Pneumothorax
A collapsed lung condition where air leaks into the space between the lung and chest wall
Quick Facts
- Type: Respiratory Emergency
- ICD-10: J93
- Prevalence: 18-28 per 100,000
- Emergency: Requires immediate care
Overview
Pneumothorax, commonly referred to as a collapsed lung, is a condition that occurs when air leaks into the pleural space—the area between the lung and the chest wall. This air accumulation causes pressure that prevents the lung from expanding normally, leading to partial or complete lung collapse. The condition can range from a small, minor air leak to a life-threatening emergency requiring immediate medical intervention.
The pleural space normally contains a small amount of fluid and maintains negative pressure, which helps keep the lungs expanded against the chest wall. When air enters this space, it disrupts this balance and causes the lung to collapse. The severity of symptoms and the urgency of treatment depend on the amount of air that has leaked and how quickly it accumulates.
There are several types of pneumothorax: spontaneous (occurring without apparent cause), traumatic (resulting from injury), and iatrogenic (caused by medical procedures). Spontaneous pneumothorax can be further classified as primary (occurring in healthy individuals) or secondary (developing in people with existing lung disease). Primary spontaneous pneumothorax typically affects young, tall, thin males, while secondary pneumothorax occurs in individuals with underlying respiratory conditions.
The prognosis for pneumothorax is generally good with appropriate treatment. Small pneumothoraces may resolve on their own, while larger ones require medical intervention. However, complications can arise, and recurrence is possible, especially in those with primary spontaneous pneumothorax. Understanding the symptoms and seeking prompt medical care is crucial for optimal outcomes.
Symptoms
The symptoms of pneumothorax typically develop suddenly and can range from mild to severe depending on the size of the collapsed area and the underlying health of the individual. Symptoms may appear during rest or physical activity.
Primary Symptoms
Additional Symptoms
- Back pain on the affected side
- Side pain that may be stabbing in nature
- Rapid, shallow breathing
- Fatigue and weakness
- Anxiety or feeling of panic
- Tight feeling in the chest
- Reduced chest movement on the affected side
Symptoms by Size of Pneumothorax
Small Pneumothorax (< 20% lung collapse):
- Mild chest discomfort
- Slight shortness of breath
- May be asymptomatic in some cases
- Symptoms may resolve spontaneously
Large Pneumothorax (> 20% lung collapse):
- Severe chest pain
- Significant breathing difficulty
- Rapid heart rate (tachycardia)
- Visible distress
- Inability to lie flat comfortably
Tension Pneumothorax (Medical Emergency)
A tension pneumothorax is a life-threatening condition with these additional symptoms:
- Severe respiratory distress
- Rapid deterioration of breathing
- Extreme chest pain
- Rapid, weak pulse
- Low blood pressure
- Cyanosis (blue discoloration of lips and fingernails)
- Neck vein distension
- Tracheal deviation (windpipe shift)
- Loss of consciousness in severe cases
Recurrent Pneumothorax Symptoms
- Similar symptoms to initial episode
- May be less severe if individual recognizes signs early
- Anxiety about recurrence
- Heightened awareness of chest sensations
Causes
Pneumothorax can occur through various mechanisms, ranging from spontaneous rupture of lung tissue to traumatic injury or medical procedures. Understanding the different causes helps in prevention and treatment planning.
