Pneumothorax (Collapsed Lung)Pneumothorax (Collapsed Lung)

AnatomyAnatomyThe human respiratory system is divided into the upper and The human respiratory system is divided into the upper and

lower respiratory tracts.lower respiratory tracts.

Upper respiratory tractUpper respiratory tractThe major passages and structures of the upper The major passages and structures of the upper respiratory tract include the nose or nostrils, nasal respiratory tract include the nose or nostrils, nasal cavity, mouth, throat (pharynx), and voice box (larynx).cavity, mouth, throat (pharynx), and voice box (larynx).

cont.cont.When you breathe in through your nose or mouth, the air is "filtered" through When you breathe in through your nose or mouth, the air is "filtered" through natural lines of defense that protect against illness and irritation of the natural lines of defense that protect against illness and irritation of the respiratory tract. Nasal hairs (vibrissae) at the opening of the nostrils trap respiratory tract. Nasal hairs (vibrissae) at the opening of the nostrils trap large particles of dust that might otherwise be inhaled. The entire respiratory large particles of dust that might otherwise be inhaled. The entire respiratory system, as with the reproductive, digestive, and urinary systems, is lined with a system, as with the reproductive, digestive, and urinary systems, is lined with a mucous membrane that secretes mucus. The mucus traps smaller particles like mucous membrane that secretes mucus. The mucus traps smaller particles like pollen or smoke. Hairlike structures called cilia line the mucous membrane and pollen or smoke. Hairlike structures called cilia line the mucous membrane and move the particles trapped in the mucus out of the nose.move the particles trapped in the mucus out of the nose.

Inhaled air is moistened, warmed, and cleansed by the nasal epithelium (the Inhaled air is moistened, warmed, and cleansed by the nasal epithelium (the tissue that lines the nasal cavity), which covers the turbinate bones (conchae) tissue that lines the nasal cavity), which covers the turbinate bones (conchae) in the nasal cavity. The nasal epithelium has increased blood flow that helps to in the nasal cavity. The nasal epithelium has increased blood flow that helps to warm the inhaled air, but also facilitates nosebleeds in some people.warm the inhaled air, but also facilitates nosebleeds in some people.

The pharynx is a muscular, funnel-shaped tube about 5 inches long that The pharynx is a muscular, funnel-shaped tube about 5 inches long that connects the nasal and oral cavities to the larynx. The pharynx houses the connects the nasal and oral cavities to the larynx. The pharynx houses the tonsils and the adenoids, which are lymphatic tissues that guard against tonsils and the adenoids, which are lymphatic tissues that guard against infection by releasing white blood cells (T and B lymphocytes).infection by releasing white blood cells (T and B lymphocytes).The larynx forms the entrance to the lower respiratory system. With the help of The larynx forms the entrance to the lower respiratory system. With the help of the epiglottis (a leaf-shaped flap), the larynx prevents food or liquid from the epiglottis (a leaf-shaped flap), the larynx prevents food or liquid from entering the lower respiratory tract while swallowing. Two pairs of strong entering the lower respiratory tract while swallowing. Two pairs of strong connective tissue bands that are stretched across the larynx vibrate to produce connective tissue bands that are stretched across the larynx vibrate to produce sounds while talking or singing.sounds while talking or singing.

Lower respiratory tractLower respiratory tract

The major passages and structures of the lower respiratory The major passages and structures of the lower respiratory tract include the windpipe (trachea) and within the lungs, the tract include the windpipe (trachea) and within the lungs, the bronchi, bronchioles, and alveoli.bronchi, bronchioles, and alveoli.

After the inhaled air moves through the larynx, it reaches the After the inhaled air moves through the larynx, it reaches the trachea. The trachea is a rigid, muscular tube about 4.5 trachea. The trachea is a rigid, muscular tube about 4.5 inches long and 1 inch wide. Embedded in the walls of the inches long and 1 inch wide. Embedded in the walls of the trachea, C-shaped cartilage rings give the trachea rigidity trachea, C-shaped cartilage rings give the trachea rigidity and allow it to stay open all the time.and allow it to stay open all the time.

Cont.Cont.

Inward airflow from the trachea then branches off to the Inward airflow from the trachea then branches off to the two bronchi. One bronchus leads to the right lung, the two bronchi. One bronchus leads to the right lung, the other to the left lung. The bronchi also contain C-shaped other to the left lung. The bronchi also contain C-shaped cartilage rings like the trachea.cartilage rings like the trachea.Deeper in the lungs, each bronchus divides into Deeper in the lungs, each bronchus divides into secondary and tertiary bronchi, which continue to branch secondary and tertiary bronchi, which continue to branch to smaller airways called the bronchioles. There is no to smaller airways called the bronchioles. There is no cartilage in the bronchioles, and therefore they are cartilage in the bronchioles, and therefore they are subject to constriction and obstruction,as during an subject to constriction and obstruction,as during an asthma attack. The bronchioles end in air sacs called the asthma attack. The bronchioles end in air sacs called the alveoli. Alveoli are bunched together into clusters to form alveoli. Alveoli are bunched together into clusters to form alveolar sacs. On the surface of each alveolus, there is a alveolar sacs. On the surface of each alveolus, there is a network of capillaries carrying blood that has come network of capillaries carrying blood that has come through veins from other parts of the body. Here gas through veins from other parts of the body. Here gas exchange occurs -- carbon dioxide from the blood is exchange occurs -- carbon dioxide from the blood is exchanged for oxygen from the alveoli. After the blood is exchanged for oxygen from the alveoli. After the blood is oxygenated, it goes to the heart (between the two lungs), oxygenated, it goes to the heart (between the two lungs), where it is pumped out to all of the body tissues and where it is pumped out to all of the body tissues and extremities. When you breathe out, the carbon dioxide is extremities. When you breathe out, the carbon dioxide is exhaled and expelled from the body.exhaled and expelled from the body.

DefinitionDefinition A collapsed lung (pneumothorax) results from a buildup of air A collapsed lung (pneumothorax) results from a buildup of air

in the space between the lung and the chest wall (pleural in the space between the lung and the chest wall (pleural space). As the amount of air in this space increases, the space). As the amount of air in this space increases, the pressure against the lung causes the lung to collapse. This pressure against the lung causes the lung to collapse. This prevents your lung from expanding properly when you try to prevents your lung from expanding properly when you try to breathe in, causing shortness of breath and chest pain.breathe in, causing shortness of breath and chest pain.

