, Wiman LG. Smoking and the increased risk of contractingspontaneous pneumothorax.Chest1987;92:100912.

7 Melton LJ 3rd, Hepper NG, Offord KP. Incidence of spontaneous pneumothoraxin Olmsted County, Minnesota: 1950 to 1974. Am Rev Respir Dis

1979;120:137982.8 Bense L, Wiman LG, Hedenstierna G. Onset of symptoms in spontaneouspneumothorax: correlations to physical activity.Eur J Respir Dis 1987;71:1816.

9 Miller DR, Harden JL, Currie GP. A case of self-inflicted bilateral pneumothorax.Resuscitation2006;71:1223.

10 Leigh-Smith S, Harris T. Tension pneumothoraxtime for a re-think?EmergMed J2005;22:816.

11 Glazer HS, Anderson DJ, Wilson BS,et al.Pneumothorax: appearance on lateralchest radiographs.Radiology1989;173:70711.

12 Reissig A, Kroegel C. Accuracy of transthoracic sonography in excluding post-interventional pneumothorax and hydropneumothorax. Comparison to chestradiography.Eur J Radiol2005;53:46370.

13 Ayed AK, Chandrasekaran C, Sukumar M. Aspiration versus tube drainage inprimary spontaneous pneumothorax: a randomised study. Eur Respir J2006;27:47782.

14 Chan SS, Rainer TH. Primary spontaneous pneumothorax: 1-year recurrence rate

after simple aspiration.Eur J Emerg Med2006;13:8891.15 Sadikot RT, Greene T, Meadows K,et al. Recurrence of primary spontaneous

pneumothorax.Thorax1997;52:8059.16 Archer GJ, Hamilton AA, Upadhyay R, et al. Results of simple aspiration of

pneumothoraces.Br J Dis Chest1985;79:17782.17 Ng AW, Chan KW, Lee SK. Simple aspiration of pneumothorax. Singapore

Med J1994;35:502.18 Laws D, Neville E, Duffy J. BTS guidelines for the insertion of a chest drain.

Thorax2003;58(Suppl II):ii539.19 Hyde J, Sykes T, Graham T. Reducing morbidity from chest drains. BMJ

1997;314:9145.20 Tariq SM, Sadaf T. Images in clinical medicine. Reexpansion pulmonary edema

after treatment of pneumothorax.N Engl J Med2006;354:2046.21 Bell RL, Ovadia P, Abdullah F,et al.Chest tube removal: end-inspiration or end-

expiration?J Trauma2001;50:6747.22 Kennedy L, Sahn SA. Talc pleurodesis for the treatment of pneumothorax and

pleural effusion.Chest1994;106:121522.23 Baumann MH, Strange C. Treatment of spontaneous pneumothorax: a more

aggressive approach?Chest1997;112:789804.24 Ayed AK, Al-Din HJ. The results of thoracoscopic surgery for primary

spontaneous pneumothorax.Chest2000;118:2358.25 Hatz RA, Kaps MF, Meimarakis G, et al. Long-term results after video-assisted

thoracoscopic surgery for first-time and recurrent spontaneous pneumothorax.Ann Thorac Surg2000;70:2537.

26 Cardillo G, Carleo F, Giunti R, et al. Videothoracoscopic talc poudrage inprimary spontaneous pneumothorax: a single-institution experience in 861cases. J Thorac Cardiovasc Surg2006;131:3228.

27 Bobbio A, Ampollini L, Internullo E, et al. Thoracoscopic parietal pleural argonbeam coagulation versus pleural abrasion in the treatment of primaryspontaneous pneumothorax.Eur J Cardiothorac Surg2006;29:68.

28 Currie GP, Kennedy AM, Paterson E,et al.A chronic pneumothorax and fitnessto fly.Thorax2007;62:1879.

29 British Thoracic Society. British Thoracic Society guidelines on respiratory aspectsof fitness for diving. Thorax2003;58:313.

30 Tumbarello M, Tacconelli E, Pirronti T,et al. Pneumothorax in HIV-infectedpatients: role of Pneumocystis carinii pneumonia and pulmonary tuberculosis.Eur

Respir J1997;10:13325.31 Spivak H, Keller S. Spontaneous pneumothorax in the AIDS population.Am Surg1996;62:7536.

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