Pneumothorax
Disease Details
Family Health Simplified
- Description
- Pneumothorax is a condition where air accumulates in the pleural space between the lung and chest wall, causing the lung to collapse.
- Type
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Pneumothorax is typically classified into several types: spontaneous (primary and secondary) and traumatic (which includes iatrogenic).
**Primary spontaneous pneumothorax** usually occurs in people without any known lung disease and is often linked to the rupture of small air sacs in the lungs called blebs.
**Secondary spontaneous pneumothorax** occurs in people with pre-existing lung conditions like Chronic Obstructive Pulmonary Disease (COPD), cystic fibrosis, or infections.
Traumatic pneumothorax results from physical injury to the chest, and iatrogenic pneumothorax can occur as a complication of medical procedures.
The genetic transmission of primary spontaneous pneumothorax can sometimes be hereditary, often following an autosomal dominant pattern. This means a single copy of an altered gene in each cell is sufficient to increase the risk of developing the condition. In contrast, secondary and traumatic pneumothoraces are usually not inherited. - Signs And Symptoms
- A primary spontaneous pneumothorax (PSP) tends to occur in a young adult without underlying lung problems, and usually causes limited symptoms. Chest pain and sometimes mild breathlessness are the usual predominant presenting features. In newborns tachypnea, cyanosis and grunting are the most common presenting symptoms. People who are affected by a PSP are often unaware of the potential danger and may wait several days before seeking medical attention. PSPs more commonly occur during changes in atmospheric pressure, explaining to some extent why episodes of pneumothorax may happen in clusters. It is rare for a PSP to cause a tension pneumothorax.Secondary spontaneous pneumothoraces (SSPs), by definition, occur in individuals with significant underlying lung disease. Symptoms in SSPs tend to be more severe than in PSPs, as the unaffected lungs are generally unable to replace the loss of function in the affected lungs. Hypoxemia (decreased blood-oxygen levels) is usually present and may be observed as cyanosis (blue discoloration of the lips and skin). Hypercapnia (accumulation of carbon dioxide in the blood) is sometimes encountered; this may cause confusion and – if very severe – may result in comas. The sudden onset of breathlessness in someone with chronic obstructive pulmonary disease (COPD), cystic fibrosis, or other serious lung diseases should therefore prompt investigations to identify the possibility of a pneumothorax.Traumatic pneumothorax most commonly occurs when the chest wall is pierced, such as when a stab wound or gunshot wound allows air to enter the pleural space, or because some other mechanical injury to the lung compromises the integrity of the involved structures. Traumatic pneumothoraces have been found to occur in up to half of all cases of chest trauma, with only rib fractures being more common in this group. The pneumothorax can be occult (not readily apparent) in half of these cases, but may enlarge – particularly if mechanical ventilation is required. They are also encountered in people already receiving mechanical ventilation for some other reason.Upon physical examination, breath sounds (heard with a stethoscope) may be diminished on the affected side, partly because air in the pleural space dampens the transmission of sound. Measures of the conduction of vocal vibrations to the surface of the chest may be altered. Percussion of the chest may be perceived as hyperresonant (like a booming drum), and vocal resonance and tactile fremitus can both be noticeably decreased. Importantly, the volume of the pneumothorax may not be well correlated with the intensity of the symptoms experienced by the victim, and physical signs may not be apparent if the pneumothorax is relatively small.
- Prognosis
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The prognosis for a pneumothorax primarily depends on the type and severity of the condition, as well as the patient's overall health.
- **Spontaneous Pneumothorax**: Often occurs in healthy individuals and may resolve on its own. Treatment can involve simple observation or the insertion of a chest tube. Prognosis is generally favorable, although recurrence is possible.
- **Tension Pneumothorax**: A medical emergency that requires immediate intervention. With prompt treatment, the prognosis improves substantially, although it may still carry risks depending on the time to treatment and any underlying health issues.
- **Secondary Pneumothorax**: Associated with underlying lung diseases such as COPD, asthma, or cystic fibrosis. The prognosis can be more guarded due to the complicating factors of the underlying disease.