A pneumothorax may become life-threatening if the pressure in A pneumothorax may become life-threatening if the pressure in your chest prevents the lungs from getting enough oxygen into your chest prevents the lungs from getting enough oxygen into the blood.the blood.

Collapsed and normal lungCollapsed and normal lung

A pneumothorax occurs when air gets between your lungs and A pneumothorax occurs when air gets between your lungs and chest wall, causing part, or more rarely, the entire lung to chest wall, causing part, or more rarely, the entire lung to collapse. In the example shown, the left lung is more than 75 collapse. In the example shown, the left lung is more than 75 percent collapsed percent collapsed

Nursing DiagnosisNursing Diagnosis

Ineffective airway clearance- Inability to clear secretions or Ineffective airway clearance- Inability to clear secretions or obstructions from the respiratory tract to maintain a clear obstructions from the respiratory tract to maintain a clear airway.airway.

Impaired gas exchange- Excess or deficit in oxygenation and/ Impaired gas exchange- Excess or deficit in oxygenation and/ or carbon dioxide elimination at the alveolar-capillary or carbon dioxide elimination at the alveolar-capillary membrane. membrane.

Risk for aspiration- At risk for entry of gastrointestinal Risk for aspiration- At risk for entry of gastrointestinal secretions, oropharyngeal secretions, solids or fluids into secretions, oropharyngeal secretions, solids or fluids into tracheobronchial passages.tracheobronchial passages.

Ineffective breathing pattern- Inspiration and/ or expiration Ineffective breathing pattern- Inspiration and/ or expiration that does not provide adequate ventilationthat does not provide adequate ventilation

Clinical manifestationClinical manifestation

If only a small amount of air enters the pleural space, you If only a small amount of air enters the pleural space, you may have few signs or symptoms, though even a minimally may have few signs or symptoms, though even a minimally collapsed lung is likely to cause some chest pain. When collapsed lung is likely to cause some chest pain. When your lung has collapsed 25 percent or more, you're likely to your lung has collapsed 25 percent or more, you're likely to experience:experience:

Sudden, sharp chest pain on the same side as the affected Sudden, sharp chest pain on the same side as the affected lunglung

Shortness of breath, which may be more or less severe, Shortness of breath, which may be more or less severe, depending on how much of the lung is collapseddepending on how much of the lung is collapsed

A feeling of tightness in your chestA feeling of tightness in your chest A rapid heart rateA rapid heart rate

Because a tension pneumothorax can compress the walls of Because a tension pneumothorax can compress the walls of your heart as well as the unaffected lung, heart function your heart as well as the unaffected lung, heart function may be impaired, leading to a potentially fatal drop in may be impaired, leading to a potentially fatal drop in

blood pressureblood pressure

EtiologyEtiologyIt It can result from:can result from: A penetrating chest woundA penetrating chest wound Barotrauma to the lungsBarotrauma to the lungs Spontaneously (most commonly in tall slim young males and in Spontaneously (most commonly in tall slim young males and in

Marfan syndrome)Marfan syndrome) Chronic lung pathologies including emphysema, asthmaChronic lung pathologies including emphysema, asthma Acute infectionsAcute infections AcupunctureAcupuncture Chronic infections, such as tuberculosisChronic infections, such as tuberculosis CancerCancer Catamenial pneumothorax (due to endometriosis in the chest Catamenial pneumothorax (due to endometriosis in the chest

cavity)cavity)

Pneumothoraces are divided into tension and non-tension Pneumothoraces are divided into tension and non-tension pneumathoraces. A tension pneumothorax is a medical pneumathoraces. A tension pneumothorax is a medical emergency as air accumulates in the pleural space with each emergency as air accumulates in the pleural space with each breath. The remorseless increase in intrathoracic pressure results breath. The remorseless increase in intrathoracic pressure results in massive shifts of the mediastinum away from the affected lung in massive shifts of the mediastinum away from the affected lung compressing intrathoracic vessels. A non-tension pneumothorax compressing intrathoracic vessels. A non-tension pneumothorax by contrast is a less severe pathology because there is no ongoing by contrast is a less severe pathology because there is no ongoing accumulation of air and hence no increasing pressure on the accumulation of air and hence no increasing pressure on the organs within the chest.organs within the chest.The accumulation of blood in the thoracic cavity (hemothorax) The accumulation of blood in the thoracic cavity (hemothorax) exacerbates the problem, creating a pneumohemothorax.exacerbates the problem, creating a pneumohemothorax.

PathophysiologyPathophysiology The lungs are located inside the chest cavity, which is a The lungs are located inside the chest cavity, which is a

hollow space. Air is drawn into the lungs by the hollow space. Air is drawn into the lungs by the diaphragm (a powerful abdominal muscle). The pleural diaphragm (a powerful abdominal muscle). The pleural cavity is the region between the chest wall and the cavity is the region between the chest wall and the lungs. If air enters the pleural cavity, either from the lungs. If air enters the pleural cavity, either from the outside (open pneumothorax) or from the lung (closed outside (open pneumothorax) or from the lung (closed pneumothorax), the lung collapses and it becomes pneumothorax), the lung collapses and it becomes mechanically impossible for the injured person to mechanically impossible for the injured person to breathe, even with an open airway. If a piece of tissue breathe, even with an open airway. If a piece of tissue forms a one-way valve that allows air to enter the forms a one-way valve that allows air to enter the pleural cavity from the lung but not to escape, pleural cavity from the lung but not to escape, overpressure can build up with every breath; this is overpressure can build up with every breath; this is known as tension pneumothorax. It may lead to severe known as tension pneumothorax. It may lead to severe shortness of breath as well as circulatory collapse, both shortness of breath as well as circulatory collapse, both life-threatening conditions. This condition requires life-threatening conditions. This condition requires urgent intervention.urgent intervention.

CausesCauses

Your two lungs are separated by your heart, airways and Your two lungs are separated by your heart, airways and the major blood vessels in the center of your chest the major blood vessels in the center of your chest (mediastinum).All these structures are enclosed by your (mediastinum).All these structures are enclosed by your chest wall, a combination of ribs, cartilage and muscle.chest wall, a combination of ribs, cartilage and muscle.

