Pneumothorax: Classification and Etiology

doi:10.1016/j.ccm.2021.08.007

Clinics in Chest Medicine

Volume 42, Issue 4, December 2021, Pages 711-727

https://doi.org/10.1016/j.ccm.2021.08.007 Get rights and content

Section snippets

Key points

•
Pneumothorax can develop because of diverse etiologies; in many cases, no specific cause may be identified.
•
Tension pneumothorax is a pathophysiologic, not a radiologic, diagnosis.
•
Patients with primary spontaneous pneumothorax may have lung abnormalities that are not apparent on chest radiographs. Tobacco smoking is the most important risk factor.
•
Chronic obstructive pulmonary disease is the most common underlying lung disorder associated with secondary spontaneous pneumothorax.Recurrent

Historical perspective

Pneumothorax has been long recognized since the days of Hippocrates (circa 460–370 bc). Ancient Greek physicians would listen to a “succussion splash,” elicited by vigorously shaking the patient’s chest, to diagnose the presence of a hydropneumothorax. The native Americans had learned that a single arrow into the chest of a North American bison could quickly incapacitate it during hunting. Unlike most mammals, the bison has a single pleural cavity because of an incomplete mediastinum, making it

Incidence

The reported incidence of pneumothorax varies depending on study regions and may be lower than the real incidence because of underreporting and underdiagnosis in asymptomatic patients. Epidemiologic studies have shown an overall incidence of spontaneous pneumothorax of 16.8 per 100,000 population per year (24/100,000/year for males; 9.8/100,000/year for females) in England.⁶ The incidence of spontaneous pneumothorax from Sweden (Stockholm, 1975–1984) was lower at 18/100,000/year in males and

Classification by Size

Several methods have been described to measure and classify pneumothorax size. Light index calculates pneumothorax size from the ratio of cubed diameters of collapsed lung and hemithorax on a chest radiograph (pneumothorax size [%] = 100 × [1 − average lung diameter³/average hemithorax diameter³]) and shows good correlation with the volume of air removed (Fig. 2).²¹ Collin formula to estimate pneumothorax volume from a chest radiograph was derived based on helical computed tomography (CT)

Pathogenesis

The exact pathogenesis and mechanisms of spontaneous pneumothorax remain unclear. Although it was believed earlier that PSP occurs in patients with no underlying lung abnormalities, several factors have been identified that predispose to pneumothorax development. An interplay of lung-related abnormalities, such as subpleural blebs (Fig. 16A–C) and bullae (Fig. 16D),²⁶^,¹⁰³ visceral pleural porosity,¹⁰⁴ emphysema-like changes (ELCs),¹⁰⁵ chronic small airway inflammation,¹⁰⁴^,¹⁰⁶ and abnormal

Future directions

Significant gaps in knowledge remain regarding classification, pathogenesis, management, and outcomes of pneumothorax. The current pneumothorax classification of spontaneous pneumothorax into PSP and SSP, based on clinical and radiologic findings, is simplistic. With improved understanding of the underlying pathogenetic mechanisms, the distinction between PSP and SSP as separate entities rather than the ends of a continual disease spectrum has blurred. An “ideal” future classification system

Clinics care points

•
Patients with primary spontaneous pneumothorax may have underlying risk factors and lung abnormalities that are not easily apparent on initial chest imaging.
•
Tension pneumothorax is a pathophysiologic, NOT a radiologic, diagnosis.
•
Tobacco smoking is the an important risk factor for both primary and secondary spontaneous pneumothorax.
•
Recurrent spontaneous pneumothorax is a common presenting manifestation in diffuse cystic lung diseases.
•
An interplay between lung-related abnormalities and

