Pneumothorax

In medicine (pulmonology), a pneumothorax or collapsed lung is a medical emergency caused by the collapse of the lung within the pleural cavity.

It can result from:

A penetrating chest wound
Barotrauma to the lungs
Spontaneously (most commonly in tall, slim young males)
Chronic lung pathologies including emphysema, asthma
Acute infections
Chronic infections, such as tuberculosis
Cancer

Pneumathoraces are divided into tension and non-tension pneumathoraces. A tension pneumathorax is a medical emergency as air accumulates in the pleural space with each breath. The remorseless increase in intrathoracic pressure results in massive shifts of the mediastinum away from the affected lung compressing intrathoracic vessels. A non-tension pneumothorax by contrast is a less severe pathology because the air in the pneumothorax is able to escape.

The accumulation of blood in the thoracic cavity (hemothorax) exacerbates the problem, creating a pneumohemothorax.

Signs and symptoms

Sudden shortness of breath, cyanosis (turning blue) and pain felt in the chest and/or back are the main symptoms. In penetrating chest wounds, the sound of air flowing through the puncture hole may indicate pneumothorax. The flopping sound of the punctured lung is occasionally heard, hence the term "sucking" chest wound.

If untreated, hypoxia may lead to loss of consciousness and coma. In addition, shifting of the mediastinum away from the site of the injury can obstruct the superior and inferior vena cava resulting in reduced cardiac preload and decreased cardiac output. Untreated, a severe pneumothorax can lead to death within several minutes.

Spontaneous pneumothoraces are reported in young people with a tall stature. As men are generally taller than women, there is a preponderance among males. The reason for this association, while unknown, is hypothesized to be the presence of subtle abnormalities in connective tissue.

Pneumothorax can also occur as part of medical procedures, such as the insertion of a central venous catheter (an intravenous catheter) in the subclavian vein or jugular vein. While rare, it is considered a serious complication and needs immediate treatment. Other causes include mechanical ventilation, emphysema and rarely other lung diseases (pneumonia).

Diagnosis

The absence of audible breath sounds through a stethoscope can indicate that the lung is not unfolded in the pleural cavity. This accompanied by hyperresonance (higher pitched sounds than normal) to percussion of the chest wall is suggestive of the diagnosis. If the signs and symptoms are doubtful, an X-ray of the chest can be performed, but in severe hypoxia, emergency treatment has to be administered first.

In a supine chest X-ray the deep sulcus sign is diagnosticKong A. The deep sulcus sign. Radiology. 2003 Aug;228(2):415-6. PMID 12893899 Full Text, which is characterized by a low lateral costophrenic angle on the affected side.Gordon R. The deep sulcus sign. Radiology. 1980 Jul;136(1):25-7. PMID 7384513 In layman's terms, the place where rib and diaphragm meet appears lower on an X-ray with a deep sulcus sign and suggests the diagnosis of pneumothorax.

Pathophysiology

The lungs are located inside the chest cavity, which is a hollow space. Air is drawn into the lungs by the diaphragm (a powerful abdominal muscle). The pleural cavity is the region between the chest wall and the lungs. If air enters the pleural cavity, either from the outside (open pneumothorax) or from the lung (closed pneumothorax), the lung collapses and it becomes mechanically impossible for the injured person to breathe, even with an open airway. If a piece of tissue forms a one-way valve that allows air to enter the pleural cavity from the lung but not to escape, overpressure can build up with every breath; this is known as tension pneumothorax. It may lead to severe shortness of breath as well as circulatory collapse, both life-threatening conditions. This condition requires urgent intervention.

First Aid

Chest wound

Penetrating wounds require immediate coverage with an occlusive dressing, field dressing, or pressure bandage made air-tight with petroleum jelly or clean plastic sheeting. The sterile inside of plastic bandage packaging is good for this purpose; however any airtight material, even the cellophane of a cigarette pack, can be used. A small opening, known as a flutter valve, needs to be left open, so the air can escape while the lung reinflates. Any patient with a penetrating chest wound must be closely watched at all times and may develop a tension pneumothorax or other immediately life-threatening respiratory emergency at any moment. They cannot be left alone.

Blast injury or spontaneous

If the air in the pleural cavity is due to a tear in the lung tissue (in the case of a blast injury or tension pneumothorax), it needs to be released. A thin needle can be used for this purpose, to relieve the pressure and allow the lung to reinflate.

Pre-hospital care

Many paramedics can perform needle thoracocentesis to relieve intrathoracic pressure. Intubation may be required, even of a conscious patient, if the situation deteriorates. Advanced medical care and immediate evacuation are strongly indicated.

An untreated pneumothorax is an absolute contraindication of evacuation or transportation by flight.

Clinical treatment

Small Pneumothoraces require no treatment other than repeat observation via Chest X-rays.

Larger Pneumothoraces may require tube thoracostomy, also known as chest tube placement. A tube is inserted into the chest wall outside the lung and air is extracted using a simple one way valve or vacuum and a water valve device, depending on severity. This allows the lung to re-expand within the chest cavity. The pneumothorax is followed up with repeated X-rays. If the air pocket has become small enough, the vacuum drain can be clamped temporarily or removed.

In case of penetrating wounds, these require attention, but generally only after the airway has been secured and a chest drain inserted. Supportive therapy may include mechanical ventilation.

Recurrent pneumothorax may require further corrective and/or preventative measures such as pleurodesis. If the pneumothorax is the result of bullae, then bullaectomy (the removal or stapling of bullae or other faults in the lung) is preferred. Pleurodesis is the injection of a chemical irritant that triggers an inflammatory reaction, leading to adhesion of the lung to the parietal pleura. Substances used for pleurodesis include talc, blood and bleomycin.

History

Jean Itard, a student of Rene Laennec, first recognised pneumothorax in 1803, and Laennec himself described the full clinical picture in 1819Laennec RTH. Traite de l'auscultation mediate et des maladies des poumons et du coeur. Part II. Paris, 1819..

Prior to the advent of anti tuberculous medications, iatrogenic pneumothoraces were intentionally given to tuberculosis patients in an effort to collapse a lobe, or entire lung around a cavitating lesion. This was known as 'resting the lung' .

Pop Culture References

In the Kaiser Chiefs song Saturday Night, frontman Ricky Wilson proclaims, "Ppp-pneumothorax is a word that is long. They're just trying to put the punk back into punctured lung."

The Mountain Goats' song Song for Dennis Brown also references lung collapse, presumably as a result of long-term cocaine abuse - the connection between Dennis Brown's drug addiction and pneumothorax is not made clear.

In the 1999 film "Three Kings," Mark Wahlberg's character "Troy" is shot and suffers from a severe lung collapse. Archie Gates (George Clooney) aleviates his condition by inserting a small chest valve.

References

External links

An X-ray with deep sulcus sign - learningradiology.com
Pneumothorax.org - Pneumothorax news, information and forums
Music as a cause of primary spontaneous pneumothorax An article from the journal Thorax detailing links between exposure to loud music and pneumothorax.
Sucking chest wound:

Medical emergencies | Pulmonology | Emergency medicine

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