Pneumothorax – Diagnosis and treatment

Diagnosis

A pneumothorax is generally diagnosed using a chest X-ray. In some cases, a computerized tomography (CT) scan may be needed to provide more-detailed images. Ultrasound imaging also may be used to identify a pneumothorax.

Treatment

The goal in treating a pneumothorax is to relieve the pressure on your lung, allowing it to re-expand. Depending on the cause of the pneumothorax, a second goal may be to prevent recurrences. The methods for achieving these goals depend on the severity of the lung collapse and sometimes on your overall health.

Treatment options may include observation, needle aspiration, chest tube insertion, nonsurgical repair or surgery. You may receive supplemental oxygen therapy to speed air reabsorption and lung expansion.

Observation

If only a small portion of your lung is collapsed, your doctor may simply monitor your condition with a series of chest X-rays until the excess air is completely absorbed and your lung has re-expanded. This may take several weeks.

Needle aspiration or chest tube insertion

If a larger area of your lung has collapsed, it’s likely that a needle or chest tube will be used to remove the excess air.

• Needle aspiration. A hollow needle with a small flexible tube (catheter) is inserted between the ribs into the air-filled space that’s pressing on the collapsed lung. Then the doctor removes the needle, attaches a syringe to the catheter and pulls out the excess air. The catheter may be left in for a few hours to ensure the lung is re-expanded and the pneumothorax does not recur.
• Chest tube insertion. A flexible chest tube is inserted into the air-filled space and may be attached to a one-way valve device that continuously removes air from the chest cavity until your lung is re-expanded and healed.

Nonsurgical repair

If a chest tube doesn’t re-expand your lung, nonsurgical options to close the air leak may include:

• Using a substance to irritate the tissues around the lung so that they’ll stick together and seal any leaks. This can be done through the chest tube, but it may be done during surgery.
• Drawing blood from your arm and placing it into the chest tube. The blood creates a fibrinous patch on the lung (autologous blood patch), sealing the air leak.
• Passing a thin tube (bronchoscope) down your throat and into your lungs to look at your lungs and air passages and placing a one-way valve. The valve allows the lung to re-expand and the air leak to heal.

Surgery

Sometimes surgery may be necessary to close the air leak. In most cases, the surgery can be performed through small incisions, using a tiny fiber-optic camera and narrow, long-handled surgical tools. The surgeon will look for the leaking area or ruptured air blister and close it off.

Rarely, the surgeon will have to make a larger incision between the ribs to get better access to multiple or larger air leaks.

Ongoing care

You may need to avoid certain activities that put extra pressure on your lungs for a time after your pneumothorax heals. Examples include flying, scuba diving or playing a wind instrument. Talk to your doctor about the type and length of your activity restrictions. Keep follow-up appointments with your doctor to monitor your healing.

Collapsed Lung (Pneumothorax)

When air fills the space between your lung and chest wall (pleural cavity), it can cause all or part of your lung to collapse. The main cause of this is an injury to the chest cavity that punctures the lungs. Damage may result from a stab or gunshot wound, car accident, fall, or certain surgeries. In some cases, it happens without a clear cause (spontaneous). 

You’re more likely to have spontaneous collapsed lung if you smoke or have a chronic lung disease, such as emphysema.

When to go to the emergency room (ER)

Serious collapsed lung can be fatal if not treated. Call 911 for a bad chest wound or any of the following symptoms:

• Sudden, sharp chest pain that may spread to your shoulder or back

• Shortness of breath or trouble breathing

• A bluish color to the skin

• Loss of consciousness or feeling faint with any of the above symptoms

What to expect in the ER

• You will be examined carefully.

• Your lungs and heart will be listened to through a stethoscope.

• You may have X-rays or a CT scan. A CT scan combines X-rays and computer scans to provide detailed pictures of your lungs.

• You will be given help with breathing if you need it.

Treatment

• If the collapsed lung is small, you may stay in the ER for 5 to 6 hours to see if it gets any worse. If it does not get worse, you may be sent home without treatment and told to follow up with your regular healthcare provider.

• If the collapsed lung needs treatment, you will be admitted to the hospital. The provider will place a hollow drainage tube in your chest. This is done at the bedside and you will be given local anesthesia. This tube is attached to a suction device that removes the air. In that case, you will be admitted to the hospital for a few days while the lung re-expands.

After treatment, you will be told what to do to care for yourself and when to follow up with your healthcare provider.

Acute Pneumothorax Evaluation and Treatment – StatPearls

Continuing Education Activity

A pneumothorax is an accumulation of gas in the pleural space (the space between the visceral and parietal pleura of the chest cavity), which can impair ventilation, oxygenation, or both. This condition can vary in its presentation from asymptomatic to life-threatening. This activity outlines the evaluation and management of patients presenting with acute pneumothorax and highlights the role of the interprofessional team in managing patients with this condition.

Objectives:

• Describe the most common presenting symptoms in a patient with an acute pneumothorax.

• Outline the treatment strategy for a patients with an acute pneumothorax.

• List the differential diagnosis for an acute pneumothorax.

• Employ an interprofessional team approach to provide optimal care to patients diagnosed with an acute pneumothorax.

Access free multiple choice questions on this topic.

Introduction

Pneumothorax – is an accumulation of air or gas in the pleural space (the space between visceral and parietal pleura of the chest cavity), which can impair with ventilation, oxygenation, or both. This condition can vary in its presentation from asymptomatic to life-threatening.[1][2]

Pneumothorax can subdivide into three broad categories according to the etiology:

1. Traumatic – resulting from blunt or penetrating chest trauma. Majority of all pneumothoraces are traumatic in origin

2. Iatrogenic – caused by manipulation by a healthcare provider, such as the insertion of central lines, etc

3. Spontaneous – a pneumothorax without any apparent cause or inciting event.

Pneumothorax can also be classified based on their physiology into the following types:

1. Simple – when the air in the pleural space does not communicate with an outside atmosphere, and there is no shift in mediastinum or hemidiaphragm. An example is a pleural laceration from a fractured rib.

2. Communicating – when there is a defect in a chest wall, such as from a gunshot wound, that causes open communication with an outside atmosphere. This loss of the chest wall integrity can create an air sucking and a paradoxical lung collapse, thus causing significant ventilatory problems.

3. Tension – progressive accumulation of air in the pleural cavity causing the shift of mediastinum to the opposite side, resulting in compression of vena cava and other great vessels, decreased diastolic filling, and ultimately compromised cardiac output. It occurs when a chest injury causes a one-valve situation when the air gets into the pleural cavity but is unable to escape freely and thus gets trapped. 

Etiology

Causes:

1. Traumatic – results from blunt or penetrating injuries to the chest wall. 

2. Spontaneous – primary spontaneous pneumothorax occurs in people with no underlying lung disease or inciting event, secondary spontaneous pneumothorax occurs in people with significant underlying parenchymal lung disease and results from some inciting incident, such as a bleb rupture.[3]

3. Iatrogenic – is a subtype of traumatic pneumothorax, where an injury occurs as a result of a diagnostic or therapeutic medical intervention (i.e., insertion of a central line, etc.)

4. Catamenial – is a non-traumatic pneumothorax that occurs in women in conjunction with their menstrual period. Although not entirely understood, the cause is believed to be endometriosis of the pleura.

Epidemiology

The incidence of non-traumatic pneumothorax is 7.4 to 18 per 100000 people per year. [4] It is much higher in smokers (12% vs. 0.1% lifetime risk)[5]

Primary spontaneous pneumothorax often affects young males, tall and thin built, often smokers. The incidence of recurrence is 20 to 60% in the first 3 years after the first episode. 

Secondary spontaneous pneumothoraces also occur in patients with underlying lung disease; thus epidemiology varies greatly. 

Catamenial pneumothorax affects young women of childbearing age. 

History and Physical

The clinical presentation varies depending on the etiology and the size of the pneumothorax. Some patients may be asymptomatic, and pneumothorax is diagnosed as an incidental finding during the workup for another condition. 

The most common presenting symptoms are chest pain and shortness of breath (64 to 85%). Chest pain is usually severe, sharp/stabbing, pleuritic and radiates to ipsilateral shoulder/arm. Symptomatic onset is sudden, and in primary spontaneous pneumothorax can decrease after 24 hours, possibly due to gradual spontaneous resolution of the pneumothorax. Patients can also present with anxiety and cough, but these symptoms are less common. The patient may have a normal physical exam if the pneumothorax is small. However, with large enough pneumothorax, there may be absent breath sounds on the affected side. Many patients with first time spontaneous pneumothorax do not seek medical help for several days.

The signs and symptoms of tension pneumothorax are more severe, and timely diagnosis and treatment are crucial for the patient’s survival. Tension pneumothorax, besides chest pain and shortness of breath, presents with hemodynamic compromise.  The patient may have profound hypoxia and hypotension. The gradual accumulation of air in the pleural space due to one-valve situation causes the shift of the mediastinum to the contralateral side and compression of vena cava and eventual compromise of the cardiac output, producing life-threatening hypotension and hypoxia. On physical exam, the patient has absent breath sounds on the affected hemithorax, tracheal deviation to the contralateral side, tachycardia, and jugular venous distention — undiagnosed and untreated tension pneumothorax results in hemodynamic collapse and death. 