Spontaneous Pneumothorax
Primary Spontaneous Pneumothorax:
- Blebs and bullae: Small air sacs on lung surface that rupture
- Genetic factors: Inherited tendency toward bleb formation
- Connective tissue disorders: Conditions affecting tissue strength
- Unknown cause: Many cases occur without identifiable trigger
Secondary Spontaneous Pneumothorax:
- COPD: Most common underlying condition
- Asthma: Severe asthma attacks can lead to pneumothorax
- Pneumonia: Infection can weaken lung tissue
- Tuberculosis: Can cause lung tissue damage
- Lung cancer: Tumors can cause tissue breakdown
- Pulmonary fibrosis: Scarring can lead to tissue rupture
- Cystic fibrosis: Genetic condition affecting lungs
- Pneumocystis pneumonia: Opportunistic infection in immunocompromised patients
Traumatic Pneumothorax
- Penetrating chest injury: Stab wounds, gunshot wounds, or impalement
- Blunt chest trauma: Motor vehicle accidents, falls, or sports injuries
- Rib fractures: Broken ribs can puncture the lung
- Crush injuries: Severe compression of the chest
- Barotrauma: Pressure changes during diving or flying
Iatrogenic Pneumothorax
- Central line placement: Insertion of central venous catheters
- Lung biopsy: Tissue sampling procedures
- Thoracentesis: Fluid removal from pleural space
- Mechanical ventilation: High-pressure ventilation
- Bronchoscopy: Airway examination procedures
- Acupuncture: Needles inserted too deeply near chest
- Subclavian line placement: Catheter insertion complications
Risk Factors for Bleb Formation
- Smoking: Increases risk of bleb development
- Air pollution exposure: Environmental lung irritants
- Extreme height changes: Rapid altitude changes
- Vigorous physical activity: Sudden pressure changes in chest
- Respiratory infections: Weakening of lung tissue
Menstrual-Related Pneumothorax
- Catamenial pneumothorax: Occurs with menstrual cycle
- Endometriosis: Endometrial tissue in chest cavity
- Hormonal factors: Estrogen and progesterone effects
- Cyclical pattern: Typically occurs 48-72 hours after menstruation begins
Risk Factors
Several factors increase the likelihood of developing pneumothorax, with some being modifiable and others being inherent characteristics:
Demographic Risk Factors
- Age: Primary spontaneous pneumothorax peaks in teens and young adults (15-30 years)
- Gender: Males are 4-6 times more likely to develop primary spontaneous pneumothorax
- Body type: Tall, thin individuals at higher risk
- Family history: Genetic predisposition to pneumothorax
Lifestyle Risk Factors
- Smoking: Increases risk 20-fold for primary spontaneous pneumothorax
- Drug use: Marijuana and cocaine use increase risk
- High-risk activities: Scuba diving, flying, mountain climbing
- Contact sports: Activities with risk of chest trauma
Medical Risk Factors
- Previous pneumothorax: 15-50% recurrence rate
- Chronic lung diseases: COPD, asthma, cystic fibrosis
- Connective tissue disorders: Marfan syndrome, Ehlers-Danlos syndrome
- Respiratory infections: Pneumonia, tuberculosis
- Lung cancer: Primary or metastatic disease
- AIDS: Increased risk due to opportunistic infections
Environmental Risk Factors
- Air pressure changes: Rapid altitude changes
- Air pollution: Exposure to lung irritants
- Occupational hazards: Exposure to lung-damaging substances
- Weather changes: Sudden barometric pressure changes
Genetic Risk Factors
- FLCN gene mutations: Birt-Hogg-Dubé syndrome
- Alpha-1 antitrypsin deficiency: Increased lung tissue breakdown
- Familial pneumothorax: Inherited tendency
- Homocystinuria: Connective tissue disorder
Gender-Specific Risk Factors
Women:
- Endometriosis: Catamenial pneumothorax
- Menstrual cycle: Hormonal fluctuations
- Pregnancy: Increased intra-abdominal pressure
Men:
- Higher smoking rates: Traditionally higher in males
- Occupational exposure: Higher risk jobs
- Risk-taking behavior: More likely to engage in high-risk activities
Age-Related Risk Patterns
- Young adults (15-30): Primary spontaneous pneumothorax
- Middle-aged (30-50): Traumatic pneumothorax
- Older adults (>60): Secondary spontaneous pneumothorax
Diagnosis
Diagnosing pneumothorax requires prompt clinical assessment combined with appropriate imaging studies. Early recognition is crucial, especially for tension pneumothorax, which is a medical emergency.