Each lung is covered by a thin, moist tissue called the Each lung is covered by a thin, moist tissue called the pleura, which also lines the chest wall. The two layers of pleura, which also lines the chest wall. The two layers of pleura are like pieces of smooth satin that allow your pleura are like pieces of smooth satin that allow your lungs to expand and contract easily.lungs to expand and contract easily.

Your lungs and chest wall are both elastic, but as you Your lungs and chest wall are both elastic, but as you inhale and exhale, your lungs recoil inward while your inhale and exhale, your lungs recoil inward while your chest wall expands outward. The two opposing forces chest wall expands outward. The two opposing forces create a negative pressure in the pleural space between create a negative pressure in the pleural space between your rib cage and lung. When air enters that space, your rib cage and lung. When air enters that space, either from inside or outside your lungs, the pressure it either from inside or outside your lungs, the pressure it exerts can cause all or part of the affected lung to exerts can cause all or part of the affected lung to collapse.collapse.

There are several types of pneumothorax, which are defined There are several types of pneumothorax, which are defined according to what causes them:according to what causes them:

Spontaneous (Primary) pneumothoraxSpontaneous (Primary) pneumothorax  Spontaneous pneumothorax occurs in individuals with no known Spontaneous pneumothorax occurs in individuals with no known lung disease.  It affects close to 9,000 persons in the United lung disease.  It affects close to 9,000 persons in the United States each year- most often among tall, thin men between 20 States each year- most often among tall, thin men between 20 and 40 years old.  The cause of this type of pneumothorax is the and 40 years old.  The cause of this type of pneumothorax is the rupture of a bleb or cyst in the lung. rupture of a bleb or cyst in the lung. 

Symptoms include:Symptoms include: Chest pain on affected side Chest pain on affected side  Dyspnea (shortness of breath)Dyspnea (shortness of breath) CoughCough Abnormal breathing movementAbnormal breathing movement Rapid respiratory rateRapid respiratory rate Spontaneous pneumothorax is diagnosed by chest radiographs. Spontaneous pneumothorax is diagnosed by chest radiographs.  The way the condition is treated is dependant on its size and The way the condition is treated is dependant on its size and

course.  The objective of treatment is to remove the air from the course.  The objective of treatment is to remove the air from the pleural space, allowing the lung to reexpand.  A small pleural space, allowing the lung to reexpand.  A small pneumothorax will resolve on its own in 1 to 2 weeks.  Larger pneumothorax will resolve on its own in 1 to 2 weeks.  Larger pneumothoraxes require either needle aspiration or a chest pneumothoraxes require either needle aspiration or a chest tube.  Hospitalization is required for chest tube management as tube.  Hospitalization is required for chest tube management as the reexpansion of the lung may take several days with the the reexpansion of the lung may take several days with the chest tube left in place.  Surgery may be performed for a chest tube left in place.  Surgery may be performed for a repeated episode to prevent recurrence repeated episode to prevent recurrence

Secondary spontaneous pneumothoraxSecondary spontaneous pneumothorax-occurs-occurs in the setting of in the setting of known lung disease, most often chronic obstructive pulmonary disease known lung disease, most often chronic obstructive pulmonary disease (COPD).  Other lung diseases commonly associated with spontaneous (COPD).  Other lung diseases commonly associated with spontaneous pneumothorax include tuberculosis, pneumonia, asthma, cystic fibrosis, pneumothorax include tuberculosis, pneumonia, asthma, cystic fibrosis, lung cancer, and certain forms of interstitial lung disease.  This condition lung cancer, and certain forms of interstitial lung disease.  This condition is generally severe and often life threatening. is generally severe and often life threatening. 

Symptoms and diagnostic procedures of secondary pneumothorax are Symptoms and diagnostic procedures of secondary pneumothorax are identical to that of primary spontaneous pneumothorax.identical to that of primary spontaneous pneumothorax.

  

The therapeutic options for this condition are also the same as those for The therapeutic options for this condition are also the same as those for primary spontaneous pneumothorax, but the circumstances are much primary spontaneous pneumothorax, but the circumstances are much more urgent.  A small pneumothorax can be life threatening and virtually more urgent.  A small pneumothorax can be life threatening and virtually all patients are treated with chest tubes.  Sudden death may occur all patients are treated with chest tubes.  Sudden death may occur before chest tubes can be place and respiratory failure can occur within before chest tubes can be place and respiratory failure can occur within hours after the tubes are inserted.  The mortality rate associated with hours after the tubes are inserted.  The mortality rate associated with secondary pneumothorax is high (15%)secondary pneumothorax is high (15%)

. . 

The recurrence rate for both primary and secondary spontaneous The recurrence rate for both primary and secondary spontaneous pneumothorax is about 40% and occurs in intervals of 1.5 to 2 years.pneumothorax is about 40% and occurs in intervals of 1.5 to 2 years.

Patients suffering from this condition should be advised to Patients suffering from this condition should be advised to discontinue smoking and avoid high altitudes, scuba discontinue smoking and avoid high altitudes, scuba diving, or flying in unpressurized aircrafts to prevent the diving, or flying in unpressurized aircrafts to prevent the recurrence of pneumothorax.recurrence of pneumothorax.

Traumatic pneumothorax-Traumatic pneumothorax- Any blunt or penetrating Any blunt or penetrating injury to your chest can cause lung collapse. Knife and injury to your chest can cause lung collapse. Knife and gunshot wounds, a blow to the chest, even a deployed air gunshot wounds, a blow to the chest, even a deployed air bag can cause a pneumothorax. So can injuries that bag can cause a pneumothorax. So can injuries that inadvertently occur during certain medical procedures inadvertently occur during certain medical procedures such as the insertion of chest tubes, cardiopulmonary such as the insertion of chest tubes, cardiopulmonary resuscitation (CPR) and lung or liver biopsies. resuscitation (CPR) and lung or liver biopsies. Pneumothorax is especially common in people whose Pneumothorax is especially common in people whose breathing is aided by a mechanical ventilator.breathing is aided by a mechanical ventilator.

