Description
Pneumothorax can occur in a variety of settings, including chronic obstructive pulmonary disease (COPD) with emphysema or after a biopsy for malignancy suspicion. In any event, it is a hazardous scenario that necessitates prompt attention and treatment. Pneumothorax is classified as either primary or secondary. Staging of pneumothorax is also critical. In our current editorial, we describe the causes and treatments of pneumothorax from a panel of pulmonary physicians, oncologists, and thoracic surgeons.
Résumé
- Pneumothorax, the presence of air in the pleural cavity, is a significant global health problem, more common in males. It is classified based on origin: spontaneous (primary with healthy lungs, secondary with lung disorder) and traumatic (iatrogenic or non-iatrogenic). Patients commonly present with chest pain and breathlessness, often acute. Horner's syndrome, a rare complication, indicates significant air and the need for urgent drainage.
- Clinical signs of pneumothorax include tachycardia, a larger, less mobile hemithorax on inspection, absent tactile vocal fremitus, possible tracheal shift, and hyper-resonant percussion. Decreased or absent breath sounds are also key. A pulse rate exceeding 140, hypotension, and electromechanical dissociation suggest a tension pneumothorax, requiring immediate intervention.
- Diagnosis involves clinical suspicion, physical examination (though it has limited sensitivity), and radiological investigations. Chest X-rays reveal hyper-lucency, a visceral pleural line, and absence of bronchovascular markings. Deep sulcus sign on supine radiographs aids diagnosis. Chest ultrasound shows absent lung sliding, confirmed by a barcode sign on M-mode, while CT thorax is the gold standard for diagnosis and quantification.
- Treatment options range from observation and high-flow oxygen to needle decompression, aspiration, chest tube drainage, and pleurodesis. High-risk characteristics like hemodynamic compromise (tension pneumothorax), significant hypoxia/dyspnea, underlying lung disease, bilateral pneumothorax, older age, smoking history, and hemo/hydro-pneumothorax necessitate chest tube drainage.
- Recurrent spontaneous pneumothorax is managed with chest tube drainage followed by pleurodesis or VATS (video-assisted thoracoscopic surgery) with blebectomy. Secondary spontaneous pneumothorax often warrants pleurodesis at the first instance due to compromised lung function. Complications include bronchopleural fistula, lung injury during chest tube insertion, hemothorax, and infection.
- Bronchopleural fistula, a communication between the airway and pleural space, requires larger bore chest tubes for rapid drainage. Management includes expectant waiting, autologous blood patch installation, bronchoscopic spigot placement, or surgical sealing. Early recognition and management of complications are vital for favorable patient outcomes.
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