Evaluation

Traumatic pneumothorax must be a suspected diagnosis in any blunt or penetrating chest trauma. Adequate history, physical exam and chest X-rays are the mainstays of the diagnosis. However, small pneumothoraces are often missed on physical exam and chest X-ray and may be present on CT chest during a diagnostic workup for other injuries.[6][1]

In patients who present with sudden onset of sharp pleuritic chest pain and shortness of breath, spontaneous pneumothorax should always be on a differential diagnosis list.[3] 

The diagnosis is often made by upright chest radiograph, except tension pneumothorax which is a clinical diagnosis.

Point of care ultrasound is commonly used in the evaluation patients with pneumothorax.  In fact, ultrasound can rapidly diagnosis pneumothoraces with better accuracty than standard chest X-ray, while sparing the patient radiation expsoure. [7]

The definition of large vs. small pneumothorax is by the distance between the lung margin and chest wall[8]:

• Small pneumothorax: the presence of a visible rim of less than 2 cm between the lung margin and the chest wall

• Large pneumothorax: the presence of a visible rim of greater than 2 cm between the lung margin and the chest wall

The chest radiograph is thought to underestimate the size of pneumothorax.

Treatment / Management

The management is guided by the etiology, clinical presentation, and risk stratification.[3][6]

The principles of treatment of pneumothorax: air elimination, reduction of air leakage, healing of pleural fistula, promoting re-expansion of the lung, prevention of future recurrences.[9]

Asymptomatic patients with pneumothorax as an incidental finding may not need any intervention unless an estimated risk of recurrence is high. Typically this decision is not made initially in the emergency department, and a patient must obtain a referral to a pulmonologist for further evaluation and care.

Symptomatic patients with stable vital signs may require needle aspiration or small bore catheter insertion (pigtail catheter) in the emergency department. Evidence suggests that in a primary spontaneous pneumothorax needle aspiration is as safe and effective as tube thoracostomy.[10] These patients require admission for high flow oxygen and observation with interval repeat of the chest radiograph. 

Generally, traumatic pneumothoraces with stable or unstable vital signs require the insertion of large vs. small bore thoracostomy catheter. Most of them can be treated with small bore pigtail catheters, although very large pneumothoraces may require treatment with large bore chest tubes.[11] If there is a concomitant hemothorax, a thoracostomy with a large bore chest tube insertion is necessary. 

Pharmacotherapy:

In the treatment of pneumothorax, the pharmacotherapy is mainly focused on an adequate control of pain from the pneumothorax itself and/or from procedures to restore lung volumes and air-free pleural space (thoracostomy or needle aspiration). Pain control is achievable through local infiltration of an anesthetic at the thoracostomy site, as well as intravenous and oral pain medication administration, or both. Typically, a thoracostomy requires IV opiates or procedural sedation analgesia for the insertion of the tube and to manage the pain associated with the indwelling thoracostomy catheter.   Some authors advocate for regional anesthesia for these patients, such as intercostal nerve blocks. Prophylactic antibiotics should be considered in patients during the chest tube insertion to prevent infection at the site of insertion and later complications, such as emphysema. 

In patients with recurrent pneumothoraces, chemical pleurodesis, or sclerotherapy with talc may be a treatment consideration.  

Differential Diagnosis

Differential diagnosis of non-traumatic spontaneous pneumothorax includes: pneumonia, acute asthma exacerbation, bronchitis, pulmonary embolism, aortic dissection, costochondritis, acute coronary syndrome, anxiety or panic attack, diaphragmatic injuries, GERD, esophageal spasm, Mallory-Weiss tear, Boerhaave’s syndrome, mediastinitis, myocarditis, pericarditis, pleurodynia, tuberculosis, pulmonary empyema, lung abscess.

In traumatic pneumothoraces, tension pneumothorax and concomitant hemothorax must always be considered. There is a high association of other traumatic injuries in the chest and abdomen in patients with traumatic pneumothorax. Therefore, an appropriate full trauma evaluation must be completed by emergency physicians and trauma surgeons to exclude other injuries.

Prognosis

Spontaneous pneumothorax has a recurrence rate close to 20 to 60% in the next 3 years after the initial episode.[12]

Complications

Misdiagnosis is a frequent complication of pneumothorax. Multiple factors, such as incomplete or inadequate history or physical exam, low index of clinical suspicion, failure to obtain a chest radiograph, or failure to recognize a pneumothorax on a chest radiograph, can contribute to misdiagnosis. Misdiagnosis leads to failure to treat the pneumothorax, and in some cases can lead to devastating consequences such as[9][13][14][15][16][15][14]:

1. Conversion to tension pneumothorax

2. Hypoxemic Respiratory Failure

3. Shock

4. Respiratory arrest

5. Cardiac arrest

6. Empyema

7. Re-expansion pulmonary edema

8. Iatrogenic complications from the needle decompression or thoracostomy procedure – the failure of the lung to re-expand, lung laceration, infection of the insertion site and pleural space, laceration of intercostal vessels or internal mammary artery, hemothorax, persistent air leak, damage to the intercostal neurovascular bundle, etc

9. Chest tube-induced arrhythmia

10. Pneumomediastinum – air from the pneumothorax can track into the mediastinum. This can be visualized on the chest X-ray as air leuncy around the heart.  Additionally, a crunching sound may be asculated during the cardiac examination.  This is called Hamman’s crunch and is best heard in the left lateral decubitus position.  

Enhancing Healthcare Team Outcomes

The management of a pneumothorax is with an interprofessional team that includes an emergency department physician, general surgeon, thoracic surgeon, critical care specialist, radiologist, and specialty-trained emergency or critical care nurse. After assisting with chest tube placement, the monitoring of these patients is performed by the nurses. Nurses must assess the wound site, breath sounds, and patency of the drainage system and report to the team any abnormalities. Further, sudden development of a tension pneumothorax can cause a rapid deterioration in a patient’s overall clinical status. Hence prompt identification by the nurse followed by treatment by the interprofessional team is essential. The nurse is usually the first to identify the condition and must be prepared to contact the clinical team immediately and then assist in any rapid intervention. It is a prevalent condition with over 5 million patients admitted to the ICUs each year in the United States with pneumothorax. While a chest x-ray remains the standard modality for diagnosing a pneumothorax, numerous enhancements in radiology software have taken place over the last few years enabling easier diagnosis, especially for less experienced practitioners.[17] Having a trained interprofessional team managing the evaluation and treatment of a pneumothorax will result in the best outcomes. Lines of communication must be open and rapid. [Level V]

Figure

Apical Ptx, Primary Spontaneous pneumothorax, X-ray. Contributed by Steve Bhimji, MS, MD, PhD

Figure

Ct rib fracture, CT Scan, pneumothorax, collapsed lung. Contributed by Steve Bhimji, MS, MD, PhD

References

1.

Swierzy M, Helmig M, Ismail M, Rückert J, Walles T, Neudecker J. [Pneumothorax]. Zentralbl Chir. 2014 Sep;139 Suppl 1:S69-86; quiz S87. [PubMed: 25264729]

2.

Papagiannis A, Lazaridis G, Zarogoulidis K, Papaiwannou A, Karavergou A, Lampaki S, Baka S, Mpoukovinas I, Karavasilis V, Kioumis I, Pitsiou G, Katsikogiannis N, Tsakiridis K, Rapti A, Trakada G, Karapantzos I, Karapantzou C, Zissimopoulos A, Zarogoulidis P. Pneumothorax: an up to date “introduction”. Ann Transl Med. 2015 Mar;3(4):53. [PMC free article: PMC4381472] [PubMed: 25861608]

3.

Baumann MH. Management of spontaneous pneumothorax. Clin Chest Med. 2006 Jun;27(2):369-81. [PubMed: 16716824]

4.

McKnight CL, Burns B. StatPearls [Internet]. StatPearls Publishing; Treasure Island (FL): Nov 16, 2020. Pneumothorax. [PubMed: 28722915]

5.

Larson R. Primary spontaneous pneumothorax presenting to a chiropractic clinic as undifferentiated thoracic spine pain: a case report. J Can Chiropr Assoc. 2016 Mar;60(1):66-72. [PMC free article: PMC4807682] [PubMed: 27069268]

6.

Idrees MM, Ingleby AM, Wali SO. Evaluation and management of pneumothorax. Saudi Med J. 2003 May;24(5):447-52. [PubMed: 12847616]

7.

Alrajab S, Youssef AM, Akkus NI, Caldito G. Pleural ultrasonography versus chest radiography for the diagnosis of pneumothorax: review of the literature and meta-analysis. Crit Care. 2013 Sep 23;17(5):R208. [PMC free article: PMC4057340] [PubMed: 24060427]

8.

MacDuff A, Arnold A, Harvey J., BTS Pleural Disease Guideline Group. Management of spontaneous pneumothorax: British Thoracic Society Pleural Disease Guideline 2010. Thorax. 2010 Aug;65 Suppl 2:ii18-31. [PubMed: 20696690]

9.