Tension pneumothorax-Tension pneumothorax- The most serious type of The most serious type of pneumothorax, this occurs when the pressure in the pneumothorax, this occurs when the pressure in the pleural space is greater than the atmospheric pressure, pleural space is greater than the atmospheric pressure, either because air becomes trapped in the pleural space or either because air becomes trapped in the pleural space or because the entering air is from a positive-pressure because the entering air is from a positive-pressure mechanical ventilator. The force of the air can cause the mechanical ventilator. The force of the air can cause the affected lung to collapse completely. It can also push the affected lung to collapse completely. It can also push the heart toward the uncollapsed lung, compressing both it heart toward the uncollapsed lung, compressing both it and the heart. Tension pneumothorax comes on suddenly, and the heart. Tension pneumothorax comes on suddenly, progresses rapidly and is fatal if not treated quickly.progresses rapidly and is fatal if not treated quickly.

Chest X-ray of Left-sided TensionChest X-ray of Left-sided Tension pneumothoraxpneumothorax

Risk FactorsRisk Factors Sex-Sex- In general, men are far more likely to have a In general, men are far more likely to have a

pneumothorax than women are, though women can pneumothorax than women are, though women can develop a rare form of pneumothorax (catamenial develop a rare form of pneumothorax (catamenial pneumothorax) related to the menstrual cycle. pneumothorax) related to the menstrual cycle. Catamenial pneumothorax, which mainly affects women in Catamenial pneumothorax, which mainly affects women in their 20s and 30s, seems to occur when endometrial their 20s and 30s, seems to occur when endometrial tissue — the tissue that normally lines the uterus — tissue — the tissue that normally lines the uterus — spreads to the lungs, pleura or diaphragm.spreads to the lungs, pleura or diaphragm.

Smoking-Smoking- This is the leading risk factor for primary This is the leading risk factor for primary spontaneous pneumothorax; more than 90 percent of spontaneous pneumothorax; more than 90 percent of people with a primary pneumothorax are smokers or people with a primary pneumothorax are smokers or former smokers. The risk increases with the length of former smokers. The risk increases with the length of time and the number of cigarettes smoked. time and the number of cigarettes smoked.

Lung disease-Lung disease- Having another lung disease, especially Having another lung disease, especially emphysema, makes a collapsed lung more likely. emphysema, makes a collapsed lung more likely.

A history of pneumothorax-A history of pneumothorax- If you've had one If you've had one pneumothorax, you're at increased risk of another, pneumothorax, you're at increased risk of another, usually within one to two years of the first episode. This usually within one to two years of the first episode. This is especially true if the first pneumothorax was small and is especially true if the first pneumothorax was small and healed on its own.healed on its own.

Screening and diagnosisScreening and diagnosisMost often, your doctor will diagnose a pneumothorax using Most often, your doctor will diagnose a pneumothorax using a chest X-ray. Other tests are sometimes performed, a chest X-ray. Other tests are sometimes performed, including:including:

Computerized tomography (CT) scan-Computerized tomography (CT) scan-In certain cases, you In certain cases, you may have a computerized tomography (CT) scan, an X-ray may have a computerized tomography (CT) scan, an X-ray technique that produces more detailed images than technique that produces more detailed images than conventional X-rays do. This is most often done if your doctor conventional X-rays do. This is most often done if your doctor suspects a pneumothorax after an abdominal or chest suspects a pneumothorax after an abdominal or chest procedure. A CT scan can help determine whether an procedure. A CT scan can help determine whether an underlying disease may have caused your lung to collapse — underlying disease may have caused your lung to collapse — something that may not show up on a regular X-ray. something that may not show up on a regular X-ray.

Blood tests-Blood tests-These may be used to measure the level of These may be used to measure the level of oxygen in your arterial blood.oxygen in your arterial blood.

ComplicationsComplicationsThe most common complication of a spontaneous or The most common complication of a spontaneous or traumatic pneumothorax is a recurrence — close to half the traumatic pneumothorax is a recurrence — close to half the people who have had one pneumothorax have another, people who have had one pneumothorax have another, usually within a year or two of the first. You're more likely to usually within a year or two of the first. You're more likely to have more than one pneumothorax if you smoke, have an have more than one pneumothorax if you smoke, have an existing lung disease or HIV/AIDS, or are tall and thin. And if existing lung disease or HIV/AIDS, or are tall and thin. And if you've had a primary spontaneous penumothorax from a you've had a primary spontaneous penumothorax from a ruptured bleb, it's highly possible that you have or will ruptured bleb, it's highly possible that you have or will develop a similar bleb in the opposite lung.develop a similar bleb in the opposite lung.

Complications of a tension pneumothorax are more serious and include:Complications of a tension pneumothorax are more serious and include:

Low blood oxygen levels (hypoxemia)-Low blood oxygen levels (hypoxemia)- Because a tension pneumothorax Because a tension pneumothorax causes near or total collapse of one lung and can compress the other, you causes near or total collapse of one lung and can compress the other, you take in less air and less oxygen enters your bloodstream. As a result, you take in less air and less oxygen enters your bloodstream. As a result, you develop lower than normal blood oxygen levels. Lack of oxygen can disrupt develop lower than normal blood oxygen levels. Lack of oxygen can disrupt your body's basic functioning, and severely low levels can be life-threatening. your body's basic functioning, and severely low levels can be life-threatening.

Respiratory failure-Respiratory failure- This occurs when blood levels of oxygen fall too low, and This occurs when blood levels of oxygen fall too low, and the level of carbon dioxide becomes too high. Severely low blood oxygen can the level of carbon dioxide becomes too high. Severely low blood oxygen can lead to heart arrhythmias and unconsciousness, and high carbon dioxide lead to heart arrhythmias and unconsciousness, and high carbon dioxide levels to sleepiness and confusion. Eventually, respiratory failure may prove levels to sleepiness and confusion. Eventually, respiratory failure may prove fatal. fatal.

Cardiac arrest-Cardiac arrest- In a tension pneumothorax, the heart is pushed toward the In a tension pneumothorax, the heart is pushed toward the unaffected lung. This can interfere with the return of blood to the heart and unaffected lung. This can interfere with the return of blood to the heart and lead to a sudden loss of heart function. Cardiac arrest is fatal if not treated lead to a sudden loss of heart function. Cardiac arrest is fatal if not treated immediately.immediately.

Shock-Shock- This critical condition occurs when blood pressure drops so low that This critical condition occurs when blood pressure drops so low that the body's vital organs are deprived of oxygen and nutrients. Shock is a major the body's vital organs are deprived of oxygen and nutrients. Shock is a major medical emergency and requires immediate care.medical emergency and requires immediate care.