Clinical Assessment
- History taking: Onset, duration, and severity of symptoms
- Risk factor evaluation: Previous pneumothorax, lung disease, smoking history
- Mechanism of injury: If trauma is suspected
- Associated symptoms: Fever, cough, chest pain characteristics
Physical Examination
- Vital signs: Blood pressure, heart rate, respiratory rate, oxygen saturation
- General appearance: Distress level, cyanosis, use of accessory muscles
- Chest inspection: Asymmetrical chest movement, tracheal deviation
- Palpation: Subcutaneous emphysema, chest expansion
- Percussion: Hyperresonance on affected side
- Auscultation: Decreased or absent breath sounds
Imaging Studies
Chest X-ray:
- Standard imaging: Upright posteroanterior and lateral views
- Pleural line: Visible edge of collapsed lung
- Size estimation: Percentage of lung collapse
- Mediastinal shift: May indicate tension pneumothorax
- Limitations: May miss small pneumothoraces (< 20%)
CT Scan:
- High sensitivity: Detects small pneumothoraces missed on X-ray
- Accurate sizing: Precise measurement of pneumothorax size
- Underlying pathology: Identifies blebs, bullae, or other lung disease
- Trauma evaluation: Assesses other injuries in trauma patients
- Occult pneumothorax: Detection in mechanically ventilated patients
Ultrasound:
- Point-of-care assessment: Rapid bedside evaluation
- Lung sliding: Absence indicates pneumothorax
- A-lines: Horizontal lines suggesting pneumothorax
- Lung point: Interface between normal and collapsed lung
- Advantages: No radiation, rapid, repeatable
Laboratory Tests
- Arterial blood gas: Assessment of oxygenation and ventilation
- Complete blood count: Check for signs of infection
- D-dimer: If pulmonary embolism is suspected
- Alpha-1 antitrypsin: If genetic deficiency suspected
Size Classification
- Small pneumothorax: < 20% lung collapse (< 2 cm gap on chest X-ray)
- Large pneumothorax: ≥ 20% lung collapse (≥ 2 cm gap on chest X-ray)
- Measurement methods: Light's formula, average interpleural distance
Emergency Assessment
Tension Pneumothorax Signs:
- Severe respiratory distress
- Hemodynamic instability
- Tracheal deviation away from affected side
- Jugular venous distension
- Absence of breath sounds on affected side
- Hyperresonance to percussion
Differential Diagnosis
- Pulmonary embolism
- Myocardial infarction
- Pneumonia
- Pleural effusion
- Rib fracture
- Costochondritis
- Aortic dissection
- Esophageal rupture
Treatment Options
Treatment of pneumothorax depends on the size, type, symptoms, and underlying health conditions. Options range from observation for small, asymptomatic cases to emergency procedures for tension pneumothorax.
Emergency Treatment
Tension Pneumothorax (Life-threatening emergency):
- Immediate needle decompression: Large-bore needle into chest
- Location: Second intercostal space, midclavicular line
- Follow-up: Chest tube placement after stabilization
- Do not delay: Treatment before imaging if clinically suspected
Conservative Management
Observation (Small, stable pneumothorax):
- Criteria: < 20% lung collapse, minimal symptoms, stable vital signs
- Monitoring: Serial chest X-rays, vital signs, oxygen saturation
- Oxygen therapy: High-flow oxygen accelerates reabsorption
- Activity restriction: Bed rest or limited activity
- Pain management: Analgesics for comfort
- Follow-up imaging: Repeat X-ray in 6-24 hours
Invasive Procedures
Needle Aspiration:
- Simple procedure: Insertion of needle and syringe
- Indications: First episode, large primary spontaneous pneumothorax
- Location: Second intercostal space, midclavicular line
- Success rate: 50-80% depending on size
- Advantages: Less invasive than chest tube
- Disadvantages: Higher recurrence rate
Chest Tube Insertion (Tube Thoracostomy):
- Gold standard: Most effective drainage method
- Indications: Large pneumothorax, failed aspiration, secondary pneumothorax
- Location: Fourth or fifth intercostal space, anterior axillary line
- Size: 12-14 French for pneumothorax, larger for hemothorax
- Drainage system: Water seal or digital drainage system
- Monitoring: Air leak, drainage output, lung expansion
Small-Bore Chest Tubes (Pigtail Catheters):
- Less invasive: 8-14 French catheter
- Image-guided placement: CT or ultrasound guidance
- Patient comfort: Less pain than large-bore tubes
- Effectiveness: Similar success rates for pneumothorax
Surgical Treatment
Video-Assisted Thoracoscopic Surgery (VATS):
- Minimally invasive: Small incisions with camera guidance
- Bleb resection: Removal of ruptured blebs or bullae
- Pleurodesis: Creating adhesions to prevent recurrence
- Recovery: Shorter hospital stay, less pain
- Success rate: > 95% prevention of recurrence
Open Thoracotomy:
- Traditional surgery: Large incision for direct access
- Indications: Complex cases, failed VATS, massive air leak
- Procedures: Bleb resection, pleurodesis, lung repair
- Recovery: Longer healing time, more postoperative pain
Pleurodesis Techniques
- Mechanical pleurodesis: Pleural abrasion during surgery
- Chemical pleurodesis: Talc, doxycycline, or bleomycin
- Electrocautery: Thermal injury to pleural surface
- Goal: Create adhesions between lung and chest wall
Treatment Algorithm
Primary Spontaneous Pneumothorax:
- Small (< 20%): Observation with oxygen
- Large (≥ 20%) first episode: Needle aspiration or chest tube
- Recurrent: VATS with pleurodesis
Secondary Spontaneous Pneumothorax:
- All cases: Chest tube insertion
- High recurrence risk: Early surgical intervention
- Poor surgical candidates: Chemical pleurodesis
Discharge Criteria
- Stable vital signs
- Complete lung re-expansion
- No air leak for 24 hours
- Adequate pain control
- Understanding of follow-up care
- Availability of emergency care
Prevention
While not all cases of pneumothorax can be prevented, especially those due to genetic factors or underlying lung disease, many risk factors are modifiable and preventive measures can reduce the likelihood of occurrence or recurrence.