Huang Y, Huang H, Li Q, Browning RF, Parrish S, Turner JF, Zarogoulidis K, Kougioumtzi I, Dryllis G, Kioumis I, Pitsiou G, Machairiotis N, Katsikogiannis N, Courcoutsakis N, Madesis A, Diplaris K, Karaiskos T, Zarogoulidis P. Approach of the treatment for pneumothorax. J Thorac Dis. 2014 Oct;6(Suppl 4):S416-20. [PMC free article: PMC4203983] [PubMed: 25337397]

10.

Zehtabchi S, Rios CL. Management of emergency department patients with primary spontaneous pneumothorax: needle aspiration or tube thoracostomy? Ann Emerg Med. 2008 Jan;51(1):91-100, 100.e1. [PubMed: 18166436]

11.

Tsai TM, Lin MW, Li YJ, Chang CH, Liao HC, Liu CY, Hsu HH, Chen JS. The Size of Spontaneous Pneumothorax is a Predictor of Unsuccessful Catheter Drainage. Sci Rep. 2017 Mar 15;7(1):181. [PMC free article: PMC5428034] [PubMed: 28298628]

12.

Sadikot RT, Greene T, Meadows K, Arnold AG. Recurrence of primary spontaneous pneumothorax. Thorax. 1997 Sep;52(9):805-9. [PMC free article: PMC1758641] [PubMed: 9371212]

13.

Eggeling S. [Complications in the therapy of spontaneous pneumothorax]. Chirurg. 2015 May;86(5):444-52. [PubMed: 25995086]

14.

Slade M. Management of pneumothorax and prolonged air leak. Semin Respir Crit Care Med. 2014 Dec;35(6):706-14. [PubMed: 25463161]

15.

Peyrin JC, Charlet JP, Duret J, Crepel N, Brichon PY. [Reexpansion pulmonary edema after pneumothorax. Apropos of a case. Review of the literature]. J Chir (Paris). 1988 Mar;125(3):199-202. [PubMed: 3286664]

16.

Cardozo S, Belgrave K. A shocking complication of a pneumothorax: chest tube-induced arrhythmias and review of the literature. Case Rep Cardiol. 2014;2014:681572. [PMC free article: PMC4131458] [PubMed: 25147742]

17.

Ley-Zaporozhan J, Shoushtari H, Menezes R, Zelovitzky L, Odedra D, Jimenez-Juan L, Brunet K, Karimzad Y, Paul NS. Enhanced pneumothorax visualization in ICU patients using portable chest radiography. PLoS One. 2018;13(12):e0209770. [PMC free article: PMC6303023] [PubMed: 30576378]

Pneumothorax – Physiopedia

Left pneumothorax. This X-ray is used on clinicalcases.org to illustrate a fictional case history of tension pneumothorax. Note the large, well-demarcated area devoid of lung markings, the tracheal deviation and movement of the heart away from the affected side.

A pneumothorax can be defined as air in the pleural cavity^[1]. This occurs when there is a breach of the lung surface or chest wall which allows air to enter the pleural cavity and consequently cause the lung to collapse.

Various causes of pneumothoraces exist and each pneumothorax is classified according to its cause^[2][3].

Primary pneumothorax[edit | edit source]

Also referred to as a spontaneous pneumothorax or primary spontaneous pneumothorax.
It is characterized by having no clear cause or no known underlying lung pathology.

There may be contributing factors, such as cigarette smoke, family history, the rupture of the bulla (small air-filled sacs in the lung tissue) but these will not cause pneumothorax itself.

Secondary pneumothorax[edit | edit source]

Also referred to as a non-spontaneous or complicated pneumothorax.
It occurs as a result of an underlying lung pathology such as COPD, Asthma, Tuberculosis, Cystic Fibrosis or Whooping Cough.

Tension or Non-tension[edit | edit source]

A pneumothorax can further be classified as tension or non-tension pneumothorax.^[4]

A tension pneumothorax is caused by excessive pressure build up around the lung due to a breach in the lung surface which will admit air into the pleural cavity during inspiration but will not allow any air to escape during expiration. The breach acts as a one-way valve. This leads to lung collapse.

The removal of the air is through the surgical incision by inserting an underwater drain in the pleural cavity. This excessive pressure can also prevent the heart from pumping effectively which may lead to shock. A non-tension pneumothorax is not considered as severe as there is no ongoing accumulation of air and therefore there is no increased pressure on the organs and the chest.

Trauma[edit | edit source]

Other causes of a pneumothorax can be trauma or incorrect medical care.

A traumatic pneumothorax is caused by trauma to the lungs. Some of the causes are the following: Stabwound, gunshot, or injury from a motor vehicle accident or any other trauma to the lungs.^[4]

A pneumothorax which develops as a result of a medical procedure or incorrect medical care i.e. accidental puncture to the lung during surgery is termed as an iatrogenic pneumothorax.^[4]

The cause of primary spontaneous pneumothorax is unknown (idiopathic), but established risk factors include^[2][5]:

• Gender
• Smoking (cannabis or tobacco) and,
• Family history of pneumothorax.

Secondary spontaneous pneumothorax occurs in the setting of a variety of lung diseases. The most common is a chronic obstructive pulmonary disease (COPD), which accounts for approximately 70% of cases^[5]. Known lung diseases that may significantly increase the risk for pneumothorax are:

Other traumatic factors may also lead to pneumothorax and eventually lung collapse^[4]:

• Injury or trauma to the chest area: Bullet or stab wounds, fractured ribs, or a blunt force injury can cause the lungs to collapse.
• Certain medical procedures: These include procedures in which the lung may inadvertently be punctured (needle aspiration to drain fluid from the lung, biopsy or the insertion of a large intravenous catheter into a neck vein).
• Activities in which there are sharp changes in air pressure: Flying in an airplane or deep-sea diving may result in a collapsed lung

• Sudden onset of chest pain – sharp pain worse on inspiration^[6]
• Dyspnoea – shortness of breath
• Tachycardia – increased heart rate
• Tachypnoea – increased respiration rate
• Dry cough
• Fatigue
• Signs of respiratory distress -nasal flaring, anxiety, use of accessory muscles
• Hypotension
• Subcutaneous emphysema

Primary spontaneous pneumothorax occurs most often in people between age 18 – 40 and Secondary spontaneous pneumothoraces occur more frequently after age 60 years. Prevalence of a pneumothorax in a newborn is a potentially serious problem and it occurs in about 1-2% of all births.^[2]

The overall person consulting rate for pneumothorax (primary and secondary combined) in the GPRD was 24.0/100 000 each year for men and 9.8/100 000 each year for women. Hospital admissions for pneumothorax as a primary diagnosis occurred at an overall incidence of 16.7/100 000 per year and 5.8/100 000 per year for men and women, respectively. Mortality rates were 1.26/million per year for men and 0.62/million per year for women.^[2]

The pleural cavity is the region between the chest wall and the lungs. If the air enters the pleural cavity, either from the outside (open pneumothorax) or from the lung (closed pneumothorax), the lung collapses and it becomes difficult for the person to breath. Tissue can form a one way-valve which allows air to enter the pleural cavity, but not to escape, overpressure can build up with each breath (tension pneumothorax). This leads to severe shortness of breath, deviation of the heart and compression on the vena cava leading to shock.^[6]

There is a loss of intrapleural negative pressure that can result in a lung collapse. Due to this there is a decrease in vital capacity as well as a decrease in PaO2 which is the main consequence of a pneumothorax. The decrease in PaO2 results from various factors i.e low ventilation-perfusion ratios, anatomic shunts and alveolar hypoventilation. Most patients that suffer from a pneumothorax also have an increase in alveolar-arterial oxygen tension.^[6]

^[7]

Initially a complete medical and physical examination needs to be conducted.

Auscultation[edit | edit source]

On examination of the chest with a stethoscope, it will be noted that there is either decreased or absent breath sounds over the area of the affected lung, which may indicate that the lung is not inflated in that particular area^[8].

There is hyper resonance (higher pitched sounds than normal) with percussion of the chest wall which is suggestive of pneumothorax diagnosis.

Imaging[edit | edit source]

Chest x- rays will then be used to confirm the diagnosis of the pneumothorax.^[9] In a supine chest x-ray, a deep sulcus sign is diagnostic and this is characterised by a low lateral costophrenic angle on the affected side^[8]. Also, the presence of air outside normal lung airways and movement or shifting of the organs away from the air leak in the thoracic cavity will be indicative of the presence of a pneumothorax.

Ultra sound scan can also provide diagnostic assistance^[9].

Diagram showing a neonate with a right tension pneumothorax. Note the tracheal deviation to the left.

Up to 50% of patients who suffer from a pneumothorax will have another or a recurring pneumothorax. However, there are no long-term complications after successful treatment.

Medical and Surgical Management[edit | edit source]

Pneumothorax is a medial emergency that needs to be addressed rapidly once diagnosed^[10]. The main aim is to relieve the pressure on the lung and allow it to expand. It is of vital importance to try and prevent the recurrence of pneumothorax.

Treatment may be determined by the severity of symptoms and indicators:

1. Acute illness – shortness of breath, tachycardia, reduction in O2 sats,
2. Presence of underlying lung disease such as COPD
3. estimated size of the pneumothorax on X-ray
4. in some instances – on the personal preference of the person involved.

