From the Guidelines
The workup for pneumothorax should begin with a thorough clinical assessment and point-of-care ultrasound, as it has become increasingly valuable for rapid bedside diagnosis, especially in unstable patients where transport for X-ray might be risky, with a sensitivity of 95% and specificity of 94% 1.
Clinical Assessment
The clinical assessment should focus on symptoms like sudden chest pain, shortness of breath, and decreased breath sounds on the affected side.
- A thorough medical history should be taken to identify any underlying lung disease or previous episodes of pneumothorax.
- Physical examination should include inspection for signs of trauma, palpation for crepitus or tenderness, and auscultation for decreased breath sounds.
Diagnostic Imaging
- Chest X-ray is the primary diagnostic tool, typically showing a visible pleural line and absence of lung markings beyond it.
- In cases where X-ray results are inconclusive but clinical suspicion remains high, a CT scan provides more detailed imaging.
- Ultrasound can be useful in emergency settings, looking for the absence of lung sliding, with a higher sensitivity than bedside chest radiograph (86.1% versus 52.7%) 1.
Additional Testing
- Arterial blood gases may reveal hypoxemia and respiratory alkalosis, while pulse oximetry helps monitor oxygen saturation.
- For patients with spontaneous pneumothorax, additional testing may include pulmonary function tests to assess underlying lung disease.
- In trauma cases, a complete trauma assessment is necessary to identify associated injuries.
- The extent of workup depends on the suspected cause, with primary spontaneous pneumothorax requiring less extensive evaluation than secondary pneumothorax, which necessitates investigation of underlying lung disease.
Management
- The management of pneumothorax depends on the size and severity of the pneumothorax, as well as the patient's clinical stability.
- Drainage of symptomatic pneumothorax, either with needle aspiration or intercostal chest drain attached to an underwater seal, is the current standard of care for spontaneous pneumothorax 1.
- Conservative management may be considered for small, asymptomatic pneumothoraces, but close monitoring is necessary to detect any signs of deterioration.
From the Research
Workup for Pneumothorax
The workup for pneumothorax typically involves a combination of physical examination, medical history, and diagnostic imaging. The following are some of the key components of the workup:
- Physical examination: to assess for signs of pneumothorax, such as decreased breath sounds, hyperresonance, and subcutaneous emphysema 2
- Medical history: to determine the presence of underlying lung disease or other conditions that may increase the risk of pneumothorax 2
- Diagnostic imaging:
- Chest X-ray (CXR): to confirm the presence of pneumothorax and assess its size 2, 3, 4
- Computed Tomography (CT) scan: to provide more detailed images of the chest and assess the size and location of the pneumothorax 2, 3, 5
- Lung Ultrasound (US): to detect pneumothorax, especially in trauma patients 3, 6
Diagnostic Criteria
The diagnosis of pneumothorax is typically made based on a combination of clinical and radiographic findings. The following are some of the key diagnostic criteria:
- Presence of air in the pleural space on CXR or CT scan 2, 3
- Decreased breath sounds and hyperresonance on physical examination 2
- Presence of subcutaneous emphysema on physical examination 2
Imaging Modalities
The choice of imaging modality depends on the clinical scenario and the availability of resources. The following are some of the key imaging modalities used in the workup of pneumothorax:
- CXR: a rapid and widely available imaging modality that can confirm the presence of pneumothorax 2, 3, 4
- CT scan: a more sensitive and specific imaging modality that can provide detailed images of the chest and assess the size and location of the pneumothorax 2, 3, 5
- Lung US: a rapid and non-invasive imaging modality that can detect pneumothorax, especially in trauma patients 3, 6
Special Considerations
The workup for pneumothorax may vary depending on the clinical scenario and the presence of underlying conditions. The following are some special considerations:
- Traumatic pneumothorax: may require more urgent and aggressive management, including the use of lung US and CT scan 3, 6
- Spontaneous pneumothorax: may be managed more conservatively, with a focus on monitoring and supportive care 2
- Underlying lung disease: may increase the risk of pneumothorax and require more aggressive management 2