Pneumothorax

Basic knowledge

Pneumothorax is the accumulation of air between the lung and the chest wall, inside the pleural space, that impairs lung function because it steals lung space. Symptoms include sudden pain and shortness of breath. When these symptoms appear, a doctor should evaluate you.

Some causes of pneumothorax are:

• Trauma: an open injury in your chest may allow external air to come into the thorax or a blunt trauma may cause an injury in the lung that can let pulmonary air escape into the pleural space. These are called traumatic pneumothoraces.

• Underlying lung disease: Some pulmonary diseases make patients prompt to develop pneumothorax. That is the case of chronic obstructive pulmonary disease (COPD), interstitial lung diseases, etc. This type of pneumothorax is known as a secondary spontaneous pneumothorax (SSP).

• Rupture of blebs. Some lungs present blebs, especially in apical zones. Those blebs tend to break, and, as a result, a pneumothorax appears. This situation is more frequent in smoker young males, usually very tall and underweight. This causes what is call a primary spontaneous pneumothorax (PSP). The most frequent one.

Risk factors include:

• Smoking: the more tobacco use, the higher the risk to suffer a pneumothorax, even in patients without emphysema.

• Underlying lung disease, as we have previously mentioned.

• Mechanical ventilation: when a patient needs mechanical ventilation to assist his breath, there is a higher risk of pneumothorax development.

For more information, please visit https://www.europeanlung.org/assets/files/factsheets/psp-en.pdf.

Diagnosis

Based on your symptoms and in your past medical history, your doctor will perform a directed physical examination, that would include auscultation of your breath sounds.

A plain CXR or a chest ultrasound can, most of the times, diagnose a pneumothorax. However, if the findings are not conclusive and the symptoms persist, a CT scan maybe needed to adequately perform the diagnosis.

Based on the amount of air outside the lung, your underlying previous conditions and your access to medical care, your doctor will propose you the most appropriate treatment.

Treatment

Treatment will depend on the size of pneumothorax and on clinical symptoms. When a pneumothorax is not occupying an important volume, it can be managed in a conservative way, with no invasive procedures. However, exercises like walking and climbing stairs will always be recommended to help your lung recover to the previous normal situation.

When the pneumothorax collapses a great part of the lung, aspiration or definitive chest tube insertion will be needed to help the air be evacuated and normality restored.

When a patient has repeated pneumothorax episodes or a bilateral one (the patient has pneumothorax in both lungs), there is an increased risk to suffer more pneumothorax events with a serious clinical repercussion. For that reason, surgery will be recommended to you.

Surgery

The aim of surgery is to decrease the risk of new pneumothorax events. Your surgeon will explain you the exact technique.

Most times, it will be performed by VATS.

Once inside the pleural space, the surgeon will inspect the lung looking for blebs.  When present, they should be removed resecting a small portion of the lung. The resected lung won´t grow again but the rest of the pulmonary tissue will compensate for it. Therefore, it won´t have any significant impact in your daily functioning and activities.

Although there are still some controversies, adding a procedure to increase the amount of pleural adherences between the lung and the pleura that covers the interior side of the ribs can also be helpful to reduce the number of future pneumothorax events or its clinical consequences. This procedure is known as pleurodesis. It can be induced mechanically or chemically. If your surgeon is going to perform it, she/he will explain you the method of choice.

Performing all these procedures will decrease the risk of having a new event in the operated hemithorax. However, the technique is not perfect. It has a percentage of failures. Ask your doctor about it.

Postoperative period

Normally this procedure is followed by a short time admission, although sometimes, it can be performed as same day surgery. This will depend on the local policy. After the operation regardless the time of admission to the hospital, you will have a chest tube in place. This will be removed as soon as no air leak from the lung is detected. Please see details on expected recovery after surgery.

For a complete recovery, and full lung reexpansion, chest physiotherapy and activity are mandatory. For further information about postoperative chest physiotherapy, please visit Perioperative chest physiotherapy.

Unfortunately, some cases will complicate. Please, review the reasons to seek medical attention.

Less frequent types of pneumothorax

Primary spontaneous pneumothorax is the most frequent of all types of pneumothorax. However, there are some other types of pneumothorax linked to other underlying causes. The most important ones, from a surgical point of view, are:

• Secondary spontaneous pneumothorax (SSP)
• Catamenial pneumothorax

As previously mentioned, SSP is related to the presence of certain diseases of the lung. Because of the underlying lung disease, small size pneumothoraces can have critical clinical repercussion like important shortness of breath (respiratory insufficiency). Treatment should aim to control new events through surgery. In these cases, pleurodesis is a must. However, sometimes the limited respiratory situation of the patient precludes that possibility. Then, non-surgical treatments can be attempted: chemical pleurodesis using talc or blood patches. Normally, long-term duration of the chest drainage can be anticipated. While in hospital and/or recovering from a SSP either after surgery or waiting for treatments’ effects, chest physiotherapy is mandatory for a full recovery.

A completely different situation is the catamenial pneumothorax. Although we don´t know the precise mechanism allowing the air into the pleural space along with the monthly menses, the fact is that these women experience a pneumothorax and all its symptoms every time they menstruate. This has an important negative impact in their normal life. In these cases, treatment has a double objective: local control of the symptoms at the pleural level and hormonal control to avoid menstruation for a certain period of time. This includes the possibility of pregnancy if it is your wish.

If this is your case, ask your doctor about the different possibilities of treatment. In the surgical procedure, your doctor will inspect the lung looking for other causes of pneumothorax (blebs, for instance).