Show Notes
We break down pneumothorax: risks, diagnosis, and management pearls.
Hosts:
Christopher Pham, MD
Brian Gilberti, MD
https://media.blubrry.com/coreem/content.blubrry.com/coreem/Pneumothorax.mp3
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Tags: Chest Trauma, Pulmonary, Trauma
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.
Symptoms & Differential Diagnosis
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.
Diagnostics
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.
Management
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.
Disposition
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.
Take Home Points
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.
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