Primary Prevention
Lifestyle Modifications:
- Smoking cessation: Most important modifiable risk factor
- Avoid drug use: Particularly marijuana and cocaine
- Gradual altitude changes: Allow acclimatization when ascending
- Proper diving safety: Follow decompression protocols
- Protective equipment: Use appropriate gear in high-risk activities
Medical Management:
- Optimize lung disease treatment: Proper management of COPD, asthma
- Infection prevention: Vaccinations, prompt treatment of respiratory infections
- Regular medical care: Monitor underlying conditions
- Medication compliance: Proper use of respiratory medications
Secondary Prevention (Preventing Recurrence)
Surgical Options:
- VATS with pleurodesis: Most effective for recurrence prevention
- Timing: Consider after first recurrence or high-risk activities
- Bilateral prophylaxis: May be considered in high-risk patients
- Success rate: > 95% reduction in recurrence
Chemical Pleurodesis:
- Talc pleurodesis: Through chest tube or thoracoscopy
- Alternative agents: Doxycycline, bleomycin
- Indications: Poor surgical candidates, patient preference
- Effectiveness: 80-90% success rate
Activity Restrictions
High-Risk Activities to Avoid:
- Flying in unpressurized aircraft: Pressure changes increase risk
- Scuba diving: Barotrauma risk, especially without pleurodesis
- Contact sports: Risk of chest trauma
- Heavy lifting: Increased intrathoracic pressure
- Wind instruments: High pressure generation
Activity Modifications:
- Gradual exercise progression: Avoid sudden intense activity
- Proper warm-up: Prepare respiratory system
- Environmental awareness: Avoid extreme weather conditions
- Travel precautions: Consider cabin pressure effects
Special Populations
Young Athletes:
- Education: Awareness of symptoms and risks
- Screening: Consider chest imaging for high-risk individuals
- Return to play guidelines: Clear protocols after pneumothorax
- Prophylactic surgery: Consider for elite athletes
Women with Endometriosis:
- Hormonal therapy: Suppression of menstrual cycles
- Surgical treatment: Removal of ectopic endometrial tissue
- Monitoring: Awareness of cyclical symptoms
- Early intervention: Prompt treatment of catamenial pneumothorax
Occupational Safety
- Workplace safety: Follow safety protocols in high-risk jobs
- Protective equipment: Use appropriate respiratory protection
- Medical surveillance: Regular health screenings
- Education: Worker awareness of pneumothorax risks
Travel Considerations
- Commercial flights: Generally safe 2-6 weeks after complete resolution
- Altitude sickness prevention: Gradual ascent, adequate hydration
- Medical clearance: Consult physician before travel
- Emergency planning: Know medical facilities at destination
Patient Education
- Symptom recognition: Early identification of recurrence
- When to seek help: Emergency vs. urgent care situations
- Risk factors: Understanding personal risk profile
- Lifestyle counseling: Ongoing support for risk reduction
When to See a Doctor
Pneumothorax can be a medical emergency requiring immediate attention. Understanding when to seek emergency care versus routine medical evaluation can be life-saving.
