174 Pneumothorax

Clinical Presentation

37-year-old man presents to the Emergency Department with pleuritic chest pain and shortness of breath

Radiologic Findings

PA (Fig. 174.1A) and lateral (Fig. 174.1B) chest X-rays show a right-sided primary spontaneous pneumothorax with near total collapse of the right lung and contralateral mediastinal displacement.

Diagnosis

Primary Spontaneous Pneumothorax

Differential Diagnosis

• Secondary Spontaneous Pneumothorax

• Traumatic Pneumothorax

Discussion

Background

Pneumothorax is the presence of air in the pleural space and is a common form of thoracic disease.

Fig. 174.1

Etiology

Pneumothorax may be classified into one of three major categories: traumatic, which can be either iatrogenic (following unsuccessful central venous line or pacemaker-ICD placement, CT-guided or transbronchial biopsy, etc.) or non-iatrogenic (e.g., following blunt or penetrating chest injuries (see Case 84); primary spontaneous, caused by rupture of an air-containing space within (bleb) or immediately deep to the pleura (bulla) (Fig. 174.2); or secondary spontaneous, related to underlying lung disease (e.g., emphysema, chronic interstitial fibrosis or cystic lung disease). Pneumothorax may also develop from pneumomediastinum as a result of air tracking from the mediastinal pleura. Primary spontaneous pneumothorax occurs most often in men (2–15M: 1F) in the third or fourth decade of life and shows a right-sided predilection and strong association with tobacco abuse. Numerous underlying conditions may be associated with secondary spontaneous pneumothorax (Table 174.1), the most common of which is COPD. In some cases, the secondary spontaneous pneumothorax is the first clinical manifestation of the underlying disease.

Clinical Findings

Chest pain and/or dyspnea are the classic clinical symptoms of spontaneous pneumothorax. Breath sounds are decreased or absent on auscultation despite normal or increased resonance on percussion.