Treatment[edit | edit source]

There are a variety of treatment options for a spontaneous pneumothorax. It has been shown that intervention has similar results to conservative management of pneumothorax including less days spent in hospital^[11][12]:

• Conservative management with observation until the air is naturally resorbed by the body
• Simple aspiration^[13]
• Chest tube placement – Simple chest tube placement alone has a very high rate of recurrence (about 65%) in patients with LAM.
• Heimlich valve (HV) insertion – a lightweight one-way valve designed for the ambulatory treatment of pneumothorax (with an intercostal catheter)^[12]
• Pleurodesis through a chest tube – a procedure which obliterates the pleural space to prevent future pneumothoraces^[14].
  • Mechanical (using physical abrasion)
  • Chemical (using talc, doxycycline, bleomycin or other agents). While chemical pleurodesis through a chest tube can be successful, this may result in incomplete pleurodesis due to the uneven distribution of the chemical.
• Surgery – Surgical treatment, using video-assisted thoracoscopy (VATS), is the preferred approach.^[13]

^[15]

Recurrent pneumothorax treatment[edit | edit source]

For patients with recurrent pneumothorax after surgical intervention, there are several options^[16]. For patients with a total or near-total lung collapse, repeat surgical intervention is recommended.

Options include:

• Repeat mechanical pleurodesis if it is unclear whether appropriate mechanical pleurodesis was done initially
• Pleurectomy in which the pleura overlying the ribs is actually removed.
• Chemical pleurodesis in which a drug or other agent is used to create an inflammatory response that results in pleurodesis. Talc is the most commonly used agent due to its effectiveness. Historically, talc pleurodesis was considered a contraindication to future lung transplantation because of the intense inflammatory response that made surgery very difficult. ^[13]
• Lung transplant

Indications for Physiotherapy[edit | edit source]

• Lung collapse^[17]
• Sputum retention^[18]
• Ventilation/perfusion mismatch (V/Q)^[19]
• Increased work of breathing
• Blood gas abnormalities
• Post operative ITU care^[19]

Goals for Physiotherapy[edit | edit source]

1. To improve ventilation and increase PaO2 levels

2. To assist in sputum removal^[18]

3. To reduce work of breathing

• Body positioning
• Breathing control
• Relaxation techniques
• Accessory muscle use

4. Improve exercise tolerance

• Early mobilisation and positioning
• Graded exercise program
• Breathing exercises

Physiotherapy outcome evaluation includes[edit | edit source]

• Respiratory rate
• O2 saturation
• Arterial blood gases
• Additional O2 requirements
• Auscultation
• Chest x-ray
• Mobility status

1. ↑ Medicinenet.com. (2009). ”Pneumothorax”. Retrieved April 6, 2009 fromhttp;//medicinenet.com/pneumothorax/page2.htm Oxford Concise Medical Dictionary.(2002). ”Pneumothorax”.(6th ed).Oxford:Oxford University Press.p 544
2. ↑ ^2.02.12.22.3 Gupta D, Hansell A, Nichols T, et al. Epidemiology of pneumothorax in England. Thorax 2000;55:666-671
3. ↑ Bascom, R.(2009). ”Pneumothorax”. eMedicine. Retrieved February 22, 2009 from http://emedicine.medscape.com/article/424547-overview
4. ↑ ^4.04.14.24.3 BAUMANN, M.H. and NOPPEN, M. Pneumothorax. Respirology, 2004. 9: 157-164
5. ↑ ^5.05.1 Bintcliffe O, Maskell N. Spontaneous pneumothorax. BMJ 2014; 348 :g2928
6. ↑ ^6.06.16.2 Roberts, D J. et al. Clinical Presentation of Patients With Tension Pneumothorax, Annals of Surgery: June 2015 – Volume 261 – Issue 6 – p 1068-1078
7. ↑ Medicosis Perfectionalis. Pneumothorax | Lung Physiology | Pulmonary Medicine. Available from: https://www.youtube.com/watch?v=ZYMcyyNMYrQ&feature=youtu.be [Last accessed 03/09/2019]
8. ↑ ^8.08.1 Rankine JJ, Thomas AN, Fluechter D. Diagnosis of pneumothorax in critically ill adults. Postgraduate Medical Journal 2000;76:399-404.
9. ↑ ^9.09.1 Wu Ding, Yuehong Shen, Jianxin Yang, Xiaojun He, Mao Zhang, Diagnosis of Pneumothorax by Radiography and Ultrasonography: A Meta-analysis, Chest, Volume 140, Issue 4, 2011, Pages 859-866,
10. ↑ Zarogoulidis P, Kioumis I, Pitsiou G, Porpodis K, Lampaki S, Papaiwannou A, Katsikogiannis N, Zaric B, Branislav P, Secen N, Dryllis G, Machairiotis N, Rapti A, Zarogoulidis K. Pneumothorax: from definition to diagnosis and treatment. J Thorac Dis. 2014 Oct;6(Suppl 4):S372-6.
11. ↑ Simon G.A et al. Conservative versus Interventional Treatment for Spontaneous Pneumothorax. N Engl J Med 2020; 382:405-415
12. ↑ ^12.012.1 Brims FJH, Maskell NA. Ambulatory treatment in the management of pneumothorax: a systematic review of the literature. Thorax 2013;68:664-669
13. ↑ ^13.013.113.2 J-M. Tschopp, R. Rami-Porta, M. Noppen, P. Astoul. Management of spontaneous pneumothorax: state of the art. European Respiratory Journal Sep 2006, 28 (3) 637-650
14. ↑ Khalid F. Almoosa, et al. Management of Pneumothorax in Lymphangioleiomyomatosis: Effects on Recurrence and Lung Transplantation Complications, Chest, 2006, Volume 129, Issue 5, Pages 1274-1281,
15. ↑ FlippedEM. Treating a tension pneumothorax. Available from: https://www.youtube.com/watch?v=ubBYHfVGzJg [last accessed: 23/09/14]
16. ↑ Weill D, Benden C, Corris PA, Dark JH, Davis RD, Keshavjee S et al. A consensus document for the selection of lung transplant candidates: 2014 – An update from the Pulmonary Transplantation Council of the International Society for Heart and Lung Transplantation. Journal of Heart and Lung Transplantation. 2015 Jan;34(1):1-15.
17. ↑ Pryor, J. A. & Prasad, S. A.(2006).”Physiotherapy for Respiratory and Cardiac Problem”.(3rd Ed.).New york: Churchill Livingston. p 389
18. ↑ ^18.018.1 Selsby DS. Chest physiotherapy. BMJ. 1989 Mar 4;298(6673):541-2.
19. ↑ ^19.019.1 C Torre, A Silva, Physiotherapy Intervention after Surgical Treatment of Pneumothorax – Case Study, European Journal of Public Health, April 2019, Volume 29, Issue Supplement_1,

How to Heal from a Collapsed Lung: 11 Steps (with Pictures)

About This Article

Medically reviewed by:

Board Certified Critical Care Surgeon

This article was medically reviewed by Jonas DeMuro, MD. Dr. DeMuro is a board certified Pediatric Critical Care Surgeon in New York. He received his MD from Stony Brook University School of Medicine in 1996. He completed his fellowship in Surgical Critical Care at North Shore-Long Island Jewish Health System and was a previous American College of Surgeons (ACS) Fellow. This article has been viewed 499,479 times.

Co-authors: 17

Updated: June 3, 2020

Views: 499,479

Medical Disclaimer

The content of this article is not intended to be a substitute for professional medical advice, examination, diagnosis, or treatment. You should always contact your doctor or other qualified healthcare professional before starting, changing, or stopping any kind of health treatment.

Article SummaryX

To heal from a collapsed lung after you leave the hospital, you should take any medications prescribed to you to help with the pain and discomfort. You should also rest while sitting up, at least for the first one to two weeks, as this reduces pressure on your lungs. Also, limit yourself to light activities such as walking, as strenuous exercise could trigger another collapse. If possible, sleep in a recliner, as this makes it easier to get up and lie down. Additionally, you should avoid smoking at all costs, as cigarette smoke can increase the risk of another lung collapse. For more tips from our Medical co-author, including how to watch for recurrences of a collapsed lung, read on!

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Thanks to all authors for creating a page that has been read 499,479 times.

Thoracentesis | Johns Hopkins Medicine

What is thoracentesis?

Thoracentesis is a procedure to remove fluid or air from around the lungs.
A needle is put through the chest wall into the pleural space. The pleural
space is the thin gap between the pleura of the lung and of the inner chest
wall. The pleura is a double layer of membranes that surrounds the lungs.
Inside the space is a small amount of fluid. The fluid prevents the pleura
from rubbing together when you breathe. Excess fluid in the pleural space
is called pleural effusion. When this happens, it’s harder to breathe
because the lungs can’t inflate fully. This can cause shortness of breath
and pain. These symptoms may be worse with physical activity.

Why might I need thoracentesis?

Thoracentesis may be done to find the cause of pleural effusion. It can
also be done to treat symptoms of pleural effusion by removing fluid. The
fluid is then examined in a lab.

Thoracentesis can help diagnose health problems such as:

• Congestive heart failure (CHF), the most common cause of pleural
  effusion

• Viral, fungal, or bacterial infections

• Cancer

• Systemic lupus erythematosus (SLE) and other autoimmune disease

• Inflammation of the pancreas (pancreatitis)

• A blood clot in the lung (pulmonary embolism)

• An area of pus in the pleural space (empyema)

• Liver failure

• Tuberculosis (TB)

• Pneumonia

• Reactions to medicines

Your healthcare provider may have other reasons to advise thoracentesis.

