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Spontaneous Pneumothorax

  • Primary spontaneous pneumothorax is a pneumothorax occurring when there is no known underlying pathology, and no precipitant such as trauma or surgery

  • Secondary spontaneous pneumothorax is a pneumothorax occurring as a complication of underlying lung disease

Symptoms

Symptoms may be minimal or absent so a high index of initial diagnostic suspicion is required. Clinical manifestations are unreliable indicators of the size of the pneumothorax. Symptoms are more severe in spontaneous secondary pneumothoraces versus those associated with primary spontaneous pneumothoraces.

  • Chest pain- stabbing, radiating to ipsilateral shoulder and increasing with inspiration (pleuritic)

  • Sudden onset SOB

  • Anxiety, cough and vague chest symptoms

Signs

Can be subtle and include:

  • General appearance can range from normal to diaphoretic and unwell

  • Respiratory distress

  • The affected side may have
    • Decreased lung expansion
    • Decreased or absent breath sounds
    • Hyper-resonance on percussion

Severe symptoms accompanied by signs of cardiorespiratory distress (cyanosis, sweating, severe tachypnoea, tachycardia and hypotension) may indicate presence of tension pneumothorax. These require immediate management with needle decompression followed by a chest drain.

Diagnosis

Diagnosis is confirmed by imaging techniques:

  • Bedside Ultrasound
    • More sensitive than CXR and rapidly available at the bedside
    • Will demonstrate the absence of lung sliding
    • Loss of “waves on the beach” sign on M mode

  • Standard erect inspiratory PA CXR

  • CT scanning is recommended for uncertain or complex cases

Discharge

  • Patients should receive verbal and written advice to return immediately to ED if they develop further breathlessness

  • All patients should have follow up ideally by a respiratory physician to ensure resolution of pneumothorax and institute optimal care

  • Those managed by Observation or needle aspiration should return for a follow up CXR after 2-4 weeks to monitor resolution

  • Normal physical activities can be resumed once all symptoms have resolved but avoid extreme exertion until full resolution

  • Patients should be advised to stop smoking as it is an associated factor in recurrence

  • Air travel should be avoided until at least 1 week after the CXR shows full resolution

  • SCUBA diving should be discouraged permanently

Further resources

  • MacDuff A, Arnold A, Harvey J on behalf of the BTS Pleural Disease Guideline Group. Management of spontaneous pneumothorax: British Thoracic Society pleural disease guideline 2010. Thorax. 2010;65:ii18:1131. Available from: https://thorax.bmj.com/content/65/Suppl_2/ii18.