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Pneumothorax: Imaging Diagnosis and Etiology
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Traumatic occult pneumothorax and ipsilateral hydatid cyst: A case report
2023, International Journal of Surgery Case Reports
Traumatic pneumothorax is a common chest condition that can be caused by a chest trauma. Hydatid cysts are also common, especially in Syria, and is caused by Echinococcus granulosis infection.
We report a case of mutual presentation of pneumothorax and a large Hydatid cyst on the same chest side in an 18 years-old patient who got stabbed in the chest. The chest x-ray reveled well-defined, homogeneous radio-opacity lesion that is consistent with Hydatid cyst but no pneumothorax was observed. Later, the chest CT showed a small pneumothorax that coexist with the Hydatid cyst. The case was treated conservatively and the patient survived.
Some studies support treating asymptomatic trauma patients with occult PT with observation and placing a chest tube if still asymptomatic. Our case questions the management protocol for such a rare encounter as the stability status of the patient was poor, and there was a large hydatid cyst close to the chest wall.
Physicians should be aware of the possible management solutions when dealing with similar cases, especially in emergency settings. Until clear guidelines are published for this matter, we recommend that high-level observation of the patient's vitals are the determining factor for suitable intervention.
The“Hand as Foot” teaching method in the spontaneous pneumothorax
2023, Asian Journal of Surgery
Surgical management of primary spontaneous pneumothorax. A national survey of the Emerging Thoracic Surgery Group of the Spanish Society of Pneumology and Thoracic Surgery (SEPAR)
2023, Open Respiratory Archives
En febrero de 2022, el Grupo Emergente de Cirugía Torácica de la Sociedad Española de Neumología y Cirugía Torácica inició un estudio multicéntrico sobre el manejo quirúrgico del neumotórax espontáneo primario (NEP). Como paso previo, se desarrolló esta encuesta cuyo objetivo fue conocer la situación actual en nuestro país, y así, concretar y dirigir dicho proyecto.
Se realizó un estudio descriptivo a partir de los resultados de esta encuesta lanzada a través de la plataforma Google Docs®. La encuesta se envió a todos los cirujanos torácicos nacionales en activo, un total de 319. Esta constaba de 20 preguntas que incluían datos demográficos, quirúrgicos y de seguimiento.
Se obtuvieron 124 respuestas (39% del conjunto de médicos especialistas y médicos en formación del territorio nacional). Las indicaciones más consistentes fueron: recidiva homolateral para 124 (100%), falta de resolución del episodio para 120 (96,7%), profesiones de riesgo para 104 (84%) y neumotórax bilateral para 93 (75%). El abordaje de elección para el 100% de los encuestados fue la videotoracoscopia. De estos, 96 contemplaban la resección pulmonar de las lesiones evidentes (77%). En relación con la técnica de pleurodesis, la abrasión pleural es la técnica más utilizada por 70 de los encuestados (56,7%), mientras que 49 (40%) realiza pleurodesis química con talco, bien sola, o en combinación con la pleurodesis mecánica.
Si bien hay cierta consistencia en algunos aspectos del manejo quirúrgico del NEP, esta encuesta hace evidente la variabilidad en cuanto a las técnicas de pleurodesis aplicadas entre los cirujanos de nuestro país.
In February 2022, the Emerging Thoracic Surgery Group of the Spanish Society of Pneumology and Thoracic Surgery initiated a multicenter study on the surgical management of primary spontaneous pneumothorax (PSP). As a preliminary step, this survey was developed with the aim of finding out the current situation in our country to specify and direct this project.
A descriptive study was carried out based on the results of this survey launched through the Google Docs® platform. The survey was sent to all active national thoracic surgeons, a total of 319. It consisted of 20 questions including demographic, surgical and follow-up data.
We obtained 124 responses (39% of all specialists and doctors in training in the national territory). The most consistent indications were: homolateral recurrence for 124 (100%), lack of resolution of the episode for 120 (96.7%), risk professions for 104 (84%) and bilateral pneumothorax for 93 (75%). The approach of choice for 100% of respondents was videothoracoscopy. Of these, 96 contemplated pulmonary resection of obvious lesions (77%). Regarding the pleurodesis technique, pleural abrasion was the technique most used by 70 respondents (56.7%) while 49 (40%) performed chemical pleurodesis with talc either alone or in combination with mechanical pleurodesis.
While there is some consistency in some aspects of surgical management of PSP, this survey makes evident the variability in pleurodesis techniques applied among surgeons in our country.
Update on pneumothorax
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El neumotórax es la presencia de aire en el espacio pleural, lo cual produce un aumento de la presión transmural y consecuentemente conduce al colapso pulmonar. Aunque se desconocen las causas del neumotórax, son factores de riesgo el sexo masculino, la estatura alta, el hábito tabáquico y una historia familiar de neumotórax. La magnitud de las manifestaciones clínicas varía desde permanecer asintomático hasta amenazar la vida del paciente. El diagnóstico se confirma con la radiografía de tórax y el tratamiento depende de la gravedad de los síntomas, del volumen de este y de las características clínicas del paciente. El objetivo del tratamiento es reexpandir el potencial colapso pulmonar a su capacidad original y evitar recurrencias.
Pneumothorax is the presence of air in the pleural space, which produces an increase in transmural pressure and consequently leads to lung collapse. Although the causes of pneumothorax are unknown, risk factors include male gender, tall stature, smoking, and a family history of pneumothorax. The magnitude of the clinical manifestations varies from remaining asymptomatic to threatening the life of the patient. The diagnosis is confirmed by chest X-ray and treatment depends on the severity of the symptoms, its volume and the clinical characteristics of the patient. The goal of treatment is to re-expand the potentially collapsed lung to its original capacity and prevent recurrences.
Pediatric Chest Pain: A Review of Diagnostic Tools in the Pediatric Emergency Department
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View all citing articles on Scopus

