0071643192.pdf

■ The physical exam may be normal if the pneumothorax is small.

■ If the pneumothorax is large, exam may reveal ↓chest movement, hyper-

resonance,↓fremitus, and ↓breath sounds.

■ Tachycardia, hypotension, and tracheal deviation should raise suspicion of

tension pneumothorax.

DIFFERENTIAL

Acute PE, MI, pleural effusion, pneumonia, pericardial tamponade

DIAGNOSIS

■ CXRis usually confirmative. An expiratory film may identify small apical

pneumothoraces. A deep sulcus sign (deep lateral costophrenic angle)

suggests pneumothorax on the supine radiograph.

■ CT can be used to assess the stable patient with underlying lung disease when

the diagnosis is in question (eg, differentiating bleb from pneumothorax).

TREATMENT

■ Small 1° pneumothoraces: This usually can be resolved with simple

observation and O 2 therapy. Supplemental O 2 accelerates the reabsorption

of gas from the pleural space to about 8–9% per day.

■ Larger, more symptomatic primary spontaneous pneumothoraces: May

be drained either with simple aspiration or with placement of a small-bore

chest tube

■ 2 °spontaneous pneumothorax:Treat with a larger-bore chest tube attached

to a water-seal device.

■ Persistent air leaks and recurrences are more common with 2°than with

1 °spontaneous pneumothorax.

■ For those with 2° spontaneous pneumothorax, recurrence is often pre-

vented with instillation of sclerosing agents (eg, talc) through the chest

tube, video-assisted thoracoscopic surgery, or limited thoracotomy.

■ Interventions to prevent recurrence in patients with 1°spontaneous pneu-

mothorax are usually recommended only after the second ipsilateral pneu-

mothorax. Pilots and divers with 1°spontaneous pneumothorax should be

cautioned against such activity in the future because of the risk of con-

tralateral pneumothorax.

PNEUMOMEDIASTINUM

Results from ↑intra-alveolar pressures →rupture of peribronchial vascular

sheaths and dissection along the hilum into the mediastinum. Usually occurs

spontaneously in young, healthy patients in their second to fourth decades

but has been associated with heavy physical exertion, eg, coughing, weight

lifting, vomiting, inhaling recreational vapors (“huffing”), Valsalva maneuvers,

iatrogenic procedures, mechanical ventilation, and trauma. Generally, this is

a benign, self-limiting condition unless associated with esophageal perforation

or mediastinitis.

SYMPTOMS

■ Chest pain worsened by inspiration, often radiating to back, neck, or shoulders

■ Dyspnea

■ Dysphagia and dysphonia

THORACIC AND RESPIRATORY

DISORDERS

Tension pneumothorax is a

medical emergency requiring

immediate decompression of

the pleural space with a 14-

gauge needle in the second

intercostal space at the

midclavicular line.