TreatmentTreatmentThe goal in treating a pneumothorax is to relieve the pressure on the lung, The goal in treating a pneumothorax is to relieve the pressure on the lung, allowing it to re-expand, and to prevent recurrences. The best method for allowing it to re-expand, and to prevent recurrences. The best method for achieving this depends on the severity of the lung collapse and sometimes on achieving this depends on the severity of the lung collapse and sometimes on your overall health:your overall health:

Observation-Observation- If your lung is less than 20 percent to 25 percent collapsed, your If your lung is less than 20 percent to 25 percent collapsed, your doctor may simply monitor your condition with a series of chest X-rays until the doctor may simply monitor your condition with a series of chest X-rays until the air is completely absorbed and your lung has re-expanded. Because it may take air is completely absorbed and your lung has re-expanded. Because it may take weeks for a pneumothorax to heal on its own, however, a needle or chest tube weeks for a pneumothorax to heal on its own, however, a needle or chest tube may be used to remove the air, even when the pneumothorax is small and may be used to remove the air, even when the pneumothorax is small and nonthreatening. nonthreatening.

Needle or chest tube insertion-Needle or chest tube insertion- When your lung has collapsed more than 25 When your lung has collapsed more than 25 percent, your doctor is likely to remove the air by inserting a needle or hollow percent, your doctor is likely to remove the air by inserting a needle or hollow tube (chest tube) into the pleural space. Chest tubes often are attached to a tube (chest tube) into the pleural space. Chest tubes often are attached to a suction device that continuously removes air from the chest cavity and may be suction device that continuously removes air from the chest cavity and may be left in place for several hours to several days. left in place for several hours to several days.

Other pneumothorax treatments-Other pneumothorax treatments- If you have had more than one If you have had more than one pneumothorax, you may have treatments to prevent further recurrences. The pneumothorax, you may have treatments to prevent further recurrences. The most common is a surgical procedure called video-assisted thoracoscopy, which most common is a surgical procedure called video-assisted thoracoscopy, which uses small incisions and a tiny video camera to guide the surgery. This uses small incisions and a tiny video camera to guide the surgery. This technique leads to less pain and a shorter recovery time than other types of technique leads to less pain and a shorter recovery time than other types of surgery do because the chest cavity can be accessed without breaking any ribs. surgery do because the chest cavity can be accessed without breaking any ribs.

Pretreatment evaluation Pretreatment evaluation The radiographic diagnosis of pneumothorax is usually The radiographic diagnosis of pneumothorax is usually

straightforward straightforward (fig 1).(fig 1). A visceral pleural line is seen without A visceral pleural line is seen without distal lung markings. Lateral or decubitus views are distal lung markings. Lateral or decubitus views are recommended for equivocal cases. On standard lateral views recommended for equivocal cases. On standard lateral views a visceral pleural line may be seen in the retrosternal a visceral pleural line may be seen in the retrosternal position or overlying the vertebrae, parallel to the chest position or overlying the vertebrae, parallel to the chest wall. Shoot-through lateral or decubitus views may be used wall. Shoot-through lateral or decubitus views may be used in ventilated patients or neonates. Although the value of in ventilated patients or neonates. Although the value of expiratory views is controversial many clinicians still find expiratory views is controversial many clinicians still find them useful in the detection of small pneumothoraxes when them useful in the detection of small pneumothoraxes when clinical suspicion is high and an inspiratory radiograph clinical suspicion is high and an inspiratory radiograph appears normal. The British Thoracic Society guidelines appears normal. The British Thoracic Society guidelines divide pneumothoraxes into small and large based on the divide pneumothoraxes into small and large based on the distance from visceral pleural surface (lung edge) to chest distance from visceral pleural surface (lung edge) to chest wall, with less than 2 cm being small and more than 2 cm wall, with less than 2 cm being small and more than 2 cm large. A small rim of air around the lung actually translates large. A small rim of air around the lung actually translates into a relatively large loss of lung volume, with a 2 cm deep into a relatively large loss of lung volume, with a 2 cm deep pneumothorax occupying about 50% of the hemithorax. A pneumothorax occupying about 50% of the hemithorax. A large pneumothorax is an objective indication for drainage.large pneumothorax is an objective indication for drainage.

In the supine patient, air in the pleural space will usually be In the supine patient, air in the pleural space will usually be most readily visible at the lung bases (most readily visible at the lung bases (fig 2fig 2) in the ) in the cardiophrenic recess and may enlarge the costophrenic cardiophrenic recess and may enlarge the costophrenic angle (the deep sulcus sign). Adherence of inflamed pleura angle (the deep sulcus sign). Adherence of inflamed pleura to the chest wall may confine a pneumothorax to a to the chest wall may confine a pneumothorax to a loculated portion of the pleural space around the site of the loculated portion of the pleural space around the site of the air leak (air leak (fig 3fig 3). A drain placed remote from this area will be ). A drain placed remote from this area will be ineffective at best. If the operator enters the chest at a site ineffective at best. If the operator enters the chest at a site of adherent pleura, parenchymal damage and a severe air of adherent pleura, parenchymal damage and a severe air leak may follow (leak may follow (fig 4fig 4). For this reason, in the authors' ). For this reason, in the authors' opinion, loculated pneumothoraxes are best approached opinion, loculated pneumothoraxes are best approached under direct fluoroscopic and occasionally computed under direct fluoroscopic and occasionally computed tomography guidance. Emphysematous bullae may tomography guidance. Emphysematous bullae may alsomimic a loculated pneumothorax, particularly when alsomimic a loculated pneumothorax, particularly when there is a background of chronic lung disease. Sometimes there is a background of chronic lung disease. Sometimes internal lung markings are visible in a bulla using a bright internal lung markings are visible in a bulla using a bright light. If there is clinical doubt in a patient with symptoms light. If there is clinical doubt in a patient with symptoms

then computed tomography is helpful.then computed tomography is helpful.

