Pneumothorax is the presence of air or gas in the pleural cavity leading to partial or complete lung collapse. It can occur spontaneously due to underlying lung disease or from trauma.

• Primary Spontaneous Pneumothorax (PSP): Occurs in healthy individuals without lung disease, often linked to ruptured subpleural blebs.

• Secondary Spontaneous Pneumothorax (SSP): Develops as a complication of underlying lung disease (e.g., COPD, tuberculosis, lung malignancy, pneumonia).

• Traumatic Pneumothorax: Caused by penetrating or non-penetrating trauma, including iatrogenic causes like medical procedures.

• Simple Pneumothorax: Involves a small air collection with limited lung collapse.

• Tension Pneumothorax: Involves increasing air buildup, compressing the other lung and mediastinal structures.

Air accumulation in the pleural cavity disrupts the lung-chest wall balance, causing lung collapse and resulting in respiratory difficulties.

Primary Pneumothorax: Caused by the rupture of small subpleural blebs or bullae in lung tissue.

Secondary Pneumothorax: Results from underlying lung diseases such as COPD, asthma, cystic fibrosis, tuberculosis, and lung cancer.

Traumatic Pneumothorax: Caused by penetrating chest trauma (e.g., stab wounds, gunshot injuries, fractured ribs).

Iatrogenic Pneumothorax: Occurs due to medical procedures (e.g., mechanical ventilation, central line placement, lung or liver biopsies).

Catamenial Pneumothorax: Linked to menstruation, possibly due to thoracic endometriosis, commonly affecting the right lung around menstruation onset.

Asthma-related Pneumothorax: Acute severe asthma can lead to pneumothorax.

Catamenial Pneumothorax is associated with thoracic endometriosis, commonly affecting the right lung around menstruation onset. Managed with ovarian suppression for 6-12 months to prevent recurrence.

– Smoking: Significantly increases risk, especially in men (22-fold) and women (9-fold).
– Gender: More common in males.
– Body Habitus: Tall and thin individuals, especially those with Marfan’s syndrome or similar habitus.
– Lung Diseases: Such as COPD, cystic fibrosis, tuberculosis, sarcoidosis, malignancy, and idiopathic pulmonary fibrosis.
– Family History: Positive family history of pneumothorax.
– Activities/Occupations: Involving changes in ambient pressure (e.g., scuba diving, aviation).
– Endometriosis in Women: Associated with pleuritic shoulder or upper abdominal pain during menstruation.
– Subpleural Blebs/Bullae: Commonly found at lung apices in cases of primary spontaneous pneumothorax (PSP).

– Cause: Air enters the pleural space.
– Causes of Entry: Rupture of a bleb or bulla, chest wall trauma, iatrogenic causes.
– Effects: Accumulation of air in the pleural cavity, positive pressure in the pleural space, collapse of the lung, impaired lung expansion during inspiration.
– Result: Respiratory distress and reduced oxygenation.
– Severity: Depends on the size of the air leak and degree of lung collapse.

– Pulmonary embolism (haemoptysis affects lower rather than upper lungs)
– Pneumonia
– Pleuritis
– Pleural effusion (slower onset, dullness to percussion)
– Other causes of acute dyspnea
– Other causes of acute chest pain (acute coronary syndrome or musculoskeletal chest pain)

Estimated to range from 8 to 28 cases per 100,000 individuals per year.

Affects all ages but is more common in young adults and those around 60 years. Higher incidence in individuals under 20 years, especially tall, thin males.

Men have higher incidence rates overall. Common in men under 20 years and around 60 years. Women have higher incidence rates around 30-34 years and 60 years.

24/100,000 per year in men, 9.9/100,000 per year in women. Most common in adolescents and young adults. Women/men ratio ranges from 1:3.3 to 1:5.

Incidence is influenced by age, gender, and underlying lung diseases like COPD.

– Respiratory Symptoms: Sudden-onset sharp or stabbing chest pain, dyspnea (shortness of breath), rapid breathing.

– Physical Examination: Decreased breath sounds, decreased chest expansion, and chest hyper-expansion on the affected side.

– Severe Cases: Cyanosis, tachycardia, hyperresonant percussion, absent tactile or vocal fremitus.

