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Pneumothorax

Pneumothorax refers to the accumulation of air in the pleural space (the area surrounding the lungs). Two layers of tissue (termed the visceral pleura and the parietal pleura) cover the lungs. The visceral pleura lies against the lung while the parietal pleura lies against the chest wall. Normally, there is only a small amount of fluid between these two layers of tissue. When air accumulates between the two layers of pleura (pleural space) a pneumothorax results. Symptoms associated with the development of a pneumothorax include shortness of breath and chest pain. On examination of the patient, a physician may find decreased breath sounds on the affected side, increased respiratory rate and increased heart rate. The diagnosis of a pneumothorax is made by the typical chest x-ray finding of a collapsed lung with a visible pleura line on the x-ray.

Pneumothoraces can be categorized as spontaneous, traumatic or iatrogenic. A primary spontaneous pneumothorax occurs in patients without known lung disease and tends to occur in young men or smokers; these are usually caused by a rupture of a bleb (air filled sac found on the surface of the lung) in the apex of the lung into the pleural space. A secondary spontaneous pneumothorax occurs in patients with underlying lung disease such as chronic obstructive lung disease, sarcoidosis, and interstitial lung diseases and is usually caused by an over-expansion of the small respiratory airways from either obstruction or inflammation. A traumatic pneumothorax may develop in patients with either penetrating trauma (a foreign object that disrupts the pleural space) or non-penetrating trauma such as rib fractures. An iatrogenic pneumothorax can occur after invasive procedures involving the chest including bronchoscopy, thoracentesis, mechanical ventilation, or insertion of catheters into the veins in the neck and are caused by damage to the pleura by the needle or other instrumentation.

The treatment of pneumothorax depends on both the cause of the pneumothorax, the size of the pneumothorax, and the severity of the patient's symptoms. With primary spontaneous pneumothoraces, the pneumothorax can frequently be observed without intervention and allowed to resolve over time. However, if patients with primary spontaneous pneumothoraces are symptomatic or the pneumothorax is large, treatment involves insertion of a chest tube to re-inflate the lung. Patients with secondary spontaneous pneumothoraces are often more symptomatic due to their underlying lung disease. The majority of these patients will require chest tube drainage for treatment of their pneumothoraces. Chest tube drainage can involve either insertion of a small tube to a flutter valve (can be done as an outpatient) or insertion of a large tube attached to suction. For both primary and secondary pneumothoraces, recurrence rates are high and treatment to prevent recurrence is often done. This may involve insertion of a chemical through the chest tube (pleurodesis), insertion of an agent (talc) through a thoracoscope or surgery. Treatment for iatrogenic or traumatic pneumothoraces generally involves either observation or chest tube drainage only.

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