Pneumothorax

Pneumothorax occurs when there is an accumulation of air in the pleural space. Normally, the pleural space is a “potential space,” a space that occurs between two adjacent structures that are normally pressed together. The area between the visceral and parietal pleura has a negative atmospheric pressure, creating a vacuum as well as containing a small amount of protective fluid to lubricate the tissues. In pneumothorax, air accumulates in the pleural space, and the pressure rises, leading to atelectasis (collapsed lung) and ineffective gas exchange. There are three major types of pneumothorax: spontaneous, traumatic, and tension. Spontaneous pneumothorax is not life threatening and occurs when a portion of the lung collapses without a known cause. Most experts suspect that it is due to the formation of small sacs of air that rupture, causing air to leak into the pleural space. Traumatic pneumothorax can be further classified as either open (when atmospheric air enters the pleural space) or closed (when air enters the pleural space from the lung). Traumatic pneumothoraces are most often associated with an injury resulting in a wound or puncture, disrupting the pleural space by changing the vacuum into a positive-pressure space. When the wound seals off, the air is trapped in the pleural space. In open traumatic pneumothorax, a chest wall defect creates an opening that connects the outside atmospheric air to the pleural space. A gunshot or stab wound that leaves a hole in the chest wall is one cause of an open pneumothorax.

The degree of distress and compromise that the patient experiences depends on the degree of collapse on the affected side. When the air in the pleural space cannot escape, tension pneumothorax occurs. If air accumulation is not stopped, the entire mediastinum shifts toward the unaffected side, causing bilateral lung collapse, which is a life-threatening condition. Tension pneumothorax is a life-threatening complication that can lead to shock, low blood pressure, and cardiopulmonary arrest. Other complications include respiratory failure, hypoxemia, and pneumonia.

Causes ⬆ ⬇

The cause of a closed or primary spontaneous pneumothorax is the rupture of a bleb (sac or vesicle) on the surface of the visceral pleura, allowing air from the lungs to enter the pleural space. Secondary spontaneous pneumothorax can result from chronic obstructive pulmonary disease (COPD), which is related to hyperinflation or air trapping, or from the effects of cancer, which can result in the weakening of lung tissue or erosion into the pleural space by the tumor. Associated conditions include HIV disease, asthma, cancer, cystic fibrosis, and inhaled drug use. Blunt chest trauma and penetrating chest trauma are the primary causes of traumatic and tension pneumothorax. Other possible causes include therapeutic procedures such as thoracotomy, thoracentesis, and insertion of a central line. Risk factors for spontaneous pneumothorax include smoking; a tall, thin stature; Marfan syndrome; pregnancy; and family history.

Genetic Considerations ⬆ ⬇

Spontaneous pneumothorax (SP) is known to be associated with certain heritable disorders of connective tissue, particularly Marfan syndrome and Ehlers-Danlos syndrome, but it may occur as an isolated familial disorder without other signs of connective tissue disease. Familial SP appears to follow an autosomal dominant transmission pattern with incomplete penetrance and variable expression, with some cases of SP associated with mutations in folliculin (FLCN). FLCN mutations are also associated with Birt-Hogg-Dubé syndrome which is characterized by lung cysts, spontaneous pneumothorax, fibrofolliculomas, and renal cell cancer.

Sex and Life Span Considerations ⬆ ⬇

Pneumothorax can occur at any age. It occurs in 2% of neonates and has a rate of approximately 20% in infants with neonatal respiratory distress syndrome. Older people with COPD and younger people with paraseptal emphysema are susceptible to spontaneous pneumothorax. Spontaneous primary pneumothorax occurs most often in tall, thin men between ages 20 and 30 years. Traumatic injuries are more common in adolescent and young adult males than in other populations.

Health Disparities and Sexual/Gender Minority Health ⬆ ⬇

Ethnicity and race have no known effect on the risk for pneumothorax. Smoking increases the risk of a first spontaneous pneumothorax by more than 20-fold in men and by nearly 10-fold in women as compared to nonsmokers. The Centers for Disease Control and Prevention (2021) report that 13.8% of heterosexual adults smoke cigarettes, whereas 19.2% of lesbian, gay, and bisexual adults smoke, as do 35.5% of trans adults. Smoking places sexual and gender minority people at risk for pneumothorax.

Global Health Considerations ⬆ ⬇

Globally, more men than women experience pneumothorax because men are more likely than women to experience traumatic injuries. Traditional Chinese medicine with acupuncture may lead to pneumothorax, which is the most serious complication reported in the literature, with an incidence of 1 in 5,000 individuals after acupuncture in the area of the lungs.

