Pneumothorax and Hemothorax

By admin Last updated Oct 22, 2023

Ovid: 5-Minute Sports Medicine Consult, The

Russell D. White

Emily Lott

Basics

Description

Air (pneumothorax), blood (hemothorax), or both (hemopneumothorax) in the pleural space between the lung and chest wall
Tension pneumothorax: Progressive accumulation of air in the pleural space causing compression of chest structures including heart and restricting venous return and the contralateral lung; can lead to cardiac arrest. Differentiated from simple pneumothorax by mediastinal shift toward the uninvolved lung on x-ray and/or ipsilateral diaphragm flattening or inversion on x-ray.
Pneumothorax can be categorized as:
- Spontaneous: No obvious precipitating factor present; further divided into:
  - Primary: No apparent underlying disease
  - Secondary: Clinically apparent underlying disease (such as COPD or cystic fibrosis)
  - Catamenial: Occurs in conjunction with menstruation
- Nonspontaneous or traumatic: Caused by trauma; can be further divided into penetrating or nonpenetrating chest injury
- Iatrogenic: Secondary to a procedure such as transthoracic or transbronchial biopsy, subacromial injections, central line placement, pleural biopsy, or thoracentesis
Synonym(s): Collapsed lung

Epidemiology

Rare, but potentially serious
<4% of all sports injuries involve the chest or abdomen.

Incidence

∼20,000 new cases of spontaneous pneumothorax are reported each year in the U.S.
Primary spontaneous pneumothorax affects ∼9,000 persons in the U.S. each year.
Activity reported to be related to pneumothorax in <10% of cases
Predominant gender: Male > Female (6:1)

Risk Factors

Tall, thin, young (20s–40s), males (primary spontaneous pneumothorax)
Smoking (spontaneous pneumothorax)
Substance use such as heroine, ecstasy, marijuana, speed, and cocaine (spontaneous pneumothorax)
Congenital apical lung blebs
Underlying lung disease (eg, COPD, cystic fibrosis, TB)
Connective tissue disorder (Marfan)
Homocystinuria
Trauma, especially rib fractures (most commonly 1st 4 and last 2, multiple, or flail segments) or scapular fractures
Preparticipation recommendations:
- If patients want to SCUBA dive, should perform assessment of expiratory flow rates and conventional spirometry in those with underlying lung disease
MEF₅₀ and MEF₂₅ or MEF_25-75 should be at least 80% of predicted values.

Genetics

Some reports of familial clustering of primary spontaneous pneumothorax: Autosomal dominant, autosomal recessive, polygenic, and X-linked recessive inheritance mechanisms all have been proposed.
Birt-Hogg-Dube syndrome:
- Autosomal dominant
- Predisposes to skin tumors and renal cancer
- Associated with increased incidence of primary spontaneous pneumothorax
- Gene responsible for this familial cancer syndrome (called FLCN) has been mapped to chromosome 17p11.2. Other mutations of FLCN have been associated with spontaneous pneumothorax and bullous lung disease in the absence of the oncologic manifestations.

General Prevention

Avoid smoking and substance use.
If history of pneumothorax, avoid contact sports and trauma.

Etiology

Spontaneous pneumothorax:
- Theorized to be caused by the rupture of subpleural blebs
- Rupture caused by increased intrathoracic pressure
Traumatic pneumothorax and iatrogenic pneumothorax:
- Caused by tear in visceral pleura resulting in air leak into the pleural space
- Trauma may be penetrating or nonpenetrating.
Hemothorax: Caused by virtually any disruption of the tissues of the chest wall and pleura with subsequent bleeding
Precipitating factors may include atmospheric pressure changes and exposure to loud music.

Commonly Associated Conditions

COPD
Cystic fibrosis

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Diagnosis

Pre Hospital

Initial evaluation should include vital sign assessment and auscultation in a quiet setting.