The chest radiograph should also be carefully examined for The chest radiograph should also be carefully examined for evidence of underlying parenchymal lung disease (evidence of underlying parenchymal lung disease (fig 5fig 5). The ). The most common of these predisposing to pneumothorax are most common of these predisposing to pneumothorax are emphysema, pulmonary fibrosis of any cause, cystic fibrosis, emphysema, pulmonary fibrosis of any cause, cystic fibrosis, aggressive or cavitating pneumonia, and cystic interstitial aggressive or cavitating pneumonia, and cystic interstitial lung diseases such as Langerhans' cell histiocytosis and lung diseases such as Langerhans' cell histiocytosis and lymphangiomyomatosis. Detection of an underlying condition lymphangiomyomatosis. Detection of an underlying condition is important for several reasons. Firstly, therapy of the is important for several reasons. Firstly, therapy of the parenchymal lung disease may be possible. Secondly, unlike parenchymal lung disease may be possible. Secondly, unlike primary spontaneous pneumothorax, patients with secondary primary spontaneous pneumothorax, patients with secondary air leaks are not candidates for early discharge and require air leaks are not candidates for early discharge and require inpatient observation.Finally, all but the smallest (defined as inpatient observation.Finally, all but the smallest (defined as apical or less than 1 cm in depth) secondary pneumothoraxes apical or less than 1 cm in depth) secondary pneumothoraxes require treatment, even when symptoms are minimal.require treatment, even when symptoms are minimal.

Several well known artefactual appearances can mimic the Several well known artefactual appearances can mimic the presence of a pneumothorax and should always be presence of a pneumothorax and should always be remembered during evaluation of a chest radiograph. The remembered during evaluation of a chest radiograph. The medial border of the scapula can imitate a lung edge but once medial border of the scapula can imitate a lung edge but once considered can be traced in continuity with the rest of the considered can be traced in continuity with the rest of the bone, revealing its true nature (fig 5). Skin folds overlying the bone, revealing its true nature (fig 5). Skin folds overlying the chest wall (fig 6) can simulate a visceral pleural line and with chest wall (fig 6) can simulate a visceral pleural line and with the relative lack of lung markings in the upper zones can lead the relative lack of lung markings in the upper zones can lead to erroneous diagnosis, particularly in children.to erroneous diagnosis, particularly in children.

Once considered, however, their true nature is readily apparent. Once considered, however, their true nature is readily apparent. Skin folds are usually seen to pass outside the chest cavity, are Skin folds are usually seen to pass outside the chest cavity, are straight or only minimally curved, and do not run parallel to the straight or only minimally curved, and do not run parallel to the chest wall as with a true visceral pleural line. If closely scrutinised, chest wall as with a true visceral pleural line. If closely scrutinised, distal lung markings are seen. Clothing or bed sheets may produce distal lung markings are seen. Clothing or bed sheets may produce a similar artefact. Skin folds also form a dense line—sharp on one a similar artefact. Skin folds also form a dense line—sharp on one side and blurred on the other—in contrast to the less dense visceral side and blurred on the other—in contrast to the less dense visceral pleural line. The latter distinction can, however, be rather pleural line. The latter distinction can, however, be rather subjective. Occasionally, doubt persists. In this situation, repeat subjective. Occasionally, doubt persists. In this situation, repeat radiography after removal of clothing and repositioning of the arm radiography after removal of clothing and repositioning of the arm will be conclusive. Radio-opaque lines are often seen accompanying will be conclusive. Radio-opaque lines are often seen accompanying the inferior margins of ribs, which may simulate a visceral pleural the inferior margins of ribs, which may simulate a visceral pleural line. These are often called companion shadows although some line. These are often called companion shadows although some restrict this term to densities accompanying the first and second restrict this term to densities accompanying the first and second ribs. They are caused by protruding extrapleural fat or the ribs. They are caused by protruding extrapleural fat or the subcostal groove. This normal variant is characterised by its faithful subcostal groove. This normal variant is characterised by its faithful relation to the inferior margin of the accompanying rib, whereas relation to the inferior margin of the accompanying rib, whereas visceral pleural lines diverge from the rib to parallel the chest wall. visceral pleural lines diverge from the rib to parallel the chest wall. Although usually close to the adjacent rib, companion shadows may Although usually close to the adjacent rib, companion shadows may sometimes protrude inferiorly for a variable distance, giving a sometimes protrude inferiorly for a variable distance, giving a confusing appearance (fig 7). After pleurectomy for recurrent confusing appearance (fig 7). After pleurectomy for recurrent pneumothorax a radio-opaque line may be visible at the operative pneumothorax a radio-opaque line may be visible at the operative site due to suture material or staples (fig 8). This may be site due to suture material or staples (fig 8). This may be misinterpreted as a new air leak, especially if compared with misinterpreted as a new air leak, especially if compared with preoperative radiographs or in ignorance of the history of previous preoperative radiographs or in ignorance of the history of previous surgery.surgery.

Fig 1 (left) Classic appearances of left sided pneumothorax with readily Fig 1 (left) Classic appearances of left sided pneumothorax with readily apparent visceral pleural line (arrow)apparent visceral pleural line (arrow)

Fig 2 (right) Supine projection showing air collected at lung base. Absent Fig 2 (right) Supine projection showing air collected at lung base. Absent lung markings and a visceral pleural line (arrow) are still visible lung markings and a visceral pleural line (arrow) are still visible (P=pneumothorax). Left basal chest drain is noted (P=pneumothorax). Left basal chest drain is noted

Fig 3 (left) Loculated left sided pneumothorax in a patient with severe chronic obstructive Fig 3 (left) Loculated left sided pneumothorax in a patient with severe chronic obstructive airways disease. Placement of chest drain into fifth intercostal space (arrow) might have airways disease. Placement of chest drain into fifth intercostal space (arrow) might have entered lung parenchyma and would most likely not have achieved complete drainage of entered lung parenchyma and would most likely not have achieved complete drainage of this loculated collection. (right) Percutaneous pigtail catheters (arrows) placed in apical this loculated collection. (right) Percutaneous pigtail catheters (arrows) placed in apical and basal components of pneumothorax under fluoroscopic guidance. After several days and basal components of pneumothorax under fluoroscopic guidance. After several days of drainage the lung re-expanded completelyof drainage the lung re-expanded completely

Fig 4 Extensive pulmonary fibrosis and left pneumothorax (p) treated by blind chest drain Fig 4 Extensive pulmonary fibrosis and left pneumothorax (p) treated by blind chest drain placement. Axial computed tomograpy shows that drain (arrow) has traversed lung placement. Axial computed tomograpy shows that drain (arrow) has traversed lung

parenchyma. This led to a deterioration in patient's clinical conditionparenchyma. This led to a deterioration in patient's clinical condition