Early and appropriate medical intervention typically improves outcomes across all types of pneumothorax. - Onset
- In the context of pneumothorax, "onset" refers to the initiation or development of the condition. Pneumothorax can have a sudden or gradual onset, depending on the cause. It may occur without warning in a person without any prior lung disease (spontaneous pneumothorax) or as a result of chest trauma, underlying lung disease, or medical procedures (secondary pneumothorax). Symptoms often include sudden chest pain and shortness of breath.
- Prevalence
- The prevalence of pneumothorax varies based on its type (primary spontaneous, secondary spontaneous, or traumatic). For primary spontaneous pneumothorax, the estimated annual incidence is about 7.4 to 18 per 100,000 men and 1.2 to 6 per 100,000 women. For secondary spontaneous pneumothorax, the incidence is generally lower but varies depending on the underlying lung disease, such as chronic obstructive pulmonary disease (COPD). Traumatic pneumothorax occurs following trauma or medical procedures and its prevalence is directly related to the frequency of such events in the population.
- Epidemiology
- The annual age-adjusted incidence rate (AAIR) of PSP is thought to be three to six times as high in males as in females. Fishman cites AAIR's of 7.4 and 1.2 cases per 100,000 person-years in males and females, respectively. Significantly above-average height is also associated with increased risk of PSP – in people who are at least 76 inches (1.93 meters) tall, the AAIR is about 200 cases per 100,000 person-years. Slim build also seems to increase the risk of PSP.The risk of contracting a first spontaneous pneumothorax is elevated among male and female smokers by factors of approximately 22 and 9, respectively, compared to matched non-smokers of the same sex. Individuals who smoke at higher intensity are at higher risk, with a "greater-than-linear" effect; men who smoke 10 cigarettes per day have an approximate 20-fold increased risk over comparable non-smokers, while smokers consuming 20 cigarettes per day show an estimated 100-fold increase in risk.In secondary spontaneous pneumothorax, the estimated annual AAIR is 6.3 and 2.0 cases per 100,000 person-years for males and females, respectively, with the risk of recurrence depending on the presence and severity of any underlying lung disease. Once a second episode has occurred, there is a high likelihood of subsequent further episodes. The incidence in children has not been well studied, but is estimated to be between 5 and 10 cases per 100,000 person-years.Death from pneumothorax is very uncommon (except in tension pneumothoraces). British statistics show an annual mortality rate of 1.26 and 0.62 deaths per million person-years in men and women, respectively. A significantly increased risk of death is seen in older patients and in those with secondary pneumothoraces.
- Intractability
- Pneumothorax is not generally considered intractable. It can often be managed and resolved with appropriate medical treatment. Common interventions include observation for small pneumothoraces, needle aspiration, chest tube insertion, or surgery in recurrent or severe cases. The prognosis is typically good with proper treatment.
- Disease Severity
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Pneumothorax, which is the presence of air or gas in the pleural space causing the lung to collapse, can range in severity:
- **Mild**: Small pneumothorax might resolve on its own without significant symptoms.
- **Moderate**: May cause symptoms like chest pain and shortness of breath and often requires medical intervention.
- **Severe**: Large pneumothorax can be life-threatening, leading to severe respiratory distress and requiring urgent medical treatment, such as chest tube insertion.
Severity depends on the size of the pneumothorax and the patient's underlying lung health. - Healthcare Professionals
- Disease Ontology ID - DOID:1673
- Pathophysiology
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Pneumothorax is the presence of air in the pleural space, which causes the lung to collapse. This condition disrupts the usual negative pressure within the pleural cavity that is crucial for lung expansion during inspiration.
Pathophysiology:
- **Air Entry**: Air can enter the pleural space through a breach in the lung surface (from trauma or disease) or the chest wall (from injury or medical procedures).
- **Pressure Changes**: The introduction of air disrupts the pressure balance, leading to positive pressure in the pleural space.
- **Lung Collapse**: With the loss of negative intrapleural pressure, the lung recoils and collapses, impairing ventilation.
- **Types**:
- **Primary Spontaneous Pneumothorax**: Occurs without any traumatic injury or underlying lung disease, often in young, tall, thin individuals.
- **Secondary Spontaneous Pneumothorax**: Occurs due to underlying lung conditions such as COPD, tuberculosis, or cystic fibrosis.