History

Trauma to thoracic wall
Persistent pain at injury site
Shortness of breath
Localized chest pain, especially on deep inspiration, frequently present: May radiate to neck, shoulder, back, or abdomen
Dyspnea and/or tachypnea frequently present
Up to 25% of patients are asymptomatic.

Physical Exam

Decreased or absent breath sounds on affected side
Decreased tactile fremitus on side of pneumothorax
Unequal expansion of right and left sides of chest with inspiration
Hyperresonance to percussion in the case of pneumothorax; dullness to percussion in the case of hemothorax
In tension pneumothorax, tracheal deviation away from site of pneumothorax, neck vein distension, and laterally displaced cardiac impulse all may be present.
Crepitation or SC emphysema may be present, especially in traumatic pneumothorax.
Possible pallor or cyanosis (usually with tension pneumothorax)
Tachycardia may be present.

Diagnostic Tests & Interpretation

Imaging

Upright posteroanterior and lateral chest films:
- Inspiratory and expiratory films have equal sensitivity in detecting pneumothoraces, so a standard inspiratory chest radiograph is sufficient in most cases (1).
- Pneumothorax is demonstrated by a white visceral pleural line on the chest radiograph.
- The visceral pleural line defines the interface of the lung and pleural air and is either straight or convex toward the chest wall with no pulmonary vessels usually visible beyond the visceral pleural edge.
Rib x-rays on affected side
CT scanning generally is not necessary unless abnormalities are noted on the plain chest radiograph that require further evaluation or poor chest tube placement is suspected (1).

Diagnostic Procedures/Surgery

ECG often demonstrates right-axis deviation, decreased QRS amplitude, and precordial T-wave inversion.
If hemodynamically unstable and findings are consistent with a pneumothorax (most likely tension pneumothorax), may consider emergency needle aspiration, which is both diagnostic and therapeutic
Diagnosis is confirmed by rapid gush of air coming through the needle.

Differential Diagnosis

Chest wall/rib contusion
Lung contusion
Costochondral separation
Muscle strain
Fracture

Treatment

Pre-Hospital

Acute treatment:
- Determine if patient is hemodynamically stable because primary job is to stabilize.
- ABCs of basic life support, especially airway management
- Determine diagnostic possibilities; transfer to hospital (x-ray) facility if suspicious for pneumothorax
- Semi-Fowler position
- Oxygen if available and if patient is dyspneic
- If unstable and/or findings consistent with a tension pneumothorax, emergency needle decompression (thoracostomy) should be performed.
- Needle decompression is performed by inserting a large-caliber needle (usually 14 or 18 gauge), preferably with a catheter over needle, into the 2nd intercostal space at the midclavicular line just above the 3rd rib.
- If catheter over needle, then remove needle and leave plastic sheath; may attach a syringe
- Flail chest may accompany rib fractures; if present, stabilize flail segment with manual pressure or a bulky dressing to the segment
Emergency personnel:
- Oxygen
- IV line placement
- Transport to emergency facility

