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Pneumothorax is the collection of air in the pleural space. Air may come from an injury to the lung tissue, a bronchial tear, or a chest wall injury allowing air to be sucked in from the outside.
|A simple pneumothorax is a non-expanding collection of air around the lung. The lung is collapsed, to a variable extent. Diagnosis on physical examination may be very difficult. The classical signs of reduced air entry and resonance to percussion are often difficult or impossible to appreciate. Careful palpation of the chest wall and apices may reveal subcutaneous emphysema and rib fractures as the only sign of an underlying pneumothorax.||
A chest X-ray is usually diagnostic, but may miss small pneumothoraces, especially with the patient supine. The presence of rib fractures on a chest X-ray should prompt a careful search for a pneumothorax. One side of the chest may appear more radiolucent than the other. This may represent an overlying pneumothorax, or alternatively an underlying haemothorax on the opposite side. A deep sulcus sign is indicative of an anterior pneumothorax.
When a haemothorax is visible on the erect chest X-ray, the presence of a flat meniscus laterally indicates the presence of an associated pneumothorax.
|Meniscus of haemothorax||Meniscus of haemopneumothorax|
Left pneumothorax or right haemothorax?
|Deep sulcus sign of anterior pneumothorax|
CT Scanning is more sensitive for the presence of pneumothorax than plain chest X-ray. However the significance of these small pneumothoraces is unknown. A small anterior pneumothorax is not visible on the plain radiograph but visible on CT in the example below. Many of these 'occult pneumothoraces' may be managed without chest tubes, even in the presence of positive pressure ventilation. More recently, ultrasound has shown promise in the diagnosis of pneumothoraces, although evaluation is difficult and operator dependent.
|CXR Normal||CT: anterior left pneumothorax|
Most simple pneumothoraces will require placement of an intercostal chest drain as definitive treatment. Small pneumothoraces, especially those visible only on CT, may be watched expectantly. The decision to observe is based on the patient's clinical status and subsequent planned procedures. Chest tube placement may be appropriate in these cases if there are multiple injuries, if a patient is due to undergo prolonged anaesthesia, or if a patient is due to be transferred a significant distance - where detection of an increasing or tension pneumothorax may be difficult or delayed.
CXR vs CT
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Conservative Rx of Occult Pneumothorax
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