B23. Types of pneumothorax. Treatment options. Indication of surgical intervention

Introduction

For introduction, etiology, and types, see the corresponding pathology 1 topic.

Clinical features

Patients with pneumothorax present with sudden, severe stabbing chest pain and, if the PTX is large enough, dyspnoea. Physical examination may reveal decreased breathing sounds and hyperresonant percussion on the affected side.

In tension pneumothorax, the increased intrathoracic pressure compresses thoracic structures like the contralateral lung, trachea, heart, and superior vena cava, causing severe symptoms, like haemodynamic instability, cyanosis, and frank obstructive shock.

Diagnosis and evaluation

The diagnosis of pneumothorax is based on a simple chest x-ray, which will show a pleural line at the border of the collapsed lung, as well as absent lung markings distal to the pleural line.

Suspected tension pneumothorax is a clinical diagnosis does not undergo imaging. They proceed immediately to treatment. Should a chest x-ray be made, a mediastinal shift and tracheal deviation toward the contralateral side will be present.

Treatment

Patients with stable, mildly symptomatic, spontaneous pneumothorax may be treated conservatively. In all other cases of regular pneumothorax, a chest tube should be placed. This tube is placed in the 4th or 5th intercostal space in the frontal axillary line (between the anterior and midaxillary lines). The tube is then connected to a water seal or a suction device. The water seal prevents air from leaking into the tube and allows for visualisation of air leaving the tube as bubbles in the water. A suction device produces negative pressure, literally sucking air out of the pleural cavity.

For tension pneumothorax, emergency decompression is necessary. A large-bore needle is inserted into the 2nd intercostal space at the midclavicular line, which immediately releases the pressure. A chest tube is then placed as described above.

Surgical treatment may be required in repeated spontaneous pneumothorax, or pneumothorax refractory to standard treatment. Surgery involves bullectomy to treat the underlying cause and applying pleurodesis (fusion of the parietal and visceral pleura, obliterating the space for air to enter). Pleurodesis may be performed mechanically, by literally sandpapering the pleura, or chemically, by applying talc or bleomycin. In case of both mechanical and chemical pleurodesis, the pleural membrane becomes inflamed, leading to fibrosis of both visceral and parietal pleura, causing them to adhere to each other.


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