From the Guidelines
A pneumothorax is diagnosed by the presence of a visible pleural line or lung edge with an absence of lung markings beyond this line toward the chest wall on chest X-rays or CT scans, as recommended by the BTS guidelines for the management of spontaneous pneumothorax 1. When evaluating a pneumothorax, it's essential to consider the clinical history and physical examination, although these are not reliable indicators of size 1. The clinical symptoms associated with secondary pneumothoraces are more severe than those associated with primary pneumothoraces, and most patients with a secondary pneumothorax complain of breathlessness which is out of proportion to the size of the pneumothorax 1. Some key features to look for in a pneumothorax picture include:
- A dark space between the chest wall and the lung on chest X-rays or CT scans
- A visible lung edge or pleural line, with an absence of lung markings beyond this line toward the chest wall
- Increased radiolucency (blackness) in the affected area due to air accumulating in the pleural space
- The size of this dark space indicates the severity of the pneumothorax
- On upright films, the air collects at the apex of the lung, while in supine patients, it may distribute anteriorly or along the lung base
- Tension pneumothorax shows mediastinal shift away from the affected side, with possible depression of the diaphragm CT scanning is recommended when differentiating a pneumothorax from complex bullous lung disease, when aberrant tube placement is suspected, and when the plain chest radiograph is obscured by surgical emphysema 1. In patients with severe bullous lung disease, CT scanning will differentiate emphysematous bullae from pneumothoraces and save the patient an unnecessary and potentially dangerous aspiration 1. The lateral decubitus radiograph is superior to the erect or supine chest radiograph and is felt to be as sensitive as CT scanning in pneumothorax detection 1. A lateral chest or lateral decubitus radiograph should be performed if the clinical suspicion of pneumothorax is high, but a PA radiograph is normal 1.
From the Research
Pneumothorax Classification
- Pneumothorax can be classified into primary and secondary, with primary occurring without an apparent cause and in the absence of significant lung disease, and secondary occurring in the presence of existing lung pathology 2
- Pneumothorax can also be classified as traumatic, iatrogenic, or spontaneous, with spontaneous further subdivided into primary spontaneous pneumothorax (PSP) and secondary spontaneous pneumothorax (SSP) 3
Pneumothorax Diagnosis
- Diagnosis of pneumothorax typically includes chest X-ray or computed tomography (CT) scan 2
- Ultrasonography is emerging as a diagnostic procedure of choice for pneumothorax, especially in critically ill patients 4
- Physical examination findings, such as dyspnea, chest pain, tachypnea, and absent breath sounds on lung auscultation, can also indicate pneumothorax 5
Pneumothorax Treatment
- Small spontaneous pneumothoraces can resolve without treatment and require only monitoring 2
- Treatment for pneumothorax can include observation, manual aspiration, insertion of a small-bore catheter, or chest tube drainage, depending on the size and severity of the pneumothorax 6
- In critically ill patients, pneumothorax should be managed with tube thoracostomy, and immediate decompression and drainage should be performed if there is suspicion for tension pneumothorax 4
- Operative procedures, such as surgery, can have a clear protective effect from recurrence in spontaneous pneumothorax, and should be considered when treating hospitalized patients 3