AUTHOR AND EDITOR INFORMATION

Section 1 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Multimedia
• References

INTRODUCTION

Section 2 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Multimedia
• References

Background

Pneumothorax refers to the presence of air or gas in the pleural cavity between the visceral and parietal pleura, which results in violation of the pleural space. It is uncommon during childhood. Primary pneumothorax occurs spontaneously in children without known lung disease, whereas secondary pneumothorax occurs as a complication of chronic or acute lung disease or because of trauma. Iatrogenic pneumothorax is a complication of certain diagnostic or therapeutic procedures such as central line placement.

Pathophysiology

Pneumothorax can be classified as either simple or complicated, but, in either case, a loss of intrapleural negative pressure causes lung collapse.

The main physiologic consequences of a pneumothorax are a decrease in vital capacity and a decrease in PaO₂. Most patients with a pneumothorax have a reduced PaO₂ and an increased alveolar-arterial oxygen tension difference. The reduction in PaO₂ appears to be caused by areas with low ventilation-perfusion ratios, anatomic shunts, and alveolar hypoventilation.

In a simple pneumothorax, air in the pleural space does not build up significant pressure but allows the lung to collapse 10-30% without further expansion of the pneumothorax.

A complicated pneumothorax is progressive and consists of continued air leakage into the pleural space and progressive lung collapse. This continued air leak results in positive pressure within the hemithorax and displacement of the mediastinum (ie, tension pneumothorax).

Tension pneumothorax is a life-threatening emergency. It is caused when air enters the pleural space during inspiration but cannot exit during exhalation. The positive pressure results in collapse of the involved lung and a shift of the mediastinal structures to the contralateral side. This causes a decrease in cardiac output as a consequence of decreased venous return and leads to rapidly progressive shock and death if not treated.

Frequency

United States

The annual incidence of primary spontaneous pneumothorax in the general population is estimated to be 5-10 per 100,000 population. The peak incidence occurs in persons aged 16-24 years. The disorder is less common in children than in adults.

Sex

Limited data in young children suggest a strong male predominance of primary spontaneous pneumothorax.

Age

• All age groups are affected.
• Premature neonates on mechanical ventilation are at high risk.

CLINICAL

Section 3 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Multimedia
• References

Physical

• The severity of the symptoms depends on the extent of the lung collapse, rate of development, and underlying clinical status of the patient.
• A patient with a simple pneumothorax may either be asymptomatic or present with symptoms such as chest pain and dyspnea. Patients with a spontaneous pneumothorax secondary to underlying lung disease may have a more dramatic presentation.
• A more extensive pneumothorax often produces pleuritic chest pain, dyspnea, tachypnea, cyanosis, and decreased breath sounds on the involved side. Acute pleuritic chest pain on the affected side occurs 95% of the time.
• Hyperresonance to percussion may be noted on the affected side.
• Patients with a tension pneumothorax may present in shock and have trachea displacement to the unaffected side.
• If the pneumothorax is due to trauma, look for contusions or abrasions on the chest wall or a small puncture wound that does not allow free movement of air between the outside and the pleural cavity.

Causes

• Simple or complicated pneumothorax is very common in both blunt (38%) and penetrating (64%) pediatric chest injuries.
• Cases not associated with trauma are generally due to a pulmonary bleb rupture with subsequent air leakage into the pleural space.
• Inhalation of some toxic substances, most notably crack cocaine, can also lead to this condition.
• Spontaneous secondary pneumothoraces may occur in patients with underlying lung diseases such as asthma, cystic fibrosis, or pneumonia.
• When trauma results in pneumothorax, it may be secondary to blunt trauma or penetrating trauma. Penetrating trauma results in open or communicating pneumothorax.

DIFFERENTIALS

Section 4 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Multimedia
• References

WORKUP

Section 5 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Multimedia
• References

Lab Studies

• Pneumothorax is generally a clinical diagnosis that is confirmed with plain radiography. However, a noncontrast chest CT scan may be helpful to look for preexisting pulmonary pathologies such as blebs or bullae. Ultrasonography has also shown to be useful in detecting pneumothorax.

Imaging Studies

• Small pneumothoraces may not be clinically apparent and require chest radiographs or chest CT scans to detect. Anteroposterior and lateral views can reveal the presence of even small amounts of intrapleural air. Air in the pleural space that outlines the visceral pleura is a characteristic finding. Hyperlucency of vascular and lung markings on the affected side can be seen because of this air. Atelectasis may also be seen on the affected side, and the mediastinum and trachea may shift away from the pneumothorax.
• A tension pneumothorax should always be a clinical diagnosis since death can occur before the radiograph is taken or developed.
• When an infant is suspected of having a pneumothorax, anterior-posterior radiographs are taken in the supine position. Small pneumothoraces can be better visualized with lateral decubitus film with the affected side up.
• Transillumination of the chest may help to establish the diagnosis in the newborn infant.

TREATMENT

Section 6 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Multimedia
• References

Medical Care

In general, treat a small, simple pneumothorax conservatively unless the patient is symptomatic; use oxygen to increase reabsorption of intrapleural air, observe the patient, and repeat chest radiographs. However, a small, simple pneumothorax in a trauma patient is best treated with a chest tube since it may rapidly convert into a tension pneumothorax, especially if positive pressure ventilation is applied. Large or symptomatic pneumothoraces require chest tube placement and surgical intervention. A tension pneumothorax requires immediate decompression with needle thoracostomy.