– Tension Pneumothorax: Hemodynamic instability, tracheal deviation, severe respiratory distress.

– Primary Pneumothorax: Typically in young males, presents with acute onset dyspnea and pleuritic chest pain.

– Secondary Pneumothorax: Occurs in older patients with underlying lung diseases like COPD.

Symptoms: May be minimal or absent with sudden onset pain and shortness of breath; more severe in Secondary Spontaneous Pneumothorax (SSP). Examination Findings: Distressed appearance, sweating, dyspnea, possible cyanosis, tachycardia (pulse rate >135 suggests tension pneumothorax), pulsus paradoxus, hypotension, raised jugular venous pressure (JVP) in tension pneumothorax, tracheal deviation, hyper-resonance on percussion, reduced or absent breath sounds over the affected area.

• Chest X-ray: Preferred initial test; diagnostic when the visceral pleural line is visible and symmetrical lung markings are absent.

• Computed Tomography (CT) scan: Useful for complex cases or accurate size measurement.

• Arterial blood gas (ABG) analysis: Assesses oxygenation status, may show hypoxia in severe cases.

• Ultrasound: Helpful for detecting small pneumothoraces and guiding procedures, especially in trauma patients.

• Bedside ultrasound: Especially useful for supine trauma patients.

• Lung ultrasound: More sensitive than supine X-rays for traumatic pneumothorax.

• Size measurement: Distance between pleural surface and lung edge (≥2 cm indicates at least 50% hemithorax pneumothorax).

• Clinical compromise: More critical for intervention than size alone.

Inspiration view is preferred for better visualization of a pneumothorax.

• Small PSP (<2cm): Observation and oxygen therapy.

• Large PSP: Needle aspiration or chest drain.

• Consider pleurodesis for recurrence.

• Chest drain is required in most cases.

• Early referral to a chest physician.

• Discuss persistent air leaks with a surgeon.

• Urgent decompression is necessary.

• Symptoms include severe dyspnea and cyanosis.

• Insert a cannula in the 4th or 5th intercostal space.

• Observation with chest X-rays for small to moderate pneumothoraces without symptoms.

• Consider the patient’s age, symptoms, and stability.

• For small PSP and small SSP in patients under 50 years old.

• Needle aspiration (14-16 G) or thoracentesis is performed.

• No repeat aspiration if the first attempt is unsuccessful.

• Indicated for SSP, large lesions, tension pneumothorax, or bilateral pneumothorax.

• Complications may include pain and infection; antibiotics are recommended for trauma patients.

• Used to prevent recurrence by closing the pleural space.

• Can be performed surgically or medically but may cause complications.

• Early referral to thoracic surgeons for challenging cases or persistent air leaks.

• Various surgical approaches are available based on the specific case.

• Pregnancy: Conservative management; surgery may be delayed until post-delivery.

• Catamenial Pneumothorax: Surgery and hormonal treatment.

• HIV Infection: Early drainage and surgical referral.

• Cystic Fibrosis: Early treatment with surgical referral.

• Quit smoking to reduce recurrence.

• Flying: No air travel for one week post-check X-ray.

• Diving: Follow BTS guidelines; avoid diving until bilateral surgical pleurectomy and a normal chest CT scan/lung function tests post-op.

• Small PSP typically has a favourable prognosis, often resolving without long-term issues.

• Risk factors for recurrence include smoking, height, and age over 60.

• Recurrence rates range from 25% to 54%, with a 15.8% recurrence rate at one year.

• Smoking cessation significantly reduces recurrence risk.

• SSP has higher morbidity and mortality compared to PSP.

• Recurrence rates at one year are 31.2%.

• Risk factors for recurrence include age, pulmonary fibrosis, and emphysema.

• Smoking cessation is crucial to reduce both initial and recurrent pneumothorax.

• Avoid diving unless definitive treatment has been performed.

• Air travel can resume after radiologically confirmed resolution.

• Death rates are rare.

• Recurrence of pneumothorax.

• Tension pneumothorax (life-threatening with increasing lung collapse and hemodynamic instability).

• Infection (such as pneumonia or empyema).

• Haemothorax (accumulation of blood in the pleural cavity).

• Respiratory failure.

• Damage to surrounding organs (rare cases).