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ED Treatment

Obtain chest x-ray.
Further treatment depends on patient characteristics and clinical circumstances.
- When pneumothorax small (<20%) tension-free pneumothorax (no mediastinal shift) and patient is hemodynamically stable, treat expectantly without chest tube and with supplemental oxygen and observation only (1)[C].
  - Must be observed in the ED for at least 6 hr with follow-up films obtained before discharge showing no progression of pneumothorax and again in 12–48 hr (1)[C]
  - Must have access to emergency medical services (1)[C]
  - Exception is when associated with underlying lung disease: Requires urgent and immediate treatment (1)[C].
- When pneumothorax is large (>20%) and clinically stable, treat initially with pleural aspiration (1)[A].
  - If aspiration fails, treat with closed thoracostomy chest tube insertion with Heimlich valve or, preferably underwater seal (1)[A].
  - Should also consider video-assisted thoracoscopic surgery (VATS) with aerosolized talc during the same hospitalization based on the high success rate of VATS, both short and long term (1)[A].
  - Chemical pleurodesis with talc slurry should be performed through the chest tube if VATS is indicated and is not readily available or patient refuses (1)[A].
- In cases of recurrent primary spontaneous pneumothorax when patient is clinically stable, treat with VATS after chest tube insertion; should perform recurrence prevention at the same time (pleurodesis) (1)[B]. Chemical pleurodesis with talc slurry should be performed through the chest tube if VATS is indicated and is not readily available or patient refuses (1)[A].
- If patient is clinically unstable, he or she should undergo chest tube insertion (1)[C].
  - If the chest tube insertion is delayed, decompression can be performed as a bridge by advancing a standard 14-gauge IV catheter into the pleural space at the junction of the midclavicular line and the 2nd or 3rd intercostal space (1)[C].
  - The chest tube can be connected to a water-seal device. Suction should be applied to the chest tube if the pneumothorax fails to resolve (1)[C].
Chest tube size recommendations:
- Patients who require mechanical ventilation or who may have a large air leak should be managed with a 24–32Fr chest tube.
- All other patients who require chest tube insertion can be managed with a 16–22Fr chest tube or a ≤14Fr chest catheter.
Hemothorax with even a small pneumothorax requires a chest tube to preclude development of “trapped lung,” which eventually may require decortication.

Medication

Lidocaine (Xylocaine) 1% for chest tube insertion
Oral or IV medication prior to chest tube insertion and after as needed for comfort
May consider Tylenol 3 or other narcotic for oral use, especially around time of chest tube insertion

Additional Treatment

Referral

Should refer to cardiothoracic surgeon in cases of persistent air leak or recurrent pneumothorax requiring further intervention.

Additional Therapies

Avoid chest binders, taping, etc., which tend to compromise deep inspiration and may contribute to the development of atelectasis.

Surgery/Other Procedures

Video-assisted thoracoscopic surgery (VATS):
- Should consider, along with chest tube placement, if pleural aspiration alone is unsuccessful (1)[A]
- Should perform in cases of recurrent primary spontaneous pneumothorax after chest tube insertion (1)[B].
- Should perform pleurodesis with aerosolized USP talc at the same time (1)[B].
- Consider in patients being managed with a chest tube who have a persistent air leak (1)[B].
- If preventive procedure is required, VATS with pleurodesis is recommended over tube thoracostomy with chemical pleurodesis because it reduces the recurrence rate to <5% (1)[B].
Thoracotomy:
- Alternative to VATS
- Rarely necessary

In-Patient Considerations

As a general rule of thumb, air from the pleural space is absorbed at a rate of 1.25% per day.
Supplemental oxygen can accelerate this rate 3-fold.
Hospital treatment:
- If aspiration fails, treat with closed thoracostomy–chest tube insertion with Heimlich valve or, preferably, underwater seal (1)[A].
- Should also consider VATS during the same hospitalization based on the high success rate of VATS, both short and long term (1)[A].
- Chemical pleurodesis with talc slurry should be performed through the chest tube if VATS is indicated and is not readily available or patient refuses (1)[A].
- In cases of recurrent primary spontaneous pneumothorax when patient is clinically stable, treat with VATS after chest tube insertion; should perform recurrence prevention at the same time (pleurodesis) (1)[B].
- Chemical pleurodesis with talc slurry should be performed through the chest tube if VATS is indicated and is not readily available or patient refuses (1)[A].
- The chest tube can be connected to a water-seal device. Suction should be applied to the chest tube if the pneumothorax fails to resolve (1)[C].
- For patients being managed with a chest tube whose lung is at least 90% expanded but who have an air leak that persists longer than 3 days, the chest tube may be attached to a Heimlich valve, and the patient may be discharged home if the patient is responsible and is easily followed on an outpatient basis (1)[C].
- For patients being managed with a chest tube who have a persistent air leak and whose lung is <90% expanded, consider VATS (1)[B].