Seek Emergency Care Immediately (Call 911)
- Sudden, severe chest pain with difficulty breathing
- Severe shortness of breath that worsens rapidly
- Blue discoloration of lips, fingernails, or skin (cyanosis)
- Rapid, weak pulse or low blood pressure
- Confusion or loss of consciousness
- Inability to speak in full sentences due to breathlessness
- Feeling of impending doom or extreme anxiety with breathing difficulty
- Chest pain after trauma or injury
- Visible distortion of chest or neck area
- Severe shoulder or back pain with breathing problems
Go to Emergency Department Immediately
- Sharp, sudden chest pain with any breathing difficulty
- Persistent shortness of breath that doesn't improve with rest
- History of pneumothorax with new chest pain or breathing problems
- Chest pain following medical procedures (central line, biopsy)
- Breathing difficulty with known lung disease
- Rapid heart rate with chest discomfort
- Inability to lie flat due to breathing problems
- Persistent cough with chest pain
Seek Urgent Medical Care (Within Hours)
- Mild to moderate chest pain with slight breathing difficulty
- Chest pain that worsens with deep breathing or coughing
- Shoulder pain on one side with mild breathing changes
- History of spontaneous pneumothorax with new symptoms
- Chronic lung disease with new or worsening symptoms
- Recent chest trauma with persistent pain
- Concern about possible pneumothorax based on symptoms
Schedule Medical Appointment
- Family history of pneumothorax and questions about risk
- Planning activities like scuba diving with pneumothorax history
- Follow-up after pneumothorax treatment
- Discussion of preventive surgery for recurrent pneumothorax
- Chronic lung disease requiring pneumothorax risk assessment
- Pre-travel consultation with pneumothorax history
Special Situations
Previous Pneumothorax History:
- Any new chest pain or breathing difficulty warrants immediate evaluation
- Lower threshold for seeking care due to recurrence risk
- Importance of early recognition and treatment
- Have medical history readily available
High-Risk Individuals:
- COPD patients: Any worsening of baseline symptoms
- Tall, thin young men: Awareness of primary spontaneous pneumothorax risk
- Women with endometriosis: Cyclical chest pain with periods
- Smokers: New respiratory symptoms
During Medical Procedures:
- Inform medical staff immediately of chest pain during procedures
- Report breathing difficulty after lung biopsy or central line placement
- Seek care for delayed symptoms after procedures
What Information to Provide
- Symptom details: Onset, duration, severity, triggers
- Medical history: Previous pneumothorax, lung disease, surgery
- Current medications: All medications and supplements
- Recent activities: Travel, diving, trauma, medical procedures
- Family history: Pneumothorax or genetic conditions
- Smoking history: Current or past tobacco use
Emergency Preparedness
- Know location of nearest emergency department
- Keep emergency contact information readily available
- Have medical history and medication list prepared
- Understand insurance coverage for emergency care
- Consider medical alert bracelet if high recurrence risk
Frequently Asked Questions
A pneumothorax typically causes sudden, sharp chest pain on one side, followed by shortness of breath. The pain may worsen with deep breathing or coughing and can radiate to the shoulder. Some people describe feeling like they "can't catch their breath" or that something is "wrong" with their breathing.
Small pneumothoraces (less than 20% lung collapse) may heal on their own as the body naturally reabsorbs the air. However, this process can take 1-2 weeks and requires medical monitoring. Larger pneumothoraces typically require medical intervention to remove the air and help the lung re-expand.
Recurrence rates vary by type: primary spontaneous pneumothorax has a 15-50% recurrence rate, with higher rates in smokers and those who don't undergo preventive surgery. Secondary pneumothorax has higher recurrence rates due to underlying lung disease. Surgical treatment (VATS with pleurodesis) reduces recurrence to less than 5%.
Flying is generally safe 2-6 weeks after complete resolution of a pneumothorax, but you should get medical clearance first. The timing depends on the size of the pneumothorax, treatment received, and whether you've had preventive surgery. Never fly with an active pneumothorax or recent chest tube removal.
Surgery is recommended for recurrent pneumothorax, large first-time pneumothorax that doesn't respond to other treatments, or when you engage in high-risk activities. Video-assisted thoracoscopic surgery (VATS) is minimally invasive and highly effective at preventing recurrence. Your doctor will discuss the best approach based on your specific situation.
References
- MacDuff A, et al. Management of spontaneous pneumothorax: British Thoracic Society pleural disease guideline 2010. Thorax. 2010;65 Suppl 2:ii18-31.
- Baumann MH, et al. Management of spontaneous pneumothorax: an American College of Chest Physicians Delphi consensus statement. Chest. 2001;119(2):590-602.
- Tschopp JM, et al. ERS task force statement: diagnosis and treatment of primary spontaneous pneumothorax. Eur Respir J. 2015;46(2):321-335.
- Bobbio A, et al. Management of spontaneous pneumothorax. J Thorac Dis. 2015;7(Suppl 1):S55-S60.
- Hallifax RJ, et al. Ambulatory management of primary spontaneous pneumothorax: an observational study. Chest. 2020;158(6):2612-2621.