- **Traumatic Pneumothorax**: Results from direct injury to the chest, such as fractures, stab wounds, or medical interventions.
- **Tension Pneumothorax**: A life-threatening variant where air enters the pleural space during inspiration and is trapped during expiration, leading to increased pressure, reduced venous return, and cardiac output, necessitating immediate intervention. - Carrier Status
- Pneumothorax, commonly referred to as a collapsed lung, does not have a carrier status because it is not a genetic condition. It is typically caused by an injury to the chest, certain medical procedures, or underlying lung diseases. In some cases, a pneumothorax can occur spontaneously without an obvious cause.
- Mechanism
- The thoracic cavity is the space inside the chest that contains the lungs, heart, and numerous major blood vessels. On each side of the cavity, a pleural membrane covers the surface of lung (visceral pleura) and also lines the inside of the chest wall (parietal pleura). Normally, the two layers are separated by a small amount of lubricating serous fluid. The lungs are fully inflated within the cavity because the pressure inside the airways (intrapulmonary pressure) is higher than the pressure inside the pleural space (intrapleural pressure). Despite the low pressure in the pleural space, air does not enter it because there are no natural connections to air-containing passages, and the pressure of gases in the bloodstream is too low for them to be forced into the pleural space. Therefore, a pneumothorax can only develop if air is allowed to enter, through damage to the chest wall or to the lung itself, or occasionally because microorganisms in the pleural space produce gas. Once air enters the pleural cavity, the intrapleural pressure increases, resulting in the difference between the intrapulmonary pressure and the intrapleural pressure (defined as the transpulmonary pressure) to equal zero, which cause the lungs to deflate in contrast to a normal transpulmonary pressure of ~4 mm Hg.Chest-wall defects are usually evident in cases of injury to the chest wall, such as stab or bullet wounds ("open pneumothorax"). In secondary spontaneous pneumothoraces, vulnerabilities in the lung tissue are caused by a variety of disease processes, particularly by rupturing of bullae (large air-containing lesions) in cases of severe emphysema. Areas of necrosis (tissue death) may precipitate episodes of pneumothorax, although the exact mechanism is unclear. Primary spontaneous pneumothorax (PSP) has for many years been thought to be caused by "blebs" (small air-filled lesions just under the pleural surface), which were presumed to be more common in those classically at risk of pneumothorax (tall males) due to mechanical factors. In PSP, blebs can be found in 77% of cases, compared to 6% in the general population without a history of PSP. As these healthy subjects do not all develop a pneumothorax later, the hypothesis may not be sufficient to explain all episodes; furthermore, pneumothorax may recur even after surgical treatment of blebs. It has therefore been suggested that PSP may also be caused by areas of disruption (porosity) in the pleural layer, which are prone to rupture. Smoking may additionally lead to inflammation and obstruction of small airways, which account for the markedly increased risk of PSPs in smokers. Once air has stopped entering the pleural cavity, it is gradually reabsorbed.Tension pneumothorax occurs when the opening that allows air to enter the pleural space functions as a one-way valve, allowing more air to enter with every breath but none to escape. The body compensates by increasing the respiratory rate and tidal volume (size of each breath), worsening the problem. Unless corrected, hypoxia (decreased oxygen levels) and respiratory arrest eventually follow.
- Treatment
- The treatment of pneumothorax depends on a number of factors and may vary from discharge with early follow-up to immediate needle decompression or insertion of a chest tube. Treatment is determined by the severity of symptoms and indicators of acute illness, the presence of underlying lung disease, the estimated size of the pneumothorax on X-ray, and – in some instances – on the personal preference of the person involved.In traumatic pneumothorax, chest tubes are usually inserted. If mechanical ventilation is required, the risk of tension pneumothorax is greatly increased and the insertion of a chest tube is mandatory. Any open chest wound should be covered with an airtight seal, as it carries a high risk of leading to tension pneumothorax. Ideally, a dressing called the "Asherman seal" should be utilized, as it appears to be more effective than a standard "three-sided" dressing. The Asherman seal is a specially designed device that adheres to the chest wall and, through a valve-like mechanism, allows air to escape but not to enter the chest.Tension pneumothorax is usually treated with urgent needle decompression. This may be required before transport to the hospital, and can be performed by an emergency medical technician or other trained professional. The needle or cannula is left in place until a chest tube can be inserted. Critical care teams are able to incise the chest to create a larger conduit as performed when placing a chest drain, but without inserting the chest tube. This is called a simple thoracostomy. If tension pneumothorax leads to cardiac arrest, needle decompression or simple thoracostomy is performed as part of resuscitation as it may restore cardiac output.