What are the risks of thoracentesis?

All procedures have some risks. The risks of this procedure may include:

• Air in the space between the lung covering (pleural space) that
  causes the lung to collapse (pneumothorax)

• Bleeding

• Infection

• Liver or spleen injury (rare)

Your risks may vary depending on your general health and other factors. Ask
your healthcare provider which risks apply most to you. Talk about any
concerns you have.

Thoracentesis should not be done in people with certain bleeding
conditions.

How do I get ready for thoracentesis?

Your healthcare provider will explain the procedure to you. Ask any
questions you have. You may be asked to sign a consent form that gives
permission to do the procedure. Read the form carefully. Ask questions if
anything is not clear.

Tell your healthcare provider if you:

• Are pregnant or think you may be pregnant

• Are sensitive to or allergic to any medicines, latex, tape, or
  anesthetic medicines (local and general)

• Take any medicines, including prescriptions, over-the-counter
  medicines, vitamins, herbs, and other supplements

• Have had a bleeding disorder

• Take blood-thinning medicine (anticoagulant), aspirin, or other
  medicines that affect blood clotting

Make sure to:

• Stop taking certain medicines before the procedure, if instructed
  by your healthcare provider

• Plan to have someone drive you home from the hospital

• Follow any other instructions your healthcare provider gives you

You may have imaging tests before the procedure. These are done to find the
location of the fluid to be removed. You may have any of the below:

• Chest X-ray

• Chest fluoroscopy

• Ultrasound

• CT scan

What happens during thoracentesis?

You may have your procedure as an outpatient. This means you go home the
same day. Or it may be done as part of a longer stay in the hospital. The
way the procedure is done may vary. It depends on your condition and your
healthcare provider’s methods. In most cases, a thoracentesis will follow
this process:

1. You may be asked to remove your clothes. If so, you will be given a
   hospital gown to wear. You may be asked to remove jewelry or other
   objects.

2. You may be given oxygen through a nasal tube or face mask. Your
   heart rate, blood pressure, and breathing will be watched during
   the procedure.

3. You will be in a sitting position in a hospital bed. Your arms will
   be resting on an over-bed table. This position helps to spread out
   the spaces between the ribs, where the needle is inserted. If you
   are not able to sit, you may lie on your side on the edge of the
   bed.

4. The skin where the needle will be put in will be cleaned with an
   antiseptic solution.

5. A numbing medicine (local anesthetic) will be injected in the area.

6. When the area is numb, the healthcare provider will put a needle
   between the ribs in your back. You may feel some pressure where the
   needle goes in. Fluid will slowly be withdrawn into the needle.

7. You will be asked to hold still, breathe out deeply, or hold your
   breath at certain times during the procedure.

8. If there is a large amount of fluid, tubing may be attached to the
   needle. This will let the fluid drain more. The fluid will drain
   into a bottle or bag. In some cases, a flexible tube (catheter)
   will be put in place of the needle and the tubing will be attached
   for a day or two. You will stay in the hospital until the catheter
   is removed.

9. When enough fluid has been removed, the needle will be taken out. A
   bandage or dressing will be put on the area.

10. Fluid samples may be sent to a lab.

11. You may have a chest X-ray taken right after the procedure. This is
    to make sure your lungs are OK.

What happens after thoracentesis?

After the procedure, your blood pressure, pulse, and breathing will be
watched. The dressing over the puncture site will be checked for bleeding
or other fluid. If you had an outpatient procedure, you will go home when
your healthcare provider says it’s OK. Someone will need to drive you home.

At home, you can go back to your normal diet and activities if instructed
by your healthcare provider. You may need to not do strenuous physical
activity for a few days.

Call your healthcare provider if you have any of the below:

• Fever of 100.4°F (38°C) or higher, or as advised by your healthcare
  provider

• Redness or swelling of the needle site

• Blood or other fluid leaking from the needle site

• Feeling short of breath

• Trouble breathing

• Chest pain

Your healthcare provider may give you other instructions after the
procedure.

Next steps

Before you agree to the test or the procedure make sure you know:

• The name of the test or procedure

• The reason you are having the test or procedure

• What results to expect and what they mean

• The risks and benefits of the test or procedure

• What the possible side effects or complications are

• When and where you are to have the test or procedure

• Who will do the test or procedure and what that person’s
  qualifications are

• What would happen if you did not have the test or procedure

• Any alternative tests or procedures to think about

• When and how will you get the results

• Who to call after the test or procedure if you have questions or
  problems

• How much will you have to pay for the test or procedure

Empyema – NHS

Empyema is the medical term for pockets of pus that have collected inside a body cavity.

They can form if a bacterial infection is left untreated, or if it fails to fully respond to treatment.

The term empyema is most commonly used to refer to pus-filled pockets that develop in the pleural space.

This is the slim space between the outside of the lungs and the inside of the chest cavity.

Empyema is a serious condition that requires treatment. It can cause fever, chest pains, breathlessness and coughing up mucus.

Although it can occasionally be life threatening, it’s not a common condition, as most bacterial infections are effectively treated with antibiotics before they get to this stage.

What causes empyema?

The lungs and inside of the chest cavity are lined with a smooth layer called the pleura.

These layers are almost in contact, but separated by a thin space (the pleural space) filled with a small amount of lubricant called pleural fluid.

The pleural fluid can sometimes build up and become infected, and a collection of pus forms.

This can thicken and cause areas of the pleura to stick together, creating pockets of pus.

Empyema can worsen to become many more pockets of pus, with thick deposits coating the outer layer of the lungs.

These deposits prevent the lungs expanding properly.

Pneumonia and other possible causes

The most common cause of empyema is pneumonia caused by a bacterial infection of the lungs.

An empyema can form when pneumonia fails to fully respond to treatment in a straightforward way.

Other possible causes are:

• bronchiectasis – a long-term condition where the airways of the lungs become abnormally widened, leading to a build-up of mucus that can make the lungs more vulnerable to infection
• a blood clot or another blockage – this can prevent blood flow to the lungs, causing some of the lung tissue to die (known as a pulmonary infarction)
• surgery to the chest – empyema is a rare complication
• an endoscopy – empyema is a rare complication
• serious injury to the chest
• an infection elsewhere in the body that’s spread through the bloodstream
• an infection caused by inhaled food if you have swallowing problems – this is rare
• tuberculosis – this is rare in the UK

You’re more at risk of developing an empyema if you:

• have diabetes
• have a weakened immune system
• have acid reflux
• drink too much alcohol or take a lot of recreational drugs

Both adults and children can be affected.

What are the symptoms?

An empyema can be distressing and uncomfortable.

It can cause:

• a fever and night sweats
• a lack of energy
• difficulty breathing
• weight loss
• chest pain
• a cough and coughing up mucus containing pus

How is it diagnosed?

An empyema is usually suspected when a person with severe pneumonia doesn’t improve with treatment and they start to show some of the symptoms listed above.

If the patient is coughing up mucus, a sample of this should be taken to be inspected under a microscope. 

The type of bacteria causing the infection is identified so the most effective antibiotics can be given.

A blood sample will also be taken to count the number of white blood cells and other markers of infection.

An X-ray or ultrasound scan will show whether there’s a collection of fluid building up around the lungs and how much there is.

Often a CT scan may also be used to give a more detailed assessment.

How is it treated?

Antibiotics

Some patients will just need antibiotics given directly into a vein through a drip (intravenously).

But they may need to stay in hospital for a long period.

Chest drain

Some patients may need both antibiotics and a chest drain.

A chest drain is a flexible plastic tube that’s inserted through the chest wall and into the affected area to drain it of fluid.

The area where the tube is inserted is numbed, and the patient may also be given a light sedative before having the drain inserted.

Painkillers are given to ease any pain while the chest drain is in.

The chest tube usually stays in place until an X-ray or ultrasound scan shows all the fluid has drained from the chest and the lungs are fully expanded.

Sometimes injections may be given through the chest drain to help clear the infected pockets of pus.

The patient may need to stay in hospital until the tube is removed.

Some patients may be able to go home with the chest tube still in place, in which case a specialist nurse will offer support and advice on how to manage this at home.

The nurse will demonstrate how to position, empty and change the bag until the family or patient feels confident they can do this themselves.

For more information, read this NHS factsheet on chest drains (PDF, 60kb).

Surgery to remove the lung lining

Surgery may be needed if the condition doesn’t improve. 

This involves making a cut in the chest to access the lungs and removing the thick layer coating the lungs so they can expand properly again.

This is only carried out if other treatments haven’t worked.

Your surgeon or specialist will explain the benefits and risks of the procedure.

Find out more about lung surgery

Stoma

A chest drain isn’t suitable for all patients. Some will instead opt to have an opening made in their chest, known as a stoma. 

A special bag is placed over the stoma to collect the fluid that leaks from the empyema.

This is worn on the body, and may be more discreet and interfere less with your lifestyle than a chest drain.

But with modern treatments, getting a stoma is uncommon.

