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Primary Spontaneous Pneumothorax

See also: 

Chest Drain Guideline
Needle Thoracocentesis Guideline

Background

Primary spontaneous pneumothorax (PSP) is a pneumothorax occuring in patients without underlying chronic lung disease when there is no provoking factor, such as trauma, surgery, or diagnostic intervention.

Assessment

Most episodes occur at rest. Consider PSP in patients with the following:

Symptoms

  • Acute onset of chest pain - Severe and/or stabbing pain, radiating to ipsilateral shoulder and increasing with inspiration (pleuritic)
  • Sudden shortness of breath
  • Anxiety, cough, and vague presenting symptoms (eg, general malaise, fatigue) are less commonly observed.

Signs

  • General appearance may be normal
  • Sweating, tachypnoea, tachycardia (most common finding)
  • Splinting chest wall to relieve pleuritic pain
  • Asymmetric lung expansion - mediastinal and tracheal shift to the contralateral side with a large pneumothorax
  • Decreased or absent breath sounds
  • Hyperresonance on percussion

Imaging Studies

  • Chest radiograph (confirms pneumothorax)
    • A linear shadow of visceral pleura with lack of lung markings peripheral to the shadow may be observed, indicating collapsed lung.
    • In supine patients, deep sulcus sign with radiolucency along costophrenic sulcus may help to identify occult pneumothorax.
    • Mediastinal shift toward the contralateral lung may also be apparent.
    • Small pleural effusions are commonly present and increase in size if the pneumothorax does not reexpand.
  • CT scan is not recommended for routine use.
  • Methods to estimate the fractional size of pneumothorax are controversial:
    • Any estimate of size should be performed in conjunction with a senior doctor in the emergency department.
    • There are currently two methods described in adults:
      • If lateral edge of lung is > 2cms. from thoracic cage, then this implies pneumothorax is at least 50%, and hence large in size.
        or
      • Calculate the ratio of the transverse radius of the pneumothorax (cubed) to the transverse radius of the hemithorax (cubed).
      • To express the pneumothorax size as a percentage, multiply the fractional size by 100. 

pneumothorax xray

Management

See Algorithm

Notes

  • Small pneumothorax is equivalent to <30% 
  • This protocol excludes: 
    • Age < 12 years
    • Underlying lung disease
      • CF
      • Chronic neonatal lung disease
      • Asthma
      • Others
    • Trauma
    • Foreign body inhalation
  • All discharged patients should have appropriate follow-up - please discuss with ED consultant or fellow.

 

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