- Compassionate Use Treatment
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Compassionate use and experimental treatments for pneumothorax are typically considered when standard treatments are ineffective or unsuitable. These may include:
1. **Endobronchial Valve Placement**: Off-label use of endobronchial valves (originally designed to treat emphysema) has been explored to manage persistent air leaks in patients with pneumothorax. These valves help reduce airflow to damaged lung areas, promoting healing.
2. **Fibrin Glue or Blood Patch**: Experimental approaches such as using fibrin glue or autologous blood patches have been used to seal persistent air leaks in spontaneous or secondary pneumothorax.
3. **Minimally Invasive Surgery Techniques**: Developing minimally invasive thoracoscopic techniques (like apical pleurectomy or bleb resection) for patients experiencing recurrent pneumothorax or those unsuitable for traditional surgical interventions.
These treatments are usually considered on a case-by-case basis, depending on the patient's condition and response to conventional therapies. - Lifestyle Recommendations
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For pneumothorax, lifestyle recommendations generally include:
1. **Avoid Smoking**: Smoking significantly increases the risk of developing a pneumothorax.
2. **Elevate Activity Gradually**: Post-recovery, gradually reintroduce physical activities and avoid strenuous exercises until fully healed, as advised by a healthcare professional.
3. **Monitor Symptoms**: Be vigilant for any signs of recurrence, such as sudden chest pain or shortness of breath, and seek immediate medical attention if they occur.
4. **Limit Air Travel and High Altitudes**: Avoid air travel and high-altitude environments until your doctor confirms it is safe, as changes in air pressure can affect lung function.
5. **Stay Hydrated and Eat Healthily**: Maintain a balanced diet and proper hydration to support overall health and recovery.
Always follow the specific guidance provided by your healthcare provider tailored to your condition. - Medication
- In the case of pneumothorax (collapsed lung), medication is generally not the primary treatment. Instead, treatment focuses on removing the air from the pleural space to allow the lung to re-expand. This can involve procedures such as needle aspiration or chest tube insertion. Pain management may involve the use of analgesics, but there is no specific medication to treat the pneumothorax itself.
- Repurposable Drugs
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Certain drugs, primarily designed for other medical conditions, have been explored for repurposing to manage pneumothorax. These include:
1. **Tetracyclines (e.g., Doxycycline):** Typically used as antibiotics, tetracyclines can induce pleurodesis, a procedure to adhere the lung to the chest wall and prevent recurrent pneumothorax.
2. **Talc:** Although not a drug in the traditional sense, medical-grade talc can be used for chemical pleurodesis to manage recurrent pneumothoraces.
Emerging research continues to explore other repurposable drugs for their potential efficacy in this context. - Metabolites
- For pneumothorax, which is the presence of air or gas in the pleural cavity causing the lung to collapse, the focus is generally on the mechanical and structural aspects rather than specific metabolites. Therefore, the term "nan" (not applicable/none) appropriately describes the role of metabolites in this context.
- Nutraceuticals
- Nutraceuticals typically do not play a direct role in the treatment or management of pneumothorax. Pneumothorax, which is the presence of air in the pleural space causing lung collapse, often requires medical interventions such as chest tube insertion, needle aspiration, or surgery, depending on its severity. Nutraceuticals—foods or supplements with health benefits—might support overall lung health but would not substitute for the necessary medical procedures to resolve pneumothorax.
- Peptides
- Pneumothorax, commonly known as a collapsed lung, occurs when air leaks into the space between the lung and the chest wall. There are currently no widely established peptides specifically used for the treatment of pneumothorax. Treatment usually focuses on removing the air from the pleural space to allow the lung to re-expand, which can be done through procedures like needle aspiration, chest tube insertion, or surgery in severe cases. Pain management and monitoring for infection or recurrence are also important aspects of care.