Page last reviewed: 22 November 2018
Next review due: 22 November 2021

90,000 Spontaneous pneumothorax, modern approaches to diagnosis and treatment

Spontaneous pneumothorax (SP) is a syndrome characterized by the accumulation of air in the pleural cavity, not associated with lung injury and medical manipulations.

Normally, the pleural cavity is represented by a slit several micrometers wide and contains 2-3 ml of transudate. The pressure in it during inhalation is 5-9 mm Hg. Art., and on exhalation – by 3-4 mm Hg. Art. below atmospheric.

According to modern literary concepts, spontaneous pneumothorax occurs due to rupture of an emphysematous bull.In all cases of spontaneous pneumothorax, along with air, an infection enters the pleural cavity and there is a threat of the development of pleural empyema. Empyema of the pleura develops only if the provision of qualified assistance to the patient is not timely.

In most cases, spontaneous pneumothorax occurs in young patients (20-40 years old), moreover, in men 8-14 times more often than in women. Approximately one in 500 men of military age has a history of spontaneous pneumothorax confirmed by objective data.In recent decades, its frequency has been increasing. In the development of spontaneous pneumothorax, thin-walled vesicular formations (bullae and blebs) located under the visceral pleura are of great importance.

Bulls are formed as a result of a sharp increase in the volume of individual alveoli and their fusion among themselves due to atrophy and complete disappearance of the interalveolar septa. In their occurrence, the leading role is played by violations of the patency of bronchioles, in which cicatricial changes after the transferred specific and nonspecific inflammatory processes create conditions for the formation of the valve mechanism.Bulls range in size from barely visible to the eye to gigantic. In some cases, a significant pathogenetic factor in the occurrence of bullous emphysema is congenital inferiority of the pulmonary parenchyma and impaired vascularization of the cortical parts of the lungs.

Blebs, subpleural air bubbles, are distinguished as a special form of thin-walled formations. Their origin is associated with interstitial emphysema of the lungs due to rupture of alveoli or bullae in the parenchyma. The rupture of the wall of such formations leads to the emergence of pathological communication between the airways and the pleural cavity.

Almost any of the acute or chronic lung diseases leading to the formation of diffuse or limited pneumosclerosis, bronchial deformation, and bullous emphysema can play a role in the etiology of spontaneous pneumothorax.

Diagnosis of spontaneous pneumothorax is based on clinical manifestations of the disease, data of objective and X-ray examination.

In the clinical picture, the main place is occupied by: chest pain on the side of the pneumothorax, often radiating to the shoulder, shortness of breath, dry cough.

In patients with chronic obstructive pulmonary disease (COPD), the severity of pneumothorax is determined not so much by the collapse of the lung as by the chronic inflammatory process and pulmonary emphysema. Even a small collapse of the lung in this group of patients leads to a significant deterioration in the condition, which is significant in determining the treatment tactics.
In patients with spontaneous pneumothorax, the course is often favorable, with the development of rapid adaptation to this condition. In this regard, it should be noted that in a significant number of cases, such patients are treated for an unacceptably long time on an outpatient basis for “intercostal neuralgia”, “myositis”, “heart disease”, etc.e. A chest x-ray should be performed as early as possible and the correct diagnosis should be established.

Chest X-ray has been and remains the leading method for diagnosing pneumothorax. Currently, computed tomography of the chest is highly informative, which allows you to identify or suspect the cause of the complication and determine the tactics of treatment. Videothoracoscopy is actively used for both diagnostic and therapeutic purposes. Differential diagnostics for pneumothorax is carried out with cystic transformation of the lung, large-bullous emphysema of the lung, diaphragmatic hernia.

Treatment tactics for spontaneous pneumothorax have undergone significant changes over the past 30 years. In the late 1980s. collectives of authors wrote: “Until recently, both in domestic and foreign literature it was noted that pulmonary tuberculosis plays a dominant role in the etiology of spontaneous pneumothorax, which explains the passive tactics of treatment.” Currently, more and more works are devoted to the most active surgical tactics for spontaneous pneumothorax.

British Society of Thoracic Surgeons Guidelines 2010.summarized the results of studies of the 1st and 2nd levels of evidence, on the basis of which it was concluded that lung resection in combination with pleurectomy is the technique that provides the lowest percentage of relapses (~ 1%). Thoracoscopic resection and pleurectomy are comparable in frequency of relapses to open surgery, but more preferable in terms of pain syndrome, duration of rehabilitation and hospitalization, and restoration of respiratory function.

Tambov Regional Clinical Hospital named.V.D. Babenko is the only institution in the region where surgical treatment of patients with spontaneous pneumothorax is performed. The entire arsenal of methods for treating this pathology is used, including the use of modern endoscopic surgical interventions using high-tech equipment and stapling endosteplers. In the period from 2016 to 2018, in the 1st surgical department of the institution, more than 70 operations were performed on patients with bullous lung disease complicated by spontaneous pneumothorax.

Surgical treatment in this category of patients helps prevent recurrence of pneumothorax and improve the quality of life. There were no recurrences of pneumothorax in the operated patients.

The accumulated experience, continuous improvement of knowledge and skills, as well as the introduction of new techniques with the use of modern instrumentation allows successfully performing thoracoscopic operations in patients with spontaneous pneumothorax.

5 August 2019

90,000 The device propels (pushes) air into the lungs, helping people with cystic fibrosis breathe, evacuate mucus, reduce respiratory distress, improve exercise tolerance

Review Question

We reviewed the evidence that the mechanical introduction of air into the lungs through a mask helps clear mucus, improve breathing during the night, reduce respiratory distress, and improve exercise tolerance.

Relevance

As cystic fibrosis progresses, breathing becomes difficult, indicating respiratory distress (too much carbon dioxide and not enough oxygen in the blood). If respiratory failure progresses, people may choke and have trouble evacuating (clearing) mucus. Respiratory failure ultimately leads to death.

Non-invasive ventilation delivers room air or oxygen through a mask and is used to help people with more severe cystic fibrosis clear mucus from the airways and make breathing easier during sleep; it can also help with exercise.How it works is not exactly known, but it can reduce respiratory muscle weakness, prevent airway closure during prolonged exhalation, and reduce the effort required to maintain ventilation and oxygen levels. Treatment has been recommended for respiratory muscle weakness, when the patient has trouble clearing mucus with other airway clearance techniques, or when high levels of carbon dioxide in the blood have been recorded during sleep or exercise.

This is an update to a previously published review.

Search Date

Evidence is current to 8 August 2016.

Characteristics of research

This review includes 10 trials (191 cystic fibrosis participants) – seven sessions of one treatment and a two-week trial, a six-week and three-month trial. Six trials of one treatment modality, a two-week and three-month study, compared non-invasive ventilation with other airway clearance techniques.Two trials of one treatment modality and a six-week study looked at non-invasive ventilation with respiratory support at night versus oxygen or normal room air. One single-treatment trial compared non-invasive ventilation versus no additional treatment during an exercise test.

Key Findings

Clinical trials of non-invasive ventilation for airway clearance have shown that this method simplifies the procedure for cleansing, and people with cystic fibrosis may prefer it to other methods.We were unable to find evidence that non-invasive ventilation increases the amount of mucus produced when coughing, but it does improve some measures of lung function, at least in the short term. The two-week study showed no clear benefit between groups. The original 3-month trial reported an improvement in lung clearance score. One person from one of these trials reported pain when testing breathing muscles.

Three clinical trials comparing NIV support at night measured pulmonary function, quality of life, and carbon dioxide levels; they have shown this method to be effective, safe and acceptable. We found no clear difference between non-invasive ventilation and the use of oxygen or room air, except that after six weeks physical activity improved with non-invasive ventilation compared to room air.Side effects have been reported in two clinical trials. In the first trial, one person experienced discomfort while using the mask. In the second trial, one person in the room air group experienced a collapse of the lungs, and two people were unable to withstand the increasing pressure during inhalation.

In a trial comparing the effect of non-invasive ventilation and no treatment on exercise capacity, no clear differences were found between groups.

Non-invasive ventilation can help along with other methods of airway clearance, especially when people with cystic fibrosis have difficulty evacuating mucus and during sleep. Long-term clinical trials with sufficient numbers of people are needed to demonstrate the clinical efficacy of non-invasive ventilation for airway clearance, during sleep and exercise in severe disease.

Quality of evidence

The benefits of non-invasive ventilation have been extensively demonstrated in single-session trials with small numbers of people.There is limited evidence for long-term improvement in lung function in one clinical trial. Our results from the night respiratory support trials differ from those of the initial analysis, likely due to the small number of participants and some statistical problems. We concluded that only the six-week trial was free of any bias. In the remaining trials, in our opinion, there was a low or uncertain chance of influencing the results, since the data were either only partially reported or not at all.We were not sure if the way in which participants were assigned to different treatment groups would affect the trial results.

Treatment of traumatic pneumothorax using videothoracoscopic technique

Treatment of traumatic pneumothorax using videothoracoscopic equipment

A.V. Bondarenko, V.E. Rozanov, M.V. Melnikov

Objectives of the study . To clarify the possibilities and prospects of using videothoracoscopic techniques for the treatment of pneumothorax in patients with chest trauma.