Assessment ⬆ ⬇

ASSESSMENT

History

Ask about chest pain; determine its onset, intensity, and location. Question if the patient has had shortness of breath, difficulty breathing, cough, or fatigue. Elicit a history of COPD or emphysema or if the patient has had a thoracotomy, thoracentesis, or insertion of a central line. Determine if the patient has had a previous pneumothorax because recurrence is common. Ask if the patient smokes cigarettes.

For patients who have experienced chest trauma, establish a history of the mechanism of injury by including a detailed report from the prehospital professionals, witnesses, or significant others. Specify the type of trauma (blunt or penetrating). If the patient has been shot, ask the paramedics for ballistic information, including the caliber of the weapon and the range at which the person was shot. If the patient was stabbed, ask about the size of the knife and the angle of the attack. If the patient was in a motor vehicle crash, determine the type of vehicle (truck, motorcycle, car); the speed of the vehicle; the victim's location in the car (driver versus passenger); and the use, if any, of safety restraints. Determine if the patient has had a recent tetanus immunization.

Physical Examination

The patient may present in a number of ways, from being asymptomatic to having profound cardiopulmonary instability. The most common symptoms are sharp or stabbing chest pain that may increase with inspiration, shortness of breath, anxiety, and cough. The severity of the symptoms depends on the extent of any underlying disease and the amount of air in the pleural space. Examine the patient's chest for a visible wound that may have been caused by a penetrating object. Patients with an open pneumothorax also exhibit a sucking sound on inspiration. Inspect the patient with pneumothorax for cyanosis, nasal flaring, asymmetrical chest expansion, dyspnea, tachypnea, and intercostal retractions. Observe whether the patient has a flail chest, a condition in which the patient has paradoxical chest movement with the chest wall moving outward during expiration and inward during inspiration. On palpation, note any tracheal deviation toward the unaffected side, subcutaneous emphysema (also known as crepitus; a dry, crackling sound caused by air trapped in the subcutaneous tissues), or decreased to absent tactile fremitus over the affected area. Percussion may elicit a hyperresonant or tympanic sound. Auscultation reveals decreased or absent breath sounds over the affected area and no adventitious sounds other than a possible pleural rub.

Examine the thorax area, including the anterior chest, posterior chest, and axillae, for contusions, abrasions, hematomas, and penetrating wounds. Note that even small penetrating wounds can be life-threatening if vital structures are perforated. Observe the patient carefully for pallor. Take the patient's blood pressure and pulse rate, noting the early signs of shock or massive bleeding, such as a falling pulse pressure, a rising pulse rate, and delayed capillary refill. Continue to monitor the vital signs frequently during periods of instability to determine changes in the condition or the development of complications.

The signs of tension pneumothorax are more intense than those of spontaneous pneumothorax; they include chest pain, shortness of breath, anxiety, and confusion. Patients show signs of hypotension and hypoxemia, with absent breath sounds on the affected side, and the trachea deviates away from the affected side. There may be hyperresonance on auscultation, tachycardia, and jugular vein distention.

Psychosocial

Patients with a pneumothorax may be confused, anxious, or restless. They may be concerned about their pain and dyspnea and could be in a panic state. Determine the patient's past ability to manage stressors and discuss with the significant others the most adaptive mechanisms to use. Note that approximately one-half of all traumatic injuries are associated with alcohol and other drugs of abuse.

Diagnostic Highlights

Test	Normal Result	Abnormality With Condition	Explanation
Chest x-ray, computed tomography scan	Clear lung fields	Lung collapse with air between chest wall and visceral pleura	Lungs are not filled with air but rather are collapsed; confirms diagnosis
Ultrasound; focused assessment with sonography for trauma (FAST)	Intact bony structure with intact lungs	Absence of lung sliding during breathing	Normal movement of the visceral pleura against parietal pleura does not occur

Other Tests: Complete blood count, plasma alcohol level, arterial blood gases, pulse oximetry, esophagography, rib x-rays, ultrasonography

Primary Nursing Diagnosis ⬆ ⬇

Diagnosis

DiagnosisImpaired gas exchange related to decreased oxygen diffusion capacity as evidenced by restlessness, agitation, anxiety, cough, air hunger, dyspnea, and/or tachycardia

Outcomes

OutcomesRespiratory status: Gas exchange; Respiratory status: Ventilation; Comfort level; Anxiety control; Symptom severity; Symptoms control; Vital signs

Interventions

InterventionsAirway insertion and stabilization; Airway management; Respiratory monitoring; Oxygen therapy; Mechanical ventilation; Anxiety reduction