Fig 5 Background fibrotic lung disease (underlying ulcerative colitis), which Fig 5 Background fibrotic lung disease (underlying ulcerative colitis), which places patient at risk of secondary pneumothorax. Although medial border of places patient at risk of secondary pneumothorax. Although medial border of scapula (arrow) is easily recognisable as such on this radiograph it can scapula (arrow) is easily recognisable as such on this radiograph it can sometimes be misinterpreted as a visceral pleural linesometimes be misinterpreted as a visceral pleural line

Fig 6 (left) Skin folds (arrows) overlying right hemithorax. Distal lung Fig 6 (left) Skin folds (arrows) overlying right hemithorax. Distal lung markings are readily apparent. Note folds are relatively straight unlike markings are readily apparent. Note folds are relatively straight unlike curved visceral pleural line of pneumothoraxcurved visceral pleural line of pneumothorax

Fig 7 (right) Prominent companion or accompanying shadow below left Fig 7 (right) Prominent companion or accompanying shadow below left sixth rib (arrow). Line is relatively parallel to accompanying rib, and sixth rib (arrow). Line is relatively parallel to accompanying rib, and

distal lung markings are evidentdistal lung markings are evident

Fig 8 This patient underwent pleurectomy for recurrent pneumothorax. Fig 8 This patient underwent pleurectomy for recurrent pneumothorax. Suture material at right apex (arrow) is thicker than visceral pleural Suture material at right apex (arrow) is thicker than visceral pleural line and should not be confused with recurrent air leak. Compare with line and should not be confused with recurrent air leak. Compare with adjacent apical pneumothorax (arrowhead)adjacent apical pneumothorax (arrowhead)

Post-treatment evaluationPost-treatment evaluation A post-drainage chest radiograph is essential after A post-drainage chest radiograph is essential after

intervention to document resolution of the pneumothorax, intervention to document resolution of the pneumothorax, detect complications, and ensure a satisfactory drain position. detect complications, and ensure a satisfactory drain position. If tissue dissection at a drain insertion site is too superficial, a If tissue dissection at a drain insertion site is too superficial, a subcutaneous or intramuscular plane may be identified by the subcutaneous or intramuscular plane may be identified by the operator's finger and lead to drain placement outside the operator's finger and lead to drain placement outside the pleural space in an ineffective position. This is more likely to pleural space in an ineffective position. This is more likely to occur if the drain is sited at a posterior location, and occur if the drain is sited at a posterior location, and subsequent radiographic position may appear satisfactory on subsequent radiographic position may appear satisfactory on the frontal film (fig 9). A lateral view or computed tomography the frontal film (fig 9). A lateral view or computed tomography examination will detect this problem. An adequate length of examination will detect this problem. An adequate length of drain must also be inserted so that all side holes are contained drain must also be inserted so that all side holes are contained within the pleural space. Failure to do so leads to inadequate within the pleural space. Failure to do so leads to inadequate drainage and air passage into subcutaneous tissues. The drainage and air passage into subcutaneous tissues. The length of the tube with side holes can be identified on length of the tube with side holes can be identified on standard surgical chest drains by a gap in the radio-opaque standard surgical chest drains by a gap in the radio-opaque marker line (fig 10). After satisfactory resolution of the marker line (fig 10). After satisfactory resolution of the pneumothorax, the drainage catheter can be removed and a pneumothorax, the drainage catheter can be removed and a further follow-up radiograph obtained to detect recurrence. A further follow-up radiograph obtained to detect recurrence. A straight radio-opaque line is occasionally seen here along the straight radio-opaque line is occasionally seen here along the line of the removed tube, known as a "drain track" (fig 11). line of the removed tube, known as a "drain track" (fig 11). This may be misinterpreted as a recurrent air leak, but its This may be misinterpreted as a recurrent air leak, but its straight course and precise relation to the drain position on straight course and precise relation to the drain position on the radiograph before removal are usually conclusive. the radiograph before removal are usually conclusive. Presumably this finding is due to indentation of the pleura by Presumably this finding is due to indentation of the pleura by the drain. the drain.

After placement of a chest drain, the tubing is connected to an After placement of a chest drain, the tubing is connected to an underwater seal or flutter valve. The patient usually underwater seal or flutter valve. The patient usually undergoes daily chest radiography until the pneumothorax has undergoes daily chest radiography until the pneumothorax has resolved. Care must be taken to ensure that an unclamped resolved. Care must be taken to ensure that an unclamped chest drain bottle is not placed on the trolley above the level chest drain bottle is not placed on the trolley above the level of the patient's thorax during the trip to the x ray department. of the patient's thorax during the trip to the x ray department. This may result in accumulation of air and fluid in the pleural This may result in accumulation of air and fluid in the pleural space, producing a hydropneumothorax on the radiograph. If space, producing a hydropneumothorax on the radiograph. If the drain bottle is later returned to a dependent position the drain bottle is later returned to a dependent position without the physician's knowledge, then inappropriate suction without the physician's knowledge, then inappropriate suction or additional drainage procedures may be carried out. This or additional drainage procedures may be carried out. This possibility should be considered in unexpected deterioration possibility should be considered in unexpected deterioration on radiographs, especially in the absence of clinical signs. on radiographs, especially in the absence of clinical signs. Questioning the patient may be helpful. This problem can be Questioning the patient may be helpful. This problem can be prevented by emphasising to nursing and portering staff the prevented by emphasising to nursing and portering staff the importance of the bottle position.importance of the bottle position.

Clamping of the chest drain before radiography is often carried Clamping of the chest drain before radiography is often carried

out to detect small air leaks. British Thoracic Society out to detect small air leaks. British Thoracic Society guidelines do not generally recommend this but consider it guidelines do not generally recommend this but consider it acceptable under the supervision of trained nursing staff in acceptable under the supervision of trained nursing staff in the ward environment. The merits of clamping of the drain are, the ward environment. The merits of clamping of the drain are, however, a matter of some controversy among chest however, a matter of some controversy among chest specialists.specialists.

