Internal Medicine

0521779407-17 CUNY1086/Karliner 0 521 77940 7 June 13, 2007 7:57

Pneumothorax 1187

Signs & Symptoms

■Ipsilateral pleuritic chest pain, acute dyspnea, tachycardia, cough

■Primary spontaneous ptx usually occurs at rest; strenuous activity

associated with∼20% of cases

■Small ptx (<15% hemithorax) may yield normal exam

■Larger ptx (>15% hemithorax): tachypnea, splinting, decreased chest

wall movement, hyperresonance, decreased fremitus, decreased or

absent breath sounds on affected side

tests

Imaging

■upright PA CXR: thin visceral pleural line

■expiratory film can uncover small apical ptx

■Chest CT: to distinguish large bullae from ptx; shows subpleural blebs

and underlying lung disease

■ECG: decreased QRS in limb leads, decreased precordial R wave;

inverted T waves with L sided ptx

■ABG: increased A-a gradient, acute respiratory alkalosis; hypoxemia

and hypercapnia in patients with underlying lung disease.

differential diagnosis

■PA CXR often confirms diagnosis. Giant bullae may mimic ptx on

CXR; obtain chest CT for confirmation

management

What to Do First

■R/o tension ptx

■treat hypoxemia and continue Rx of any underlying lung disease

General Measures

■history and physical to r/o underlying lung disease

■Encourage smoking cessation

specific therapy

■Observation – for young healthy patients with small primary sponta-

neous ptx, no SOB, and no hemodynamic instability; hospitalization

not required.

■Oxygen – accelerates rate of reabsorption 4-fold; administer to all

hospitalized patients.

■Needle aspiration – recommended for first large (>15% hemithorax)

primary spontaneous ptx; success rate∼70%; not for recurrent pri-

mary or secondary ptx (success rate only∼30%)