: Funding: R. Thomas has received career research fellowship funding from National Health and Medical Research Council, Australia and Cancer Council Western Australia, Australia.

: Declaration of interest: The authors have nothing to disclose.

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Pneumothorax: Classification and Etiology

Section snippets

Key points

Historical perspective

Incidence

Classification by Size

Pathogenesis

Future directions

Clinics care points

First page preview

Chest

Chest

J Adolesc Health

Clin Chest Med

Arch Bronconeumol

Lancet Respir Med

Respir Med

Respir Med

Anesthesiology

Injury

J Altern Complement Med

Chest

J Crit Care

Am J Emerg Med

J Thorac Cardiovasc Surg

Respir Med

Eur J Radiol

Chest

Chest

Chest

Ann Thorac Surg

Eur J Radiol

Ann Thorac Surg

Chest

Chest

Am J Med

Chest

Chest

Pleural diseases

Dissertation sur le pneumothorax, ou les congestions gazeuses qui se forment dans la poitrine

De l'auscultation médiate: ou traité du diagnostic des maladies des poumons et du coeur

Spontaneous pneumothorax: contrast of the benign idiopathic and the tuberculous types

Ann Intern Med

Spontaneous pneumothorax in the apparently healthy

Acta Med Scand

Epidemiology of pneumothorax in England

Thorax

Incidence of spontaneous pneumothorax in Olmsted County, Minnesota—1950 to 1974

Am Rev Respir Dis

The incidence and risk factors of asymptomatic primary spontaneous pneumothorax detected during health check-ups

BMC Pulm Med

Current aspects of spontaneous pneumothorax

Eur Respir J

Recurrence of primary spontaneous pneumothorax

Thorax

Recurrent primary spontaneous pneumothorax is common following chest tube and conservative treatment

World J Surg

Recurrence rates in primary spontaneous pneumothorax: a systematic review and meta-analysis

Eur Respir J

Epidemiology of spontaneous pneumothorax: gender-related differences

Thorax

Independent risk factors for cumulative recurrence rate after first spontaneous pneumothorax

Eur Respir J

Spontaneous pneumothorax in chronic obstructive pulmonary disease: complications, treatment and recurrences

Eur J Respir Dis

Spontaneous pneumothorax in the USAF aircrew population: a retrospective study

Aviat Space Environ Med

Pleural diseases

Quantification of pneumothorax size on chest radiographs using interpleural distances: regression analysis based on volume measurements from helical CT

AJR Am J Roentgenol

Management of spontaneous pneumothorax: British Thoracic Society Pleural Disease Guideline 2010

Thorax

BTS guidelines for the management of spontaneous pneumothorax

Thorax

A need to reconsider guidelines on management of primary spontaneous pneumothorax?

Int J Emerg Med

ERS task force statement: diagnosis and treatment of primary spontaneous pneumothorax

Eur Respir J