Materials and Methods . The basis of the work was the materials of observations of 211 victims with chest trauma, in whom videothoracoscopic technique was used to treat pneumothorax. The average age of the victims was 30.9 ± 1.8 years. The severity of chest injuries was assessed using the ISS system: 4.3 ± 0.9 points were found in 95 cases, 9.7 ± 1.0 – in 72, 26.2 ± 1.8 – in 44. The severity of the condition according to the APACHE-II system 13.1 ± 1.9 points were found in 99 cases, 25.7 ± 2.8 in 111 and 33.2 ± 2.7 in 19.Videothoracoscopy was performed using a complex that included a Storz or Fudjinon thoracoscope and Auto Suture instrumentation under anesthesia with separate bronchial intubation and ventilation of one lung. In all cases, fibrobronchoscopy was performed before surgery to exclude trachea and large bronchi trauma. The thoracoscope was introduced into the pleural cavity in the 5th intercostal space through a trocar with a diameter of 10 mm. Taking into account the nature of the revealed injuries and the estimated volume of the surgical aid, two additional manipulators were introduced through 5 mm trocars.Diathermocoagulation was carried out using an electrosurgical apparatus and a diathermocoagulator from a set for a thoracoscope, lung wounds were sealed by photocoagulation using a Raduga-1 YIG laser device using sapphire and quartz tips, as well as an absorbent wound coating TachoKomb.

Depending on the methods of treatment, the victims were divided into two groups. Group I consisted of 95 people, the treatment of which was carried out by the “traditional” method, in Group II – 116 people.in which videothoracoscopy was used. Patients in both groups were comparable in terms of age, reasons for the development of pneumothorax, and the severity of the condition and injury.

The effectiveness of treatment methods was assessed by the degree of lung expansion on the first day, as well as by the frequency and severity of complications. Full effect – complete expansion of the lung; almost complete – a small air vacuole that disappears on its own in 3-4 days; a partial effect is the preservation of a limited pneumothorax, which required further evacuation of air.Ineffectiveness of treatment – preservation of the collapse of the same degree. Deterioration – an increase in the collapse of the lung, the development of a tense pneumothorax.

Results . Drainage of the pleural cavity with active aeroaspiration was considered the method of choice in the treatment of pneumothorax in group I patients, i.e. forced expansion of the lung. The method of thoracocentesis with drainage and active aspiration of gas from the pleural space was used for uncomplicated pneumothorax (the severity of injuries was 4.3 ± 0.9 points according to ISS).Nevertheless, in 20 (21.1%) cases, pneumothorax and / or air discharge through the pleural drainage persisted for more than 24 hours, which required an urgent thoracotomy.

In addition, in 18 (18.9%) cases developed various complications: persistent bronchopleural fistula (in 6), rigid lung (in 3), lung atelectasis (in 2), pleural empyema (in 7). It should be noted that drainage also did not guarantee against recurrence of pneumothorax in 16 (18%) patients.

In group II, patients underwent targeted diagnostics of the causes of pneumothorax by performing primary thoracoscopy (before draining the pleural cavity).Surgical thoracoscopy was performed in the first hours from the moment of admission of the victim, since already 2 hours after the injury, inflammatory changes occurred in the pleural cavity, which reduced the therapeutic potential of the method.

In case of pneumothorax due to post-traumatic bullous lesion of the lung, the nature of the pathological process (the number, size and localization of bullae, the size of the defect in the visceral pleura) was first assessed. The operation of choice in such patients was considered to be partial or subtotal pleurectomy with the aim of performing pleurodesis in combination with various types of elimination of bronchopleural messages (fistula suturing, excision of individual large bullae, economical lung resection).In our opinion, such combined operations were a reliable prevention of recurrent pneumothorax and were regarded as a radical method of treatment.

In case of lung injury, electrocoagulation, wound ligation with an “Endoloop” loop, suturing with the “Endo-Stitch” apparatus, marginal or wedge-shaped resection of the lung with “Endo-GIA-30” apparatus were performed. In all cases, aerostasis was carried out endoscopically, which was controlled by a water sample during lung inflation.

In all cases, videothoracoscopy was the definitive treatment.In the postoperative period, no air release was noted; pleural drains were removed in all patients within 3 days. There were no complications. After performing curative videothoracoscopy, I never had to resort to thoracotomy, and additional drainage and subsequent pleural punctures became rare.

The use of the unified technique of operative videothoracoscopy made it possible to reduce the number of thoracotomies by 4 times, postoperative complications by 46.0%, postoperative mortality by 27.8%, and also reduce the duration of inpatient treatment by an average of 5.9 days, and temporary disability by 10.6 days.

Conclusion . We believe that a one-sided tactic aimed only at expanding the lung in patients with chest trauma is currently not justified. In ideothoracoscopy for traumatic pneumothorax, it should be used as an emergency study, including diagnostic and therapeutic techniques.

Bullous emphysema of the lungs

Pulmonary emphysema – a disease of the respiratory tract, characterized by pathological expansion of the air spaces of the distal bronchioles, which is accompanied by destructive and morphological changes in the alveolar walls; one of the most common forms of chronic nonspecific lung diseases.

There are two groups of reasons leading to the development of pulmonary emphysema. The first group includes factors that violate the elasticity and strength of the elements of the structure of the lungs: pathological microcirculation, changes in the properties of the surfactant, congenital deficiency of alpha-1-antitrypsin, gaseous substances (cadmium compounds, nitrogen oxides, etc.), as well as tobacco smoke, dust particles in inhaled air. These reasons can lead to the development of primary, always diffuse emphysema. Its pathogenesis is based on pathological restructuring of the entire respiratory part of the lung; the weakening of the elastic properties of the lung leads to the fact that during exhalation and, consequently, an increase in intrathoracic pressure, small bronchi, which do not have their cartilaginous framework and are devoid of elastic traction of the lung, passively collapse, thereby increasing bronchial resistance on exhalation and an increase in pressure in the alveoli.Bronchial permeability on inspiration with primary emphysema is not impaired.

Factors of the second group contribute to an increase in pressure in the respiratory region of the lungs and increase the stretching of the alveoli, alveolar passages and respiratory bronchioles. The most important among them is the obstruction of the airways that occurs in chronic obstructive bronchitis. This disease becomes the main reason for the development of secondary, or obstructive pulmonary emphysema, since it is with it that conditions are created for the formation of a valve mechanism for overstretching of the alveoli.So, a decrease in intrathoracic pressure during inhalation, causing passive stretching of the bronchial lumen, reduces the degree of existing bronchial obstruction; positive intrathoracic pressure during expiration causes additional compression of the bronchial branches and, exacerbating the existing bronchial obstruction, contributes to the retention of inspired air in the alveoli and their overstretching.

Symptoms of the disease . Characterized by shortness of breath, a barrel-shaped chest, a decrease in its respiratory excursions, an expansion of the intercostal spaces, swelling of the supraclavicular regions, a boxed percussion sound, weakened breathing, a decrease in the area of ​​relative dullness of the heart, a low standing of the diaphragm and a decrease in its mobility, an increase in the transparency of the pulmonary fields on the roentgenogram.Primary emphysema, to a much greater extent than secondary emphysema, is characterized by severe shortness of breath, with which (without a previous cough) the disease begins; in patients, already at rest, the volume of ventilation is extremely large, therefore, their exercise tolerance is very low. Known for patients with primary emphysema, the symptom of “panting” (covering on expiration of the mouth opening with swelling of the cheeks) is caused by the need to increase the intrabronchial pressure during expiration and thereby reduce the expiratory collapse of the small bronchi, which interferes with the increase in ventilation.In primary emphysema, less than in secondary emphysema, the gas composition of the blood is disturbed.

Treatment of emphysema of the lungs (the presence of air cavities in the lungs) is possible with the help of thoracoscopy. With secondary emphysema, treatment of the underlying disease and therapy aimed at arresting respiratory and heart failure are carried out. There are attempts at surgical treatment of focal emphysema – resection of the affected areas of the lung.

Prevention of secondary emphysema is reduced to the prevention of chronic obstructive syndrome.Respiratory gymnastics, aimed at maximizing the inclusion of the diaphragm in the act of breathing; oxygen therapy courses, exclusion of smoking and other harmful effects, including occupational; limiting physical activity. A therapy with a1-antitrypsin inhibitors is being developed. Accession of a bronchopulmonary infection requires the appointment of antibiotics.

90,000 Pneumothorax (collapse of the lung): symptoms, causes and treatment

Retrieved on 10/10/2019

Pneumothorax (Lung Collapse): Definition and Facts

Pneumothorax (Lung Collapse) Image

• Pneumothorax is an accumulation of free air in the chest cavity (chest cavity) that causes the lung to collapse.
• Pneumothorax can occur spontaneously in the absence of the underlying disease; this is called a spontaneous pneumothorax.
• Pneumothorax can also occur from trauma or an underlying lung disease.
• Small spontaneous pneumothorax may resolve without treatment. Pneumothorax caused by lung disease or injury requires immediate treatment.
• Treatment may include insertion of a drainage tube or aspiration of free air into the chest cavity.

What is pneumothorax?

liprosil side effects of blood pressure medication

Pneumothorax is an accumulation of free air in the chest outside of the lung that causes the lung to collapse.

What is

tension pneumothorax ?

