Show Notes

Risk Factors for Pneumothorax

Secondary pneumothorax
- Trauma: rib fractures, blunt chest trauma (as in the case).
- Iatrogenic: central line placement, thoracentesis, pleural procedures.
Primary spontaneous pneumothorax
- Young, tall, thin males (10–30 years).
- Connective tissue disorders: Marfan, Ehlers-Danlos.
- Underlying lung disease: COPD with bullae, interstitial lung disease, CF, TB, malignancy.
Technically, anyone is at risk.

Typical PTX presentation: Dyspnea, chest pain, pleuritic discomfort.
Exam clues: unilateral decreased breath sounds, focal tenderness/crepitus.
Red flags (suggest tension PTX):
- JVD
- Tracheal deviation
- Hypotension, shock physiology
- Severe tachycardia, hypoxia
Differential diagnoses:
- Pulmonary: asthma, COPD, pneumonia, pulmonary edema (SCAPE), ILD, infections.
- Cardiac: ACS, CHF, pericarditis.
- PE and other acute causes of dyspnea.

Bloodwork: limited role, except type & screen if intervention likely.
EKG: reasonable given chest pain/shortness of breath.
Imaging:
- POCUS (bedside ultrasound)
  - High sensitivity (86–96%) & specificity (97–100%).
  - Signs:
    - Seashore sign: normal lung sliding.
    - Barcode sign: absent lung sliding.
    - Lung point: most specific for PTX.
- CXR
  - Sensitivity ~70–90% for small PTX.
  - May show pleural line, hyperlucency.
- CT chest (gold standard)
  - Defines size/severity.
  - Rules out mimics (bullae, pleural effusion, hemothorax).
  - Guides intervention choice.

First step for all: Oxygen supplementation (non-rebreather if possible).
- Accelerates resorption of pleural air.
Stable vs. unstable decision point:
- Unstable/tension PTX
  - Immediate needle thoracostomy (14-g angiocath, 2nd ICS midclavicular).
  - Temporizing until chest tube/pigtail placed.
- Stable, small PTX (<2 cm on O₂)
  - Observation, supplemental O₂, conservative management.
- Stable, larger PTX or symptomatic
  - Chest tube or pigtail catheter insertion.
  - Pigtail catheters: less invasive, more comfortable, similar efficacy for simple PTX.
  - Large bore tubes: indicated if associated with blood, pus, large collections.

Admit all patients with chest tubes; cannot be discharged with tube in place.
Service responsible varies by hospital: trauma, CT surgery, MICU, etc.
Level of care (ICU vs. floor) depends on stability:
- ICU if unstable course, intubated, shock physiology.
- Stepdown/floor if stable and straightforward.

Always broaden differential in dyspnea/chest pain → don’t anchor on asthma/COPD.
Exam findings + history (trauma, risk factors) crucial to raising suspicion.
Ultrasound is more sensitive than CXR and highly specific when lung point found.
Oxygen is first-line; intervention determined by size + stability.
Pigtail catheters increasingly favored for simple, stable PTX.
All patients with intervention require admission; service varies by institution.