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Pneumothorax: Understanding Lung Collapse and Causes

Pneumothorax is the presence of air in the pleural space, causing partial or complete lung collapse by disrupting the negative intrapleural pressure that keeps the lung expanded against the chest wall.

Classification

TypeCauseTypical Patient
Primary Spontaneous (PSP)Rupture of subpleural blebs (no lung disease)Tall, thin males 15–35; smokers
Secondary Spontaneous (SSP)Underlying lung disease (COPD, CF, TB, cancer, IPF)Older adults with known lung disease
TraumaticPenetrating/blunt chest trauma, rib fractureAny age post-injury
IatrogenicMedical procedures (central line, biopsy, ventilation, CPR)Hospitalized patients
CatamenialEndometriosis of pleura (menstruation-linked)Women of reproductive age

Symptoms

  • Sudden pleuritic chest pain (ipsilateral)
  • Dyspnea (severity correlates with collapse size)
  • Tachycardia, hypotension (if tension pneumothorax)
  • Decreased breath sounds, hyperresonance on affected side

Diagnosis

  • Chest X-ray (upright): Visible pleural line, absent lung markings peripherally.
  • Ultrasound (bedside): "Lung point" sign – highly sensitive/specific.
  • CT: For complex/recurrent cases or surgical planning.

Management

  • Small, asymptomatic PSP: Observation, high-flow O₂, repeat imaging.
  • Large/symptomatic: Needle aspiration or chest tube (thoracostomy) drainage.
  • Tension pneumothorax: Immediate needle decompression (2nd ICS midclavicular) → chest tube.
  • Recurrent/persistent air leak: Video-assisted thoracoscopic surgery (VATS) with bleb resection + pleurodesis.

Recurrence

PSP: 30–50% recurrence; higher with smoking. SSP: higher recurrence, greater morbidity. Smoking cessation is critical.

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