Planning and Implementation ⬆ ⬇

PLANNING AND IMPLEMENTATION

Collaborative

The priority is to maintain airway, breathing, and circulation. The most important interventions focus on reinflating the lung by evacuating the pleural air. Patients with a primary spontaneous pneumothorax that is small with minimal symptoms may have spontaneous sealing and lung reexpansion. Some patients receive outpatient care as long as they have reliable follow-up and clear instructions about when to return to the emergency department if they worsen. The patient may be observed for 4 to 6 hours in the emergency department or for a longer period as an inpatient without chest drainage. For patients with jeopardized gas exchange, chest tube insertion or other strategies may be necessary to achieve lung reexpansion.

An ambulatory device that incorporates a one-way valve is available for stable patients in some situations (Hallifax et al., 2020 [see Evidence-Based Practice and Health Policy]), or simple aspiration with a small-bore catheter may be used. A chest tube system with a closed chest drainage system may be used if the patient is unstable or needs continuous fluid and/or air evacuation. Regulate suction according to the chest tube system directions; generally, suction does not exceed 20 to 25 cm H₂O negative pressure. Monitor a chest tube unit for any kinks or bubbling, which could indicate an air leak, but do not clamp a chest tube without a physician's order because clamping may lead to tension pneumothorax. Stabilize the chest tube so that it does not drag or pull against the patient or against the drainage system. Maintain aseptic technique, changing the chest tube insertion site dressing and monitoring the site for signs and symptoms of infection such as redness, swelling, warmth, and drainage.

Oxygen therapy and mechanical ventilation are prescribed as needed. Some patients may be managed with video-assisted thoracic surgery (VATS), which allows for closure of leaks and is less invasive than other more traditional surgical procedures. Surgical interventions include removing the penetrating object, exploratory thoracotomy if necessary, thoracentesis, and thoracotomy for patients with two or more episodes of spontaneous pneumothorax or patients with pneumothorax that does not resolve within 1 week.

Pharmacologic Highlights

No routine pharmacologic measures will treat pneumothorax, but the patient may need antibiotics, local anesthesia agents for procedures, and analgesics, depending on the extent and nature of the injury. Analgesia is administered for pain once the patient's pulmonary status has stabilized.

Independent

Place the patient in a semi-Fowler position to improve lung expansion. Change the patient's position every 2 hours to prevent infection and allow for lung drainage. For a patient with a traumatic closed pneumothorax, turn the patient onto the unaffected side to improve the ventilation-to-perfusion ratio. Encourage coughing and deep breathing to remove secretions.

For patients with traumatic open pneumothorax, prepare a sterile occlusive dressing and cover the wound. Monitor carefully for a tension pneumothorax (absent breath sounds, tracheal deviation) because the occlusive dressing prevents air from escaping the lungs. Teach alternative pain relief techniques. Explain all procedures in advance to decrease the patient's anxiety.

Evidence-Based Practice and Health Policy

Hallifax, R., McKeown, E., Sivakumar, P., Fairbairn, I., Peter, C., Leitch, A., Knight, M., Stanton, A., Ijaz, A., Marciniak, S., Cameron, J., Bhatta, A., Blyth, K., Reddy, R., Harris, M., Maddekar, N., Walker, S., West, A., Laskawiec-Szkonter, M., . . . Rahman, N. (2020). Ambulatory management of primary spontaneous pneumothorax: An open-label, randomised controlled trial. The Lancet, 396, 39–49.

The authors note that the optimal management of primary spontaneous pneumothorax is not defined. They tested an ambulatory device that incorporates a one-way valve as compared to the standard chest tube system with outcomes including the duration of hospitalization and safety of ambulatory management. Their study design was an open-label, randomised controlled trial of adults (aged 16–55 years) with symptomatic primary spontaneous pneumothorax, recruited from 24 hospitals over a period of 3 years. Patients were randomly assigned to treatment with either an ambulatory device or standard guideline-based management (aspiration, standard chest tube insertion, or both).
After 30 days, the median hospitalization was significantly shorter in the ambulatory treatment group. More patients in the standard care group had adverse events, but all serious adverse events occurred in patients who received ambulatory care, including an enlarging pneumothorax, asymptomatic pulmonary edema, and the device malfunctioning, leaking, or dislodging. The authors concluded that ambulatory management of primary spontaneous pneumothorax significantly reduced the duration of hospitalization, including readmissions in the first 30 days, but at the expense of increased adverse events.

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DRG Information ⬇

Introduction ⬆ ⬇