In some cases, air continues to flow from the lungs into the chest cavity, which leads to compression of the structures of the chest, including the vessels through which blood returns to the heart.This is called a tension pneumothorax and can be fatal if not treated immediately.

What are the

types of pneumothorax?

• Spontaneous pneumothorax, also called primary pneumothorax, occurs in the absence of traumatic chest injury or known lung disease.
• Secondary (also called complicated) pneumothorax occurs due to an underlying condition.

What are the signs and

symptoms of pneumothorax?

Symptoms of pneumothorax include:

• chest pain that usually comes on suddenly.
• The pain is acute and may cause chest tightness.
• Shortness of breath,
• heart palpitations,
• rapid breathing,
• cough,
• and fatigue are other symptoms of pneumothorax.

The skin may become bluish (called cyanosis) due to a decrease in oxygen levels in the blood.

What causes pneumothorax?

The lung is usually inflated by increasing the size of the chest cavity, which results in negative (vacuum) pressure in the pleural cavity (the area inside the chest cavity but outside the lungs).If air enters the pleural space through an opening in the lung or chest wall, the pressure in the pleural space is equal to the pressure outside the body. Thus, the vacuum is lost and the lung collapses.

Spontaneous pneumothorax is caused by a ruptured cyst or small sac (bladder) on the surface of the lung. Pneumothorax can also occur after trauma to the chest wall, such as a broken rib, any penetrating wound (gunshot or stabbing), surgery to the chest, or it can be deliberately caused to collapse the lung.Pneumothorax can also develop as a result of major lung diseases, including:

• cystic fibrosis,
• chronic obstructive pulmonary disease (COPD),
• lung cancer, asthma, and
• lung infections.

How is pneumothorax diagnosed?

Examination of the chest with a stethoscope reveals a decrease or absence of breathing sounds over the affected lung. Diagnosis is confirmed by chest x-ray.

What is

treatment for pneumothorax?

• A small pneumothorax without underlying lung disease may resolve on its own within one to two weeks.
• Larger pneumothorax and pneumothorax associated with underlying lung disease often require aspiration of free air and / or placement of a drain tube to remove air. Potential complications with chest tube placement include:
  • pain,
  • infection of the space between the lung and chest wall (pleural cavity),
  • hemorrhage (bleeding),
  • fluid accumulation in the lungs, and
  • low blood pressure (hypotension).
• In some cases, the leak will not close on its own. This is called a bronchopleural fistula (punctured lung), and breast surgery may be required to repair the opening in the lung.

Who is at risk for pneumothorax?

Spontaneous pneumothorax is more common in men. Smoking has been shown to increase the risk of spontaneous pneumothorax.

What is the prognosis for pneumothorax?

The outcome of pneumothorax depends on the degree and type of pneumothorax.

• Small spontaneous pneumothorax usually resolves on its own without treatment.
• Secondary pneumothorax (even small) associated with the underlying disease is much more serious and has significant mortality. Secondary pneumothorax requires urgent and immediate treatment.
• A single pneumothorax increases the risk of recurrence of this condition. Most relapses occur within the first year.

References REVIEW:

American Lung Association.

Trachea stenting in case of collapse in dogs in Minsk

The trachea is a rigid structure that must ensure the unhindered flow of air from the oropharynx to the bronchial tree of the lungs. Normally, it always retains a gap and has sufficient rigidity to withstand external pressure.

Tracheal collapse is a decrease in the rigidity of the tracheal cartilage and sagging of its upper membrane, due to which it may even collapse, making it impossible to inhale or exhale.

Dogs of miniature breeds in middle age are usually susceptible to this pathology. So the collapse of the trachea is most often found in Yorkshire terriers, toy terriers, toy poodles, Pomeranian, Chihuahuas. Typically, patients come to the clinic at the age of 6-7 years with a cough of the “goose cackle” type, which can be aggravated by physical or emotional stress, heat. In the last stages of this pathology, breathing is difficult even in a calm state.

Dogs with tracheal collapse usually also suffer from other concomitant pathologies: heart problems, which for a long time worked for wear and tear in order to provide the body with oxygen in conditions of insufficient supply; inflammation of the trachea and bronchi – in a convulsive desire to breathe, the animal often inhales saliva with an abundance of pathological bacteria due to problems with tartar and periodontal disease. There are often problems with the liver, which cannot function well under conditions of hypoxia (lack of oxygen).

How to make a diagnosis

An experienced physician “sees from afar” and prescribes studies to confirm the diagnosis, determine the place of collapse of the tracheal lumen and its degree.

The most informative research method is tracheoscopy (to get a camera into the trachea and see where the problem is and how much its lumen has collapsed). The collapse of the trachea is a dynamic problem: when you inhale, its cervical region collapses and straightens the chest, and when you exhale, vice versa.Tracheoscopy allows you to see in real time what is happening in a particular section of the trachea or bronchi, while simultaneously assessing concomitant inflammation, the presence of foreign objects or neoplasms (the latter are very similar in symptoms to tracheal collapse).

Another method of diagnosis is an X-ray of the cervical and thoracic trachea, on which we can see the collapse itself and measure the length of the affected trachea and its diameter, for a clear selection of the stent size.

How to treat a collapsed trachea in a dog?

In the early stages of tracheal collapse in dogs, therapeutic treatment is recommended, which consists in giving sedatives and mucolytic drugs, and in the fight against excess weight. In the last stages of the disease, when the animal cannot breathe normally and constantly suffocates, the most effective and painless method is tracheal stenting in dogs – placing a metal frame in the lumen of the trachea, which does not allow it to collapse and provides free breathing in dogs.This manipulation is performed under general anesthesia using endoscopic equipment. The results after stenting amaze not only the owners, but also the doctors – the dog literally immediately after placing the stent begins to breathe calmly and without hindrance.

Our clinic has everything for the examination of such patients: blood tests within 30 minutes, endoscopy and X-rays, which are always at the ready, special veterinary tracheal stents.

Sas Animal Service Veterinary Clinic: we are responsible for those you have tamed.

Tracheal collapse

Tracheal collapse.

Frequent pathology of the respiratory tract of decorative dogs.

What is it?

Tracheal collapse is a narrowing of the tracheal diameter due to deformation of the tracheal rings.

Primarily this condition is associated with weakening of the cartilage of the tracheal rings. And they are considered as an anatomical defect inherent in some dog breeds.

Factors causing the clinical manifestation of tracheal collapse may be associated with:

1. Injury to the respiratory tract, eg during intubation.
2. Postponed respiratory infections.
3. By squeezing the tissues surrounding the trachea. For example, when jerking a collar or in a fight.
4. Allergic reaction to irritating aerosols (household chemicals, tobacco smoke).
5. Overweight.

When the walls of the trachea come together, a chronic inflammation of the walls of its mucous membrane develops, leading to the replacement of the epithelium with fibrous tissue.

The clinical manifestation depends on the severity of the pathology.

There are 4 stages of tracheal narrowing:

1. 1st degree 25% narrowing
2. 2nd degree 50% constriction
3. 3rd degree 75% constriction
4. 4th degree – malformation of the tracheal rings (no patency)

Can be observed in a dog:

1. Cough (intermittent or regular)
2. Heavy breathing, shortness of breath – “goose cackle”
3. Visible mucous membranes may change color (cyanosis)

In very severe cases, the animal may faint from lack of oxygen.Of course, this is a reason to urgently go to the veterinary clinic.

For the diagnosis of tracheal collapse, :

are required

Thorough examination of the patient, auscultation of the chest cavity. If the patient’s condition permits, then an X-ray of the chest cavity. Also, for further treatment, tracheo and bronchoscopy with the collection of washes from the lungs for cytological and bacteriological studies are necessary.

If the patient is unstable, the diagnosis is postponed until the condition stabilizes.Such a patient should be admitted to a hospital. The most important thing is to ensure the supply of oxygen to the body. For this, the dog is placed in an oxygen chamber. In the most severe cases, after sedation, the patient is placed in an endotracheal tube and oxygen is supplied through it.

Tracheal collapse treatment:

Based on the use of nebulizers, spacers or inhalations using hormonal drugs to reduce edema in the trachea. Antitussives and antibiotics are also used if a bacterial infection is confirmed.

In the most critical cases, stent placement is required – tracheal stenting. The stent is a braided mesh tube made of nitinol that supports the tracheal lumen. However, this technique has a lot of complications and you need to carefully weigh the pros and cons.

Not so long ago, a 9-year-old spitz Elf entered our clinic. The baby had a cough for a long time, and the owners turned to the clinic about this. At the same time, the general condition was normal, the cough did not interfere with the dog’s life.During examination, Elf was found to have collapse of the trachea.

One night the dog developed acute respiratory distress. The unfortunate man could not breathe normally and lost consciousness.

There was a classic symptom – “goose cackle”. Characteristic inspiratory sounds caused by obstructed air passage.

At night, Elf was brought to the clinic in Radenis-Zelenograd. The dog was immediately placed in an oxygen chamber and sedated. Within an hour, when the patient’s condition stabilized, the doctor performed an X-ray of the chest cavity, and was convinced of a significant narrowing of the tracheal lumen, up to complete overlap.

After a series of manipulations, the patient’s condition stabilized and he was discharged home with further appointments.