Patients with cystic fibrosis who sustain recurrent pneumothoraces may benefit from sclerotherapy, although this may not prevent all future recurrences.

Only pleurodesis, video-assisted thoracoscopy, and thoracotomy reduce the risk of future recurrence.

Surgical Care

Percutaneous aspiration or tube thoracostomy (chest tube) placement is typically required for large or symptomatic pneumothoraces. Tension pneumothoraces need immediate decompression with needle thoracostomy, followed by tube thoracostomy.

Consultations

Unless the physician is skilled at placing a chest tube and handling potential complications, an emergent emergency medicine, pulmonary, critical care, or surgical consultation is warranted.

Diet

For patients with small pneumothoraces that are being watched, restriction to nothing by mouth (NPO) or clear liquids is appropriate. If chest tube placement is imminent, the patient should be NPO. After chest tube placement and recovery from any sedation, a regular diet may be started unless contraindicated based on other injuries or planned surgery.

Activity

A patient with a chest tube in place may only be able to tolerate restricted movement, such as from a bed to a chair.

MEDICATION

Section 7 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Multimedia
• References

The only drug therapy that is currently a component of the standard of care for this condition is administration of 100% oxygen. Patients with a thoracostomy tube in place should receive appropriate pain management. Patients in severe pain should receive morphine sulfate intravenously or a patient-controlled analgesia pump when appropriate. Some patients' pain can be controlled well with oral medications such as acetaminophen.

FOLLOW-UP

Section 8 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Multimedia
• References

Further Inpatient Care

• After a small pneumothorax has resorbed completely, the patient requires no further inpatient care.
• If a chest tube was placed, daily radiographs are sometimes required. If reexpansion occurred on initial placement with no subsequent air leaks, the tube can be removed in as little as 2-3 days. The decision to remove a chest tube is generally made by the surgeon, not the pediatrician.

Further Outpatient Care

• Instruct parents to return if the patient has chest pain or shortness of breath.
• The chest tube wound site should be monitored for infection and to ensure proper healing.

In/Out Patient Meds

• Pain medication should be given on discharge.

Transfer

• If the patient is in a clinic or office setting, order an immediate transfer to an emergency department by ambulance (advanced cardiac life support capability is preferred).

Complications

• Complications directly related to pneumothorax are few. Recognition and proper treatment of a pneumothorax are needed to prevent expansion, hypoxia (with its complications), and tension with subsequent cardiovascular collapse and death.
• Chest tube insertion may result in significant bleeding, infection, or both.

Prognosis

• If the pneumothorax was an isolated event and treatment was initiated early, the prognosis is excellent. The rate of recurrence of a simple spontaneous pneumothorax can be as high as 30% ipsilateral and 10% contralateral. Patients with cystic fibrosis have an especially high rate of recurrence.
• If other trauma was sustained at the same time or tension pneumothorax occurred with subsequent shock and hypoperfusion, the prognosis worsens.
• If the patient was allowed to be hypoxic for a long period, brain injury is possible.

Patient Education

• For excellent patient education resources, visit eMedicine's Lung and Airway Center and Heart Center. Also, see eMedicine's patient education articles Collapsed Lung and Chest Pain.

MULTIMEDIA

Section 9 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Multimedia
• References

Media file 1:  Neonate with a right tension pneumothorax. Note the tracheal deviation to the left.
	View Full Size Image
Media type:  X-RAY

REFERENCES

Section 10 of 10

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Multimedia
• References

• American College of Surgeons Committee on Trauma. Thoracic trauma. In: Advanced Trauma Life Support for Doctors, Student Course Manual. 6th ed. Chicago, Ill:. American College of Surgeons;1997:125-41.
• Boat TF. Cystic fibrosis. In: Behrman RE, Kliegman RM. Nelson Textbook of Pediatrics. 16th ed. Philadelphia, Pa:. Elsevier Science;2000:1324, 1331-3.
• Kemp JS, Seilheimer DK. Diseases of the pleura. In: Principles and Practice of Pediatrics. 2nd ed. 1994:1511-3.
• Light RW, Broaddus VC. Pneumothorax, chylothorax, hemothorax, and fibrothorax. In: Murray RF, Nadel JA. Textbook of Respiratory Medicine. 3rd ed. Philadelphia, Pa:. Elsevier Science;2000:2043-55.
• Richardson DJ, Miller FB. Injury to the lung and pleura. In: Moore EE, Matox KL, Feliciano DV, eds. Trauma. 3rd ed. New York, NY:. McGraw-Hill;1996:387-97.
• Stern RC. The respiratory system. In: Behrman RE, Kliegman RM. Nelson Textbook of Pediatrics. 14th ed. Philadelphia, Pa:. Elsevier Science;1992:1118-9.
• Templeton JM Jr. Thoracic emergencies. In: Textbook of Pediatric Emergency Medicine. 3rd ed. Baltimore, Md:. Lippincott Williams & Wilkins;1993:1348-9.
• Templeton JM Jr. Thoracic trauma. In: Textbook of Pediatric Emergency Medicine. 3rd ed. Baltimore, Md:. Lippincott Williams & Wilkins;1993:1150-2.
• Young WF, Jr., Humphries, R. Spontaneous and Iatrogenic Pneumothorax. Tintinalli's Emergency Medicine: A comprehensive Study Guide, 6th Edition. McGraw Hill 2004;Section 8, Chapter 66.

Article Last Updated: Sep 13, 2006