Fig 9 (top) Chest radiography shows unremarkable appearance of intercostal Fig 9 (top) Chest radiography shows unremarkable appearance of intercostal drain (arrow), apart from its medial location. (bottom) Axial computed drain (arrow), apart from its medial location. (bottom) Axial computed tomography shows drain (arrow) is located in subcutaneous tissues. More tomography shows drain (arrow) is located in subcutaneous tissues. More superior images showed that the drain terminated in this superficial positionsuperior images showed that the drain terminated in this superficial position

Fig 10 (top) Two large bore chest drains in a patient who developed a Fig 10 (top) Two large bore chest drains in a patient who developed a pneumothorax secondary to cavitating pneumonia. Lower drain (white pneumothorax secondary to cavitating pneumonia. Lower drain (white arrows) is satisfactorily sited, but upper drain (open arrow) has side holes arrows) is satisfactorily sited, but upper drain (open arrow) has side holes protruding into subcutaneous tissues, leading to extensive air leak. (bottom) protruding into subcutaneous tissues, leading to extensive air leak. (bottom) Small pigtail catheter inserted into basal pneumothorax (p). Progressive Small pigtail catheter inserted into basal pneumothorax (p). Progressive traction on drain has led to extrusion of side holes into subcutaneous tissues traction on drain has led to extrusion of side holes into subcutaneous tissues (open arrow) and through skin surface (white arrow) (open arrow) and through skin surface (white arrow)

Fig 11 (left) Left apical chest drain (open arrow) in satisfactory position Fig 11 (left) Left apical chest drain (open arrow) in satisfactory position after lobectomy. (right) Chest radiograph after removal of drain next day after lobectomy. (right) Chest radiograph after removal of drain next day shows faint radio-opaque line (arrow), known as a "drain track." This was shows faint radio-opaque line (arrow), known as a "drain track." This was seen to resolve on subsequent radiographsseen to resolve on subsequent radiographs

Fig 12 (left) Small pneumothorax post-pleurectomy at right apex (open Fig 12 (left) Small pneumothorax post-pleurectomy at right apex (open arrow). Fluoroscopic guided needle puncture (white arrow) is being arrow). Fluoroscopic guided needle puncture (white arrow) is being carried out. This unusual approach through the first intercostal space carried out. This unusual approach through the first intercostal space could damage subclavian vessels, which can be avoided by preliminary could damage subclavian vessels, which can be avoided by preliminary ultrasound examination of the needle path (arrowhead=suture material). ultrasound examination of the needle path (arrowhead=suture material). (centre) Wire (arrow) is placed through the needle after aspiration of air. (centre) Wire (arrow) is placed through the needle after aspiration of air. (right) Pigtail catheter coiled in pneumothorax and connected to (right) Pigtail catheter coiled in pneumothorax and connected to underwater seal underwater seal

PrognosisPrognosis

The outcome of pneumothorax depends upon the extent The outcome of pneumothorax depends upon the extent and type of pneumothorax. A small spontaneous and type of pneumothorax. A small spontaneous pneumothorax will generally resolve on its own without pneumothorax will generally resolve on its own without treatment. A secondary pneumothorax associated with treatment. A secondary pneumothorax associated with underlying disease, even when small, is much more underlying disease, even when small, is much more serious and carries a 15% mortality (death) rate. A serious and carries a 15% mortality (death) rate. A secondary pneumothorax requires urgent and immediate secondary pneumothorax requires urgent and immediate treatment. Having one pneumothorax increases the risk of treatment. Having one pneumothorax increases the risk of developing the condition again. The recurrence rate for developing the condition again. The recurrence rate for both primary and secondary pneumothorax is about 40%; both primary and secondary pneumothorax is about 40%; most recurrences occur within 1.5 to two years.most recurrences occur within 1.5 to two years.

PreventionPrevention Most cases of collapsed lung cannot be prevented. Most cases of collapsed lung cannot be prevented.

Quitting smoking can reduce your risk of developing the Quitting smoking can reduce your risk of developing the types of lung disease associated with this problem. types of lung disease associated with this problem. Wearing your seat belt in the car and avoiding other Wearing your seat belt in the car and avoiding other activities that put you at risk of chest injuries can help activities that put you at risk of chest injuries can help you to avoid a collapsed lung caused by traumayou to avoid a collapsed lung caused by trauma

Nursing InterventionsNursing Interventions Respiratory monitoring-Respiratory monitoring- Collection and analysis of patient Collection and analysis of patient

data to ensure airway patency and adequate gas exchange.data to ensure airway patency and adequate gas exchange. Airway management-Airway management- Facilitation of patency of air Facilitation of patency of air

passages.passages. Cough enhancement-Cough enhancement- Promotion of deep inhalation by the Promotion of deep inhalation by the

patient with subsequent generation of high intrathoracic patient with subsequent generation of high intrathoracic pressures and compression of underlying lung parenchyma pressures and compression of underlying lung parenchyma for the forceful expulsion of air.for the forceful expulsion of air.

Ventilation assistance-Ventilation assistance- Promotion of an optimal Promotion of an optimal spontaneous breathing pattern that maximizes oxygen and spontaneous breathing pattern that maximizes oxygen and carbon dioxide exchange in the lungs.carbon dioxide exchange in the lungs.

Airway sunctioning-Airway sunctioning- Removal of airway secretions by Removal of airway secretions by inserting a sunctions catheter into the patients.inserting a sunctions catheter into the patients.

Nursing Evaluation(Outcomes)Nursing Evaluation(Outcomes)

Return to functional baseline status, stabilization of, or Return to functional baseline status, stabilization of, or improvement in:improvement in:

Respiratory status: Airway patency-Respiratory status: Airway patency- Extent to which the Extent to which the tracheobronchial passages remain open; measured on a scale tracheobronchial passages remain open; measured on a scale of extremely compromised to not compromised.of extremely compromised to not compromised.

Respiratory status: Gas exchange-Respiratory status: Gas exchange- The alveolar exchange of The alveolar exchange of O2 or CO2 to maintain arterial blood gas concentrations; O2 or CO2 to maintain arterial blood gas concentrations; measured on a scale of extremely compromised to not measured on a scale of extremely compromised to not compromised.compromised.

Respiratory status: Ventilation-Respiratory status: Ventilation- movement of air in and out of movement of air in and out of the lungs; measured on a scale of extremely compromised to the lungs; measured on a scale of extremely compromised to not compromised.not compromised.