Initial Stabilization

Should be accomplished in ED, but continue to be mindful.
Airway management, if change in condition
Chest tube placement, if not done in ED
Continue supplemental oxygen.

Admission Criteria

Hemodynamically unstable
Tension pneumothorax and/or chest tube placement
Pneumothorax with >15–20% volume loss
All patients with secondary spontaneous pneumothorax

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IV Fluids

With pneumothorax, needed only if hemodynamically unstable
Recommended in case of hemothorax because there is likely to be volume loss, which may lead to shock if not treated appropriately
Isotonic fluids, such as normal saline or lactated Ringer's

Discharge Criteria

Resolution of pneumothorax with removal of chest tube
Chest tube can be removed when air leak has stopped and x-ray confirms lung expansion; usually within 24–72 hr.
Re-x-ray after removal of chest tube (prior to discharge) to check for recurrence.

Ongoing Care

Preventative intervention with VATS or chemical pleurodesis with tube thoracostomy recommendations:

If recurrence occurs, consider VATS, pleurodesis, or on occasion, thoracotomy.
For patients who are not operative candidates or who refuse VATS, tube thoracostomy with chemical pleurodesis is recommended over tube thoracostomy drainage alone because it reduces the recurrence rate to <25% (1)[A].

Follow-Up Recommendations

Advise patient that pain likely will be present for at least 6 wks, especially if rib fracture produced the pneumothorax.
May return to conditioning 3–4 wks after pneumothorax resolved, provided no evidence of pneumothorax on chest x-ray
May return to play soon after
Should consider extra padding

Patient Monitoring

Recheck chest x-ray in 4–6 wks.

Diet

No special considerations

Patient Education

Counsel on high risk of recurrence: For traumatic pneumothorax, there is no increased risk of recurrence compared with other types.
Counsel against smoking.
Air travel recommendations (2):
- Commercial air travel is contraindicated in the presence of an acute, unresolved pneumothorax or congenital pulmonary cysts.
- Avoid during exacerbations of chronic lung disease.
- For commercial travelers, no travel for 4–6 wks after resolution of pneumothorax
- For the military, air travel may be restricted for 6–9 mos
- Take all prescribed pulmonary medications before and during flight as scheduled.
- May restrict air travel in persons with a history of pneumothorax with underlying lung disease
SCUBA diving absolute contraindications:
- A history of a spontaneous pneumothorax (3)[A]
- Diving within 3 mos after any type of nonspontaneous pneumothorax (4)
- Expert divers with recurrent pneumothorax following a pleurectomy (4)

Prognosis

Depends on type and extent: Small (<20%) usually resolve on own without treatment.
When associated with underlying disease, even when small, is more serious and has a mortality rate of ∼15%.
Recurrence rate is ∼40% for both primary and secondary pneumothoraces.
Most recurrences occur within 1.5–2 yrs; recurrence is at its highest likelihood in the 1st few months after the initial pneumothorax.
For traumatic pneumothorax, there are no data to suggest that there is an increased risk of recurrence with or without return to play.
Recurrence rate increases with each recurrence.
Most recurrences are seen on the same side, but not always.

Complications

Recurrence: If it occurs, consider VATS pleurodesis or thoracotomy.

References

1. http://uptodateonline.com/online/content/topic.do?topicKey=pleurdis/9228&selectedTitle=2∼150&source=search/result, accessedon August 30, 2009.

2. http://uptodateonline.com/online/content/topic.do?topicKey=pleurdis/9127&selectedTitle=7∼150&source=search/result, accessed on August 30, 2009.

3. http://diversalertnetwork.org/medical/faq/faq.aspx?faquid=36

4. http://scuba-doc.com/spntpnu.htm

Additional Reading

Amaral JF. Thoracoabdominal injuries in the athlete. Clin Sports Med. 1997;16:739–753.

Codes

ICD9

512.0 Spontaneous tension pneumothorax
512.1 Iatrogenic pneumothorax
512.8 Other spontaneous pneumothorax