Diagnosis and Treatment of Pneumothorax

Diagnosis

1. Medical history and examination

Through medical history and physical examination, pneumothorax can be diagnosed relatively easily in patients with clear chest pain and shortness of breath.

However, small pneumothoraxes may not show any particular abnormal symptoms or findings on examination, so they are sometimes discovered through chest X-rays. Meanwhile, since pneumothorax recurs after the initial episode in about 40–50% of patients, it can also be suspected from the patient’s medical history.

2. Chest X-ray

A chest X-ray is an essential test that can confirm whether pneumothorax has occurred and how extensive it is.

In healthy people, the lungs fill the entire inside of the rib cage, whereas in patients with pneumothorax, the air-filled area within the pleural cavity and the collapsed lung are seen as separate.

Meanwhile, immediately after procedures that are likely to cause pneumothorax, such as subclavian vein catheter insertion or thoracentesis, a chest X-ray should be taken even if there are no special abnormalities, to check in advance whether pneumothorax has occurred. If pneumothorax is found, appropriate measures can be taken early.

3. Chest CT scan

CT scans are not ordinarily performed to diagnose pneumothorax itself. However, they may be used in patients who require surgical treatment to accurately assess the location and size of blebs that cause pneumothorax, or to check for associated conditions such as lung cancer.

Treatment

When pneumothorax occurs, the patient becomes short of breath, so they should rest and are usually admitted to the hospital for treatment.

To treat pneumothorax, a special tube called a 'chest tube' is inserted into the chest to remove air and re-expand the collapsed lung. In the case of traumatic pneumothorax, treatment for the trauma itself is also necessary at the same time. In particular, in cases of open pneumothorax or tension pneumothorax, the patient’s breathing difficulty is severe and fatal complications such as hypotension may occur, so immediate emergency treatment is required.

The treatment principle for spontaneous pneumothorax is to remove air from the pleural cavity and effectively close the pleural space to prevent recurrence.

Specific treatment methods for pneumothorax are selected by comprehensively considering the patient’s condition, whether there has been a recurrence, and the condition of the lungs, and the following methods are mainly used.

1. Rest and oxygen therapy

If the amount of pneumothorax is small (20% or less), the patient does not feel any particular symptoms, and there is no longer any air leakage so the pneumothorax is not enlarging, the patient can be rested and given oxygen while being observed without any special treatment. Since the air in the pleural cavity is naturally absorbed at a rate of 1.25% of one side of the chest volume per day, a relatively small pneumothorax occupying about 15% of one lung will be completely absorbed after about 10 to 15 days.

2. Chest tube insertion

Chest tube insertion is a treatment method in which a tube called a chest tube is inserted into the pleural cavity where pneumothorax has occurred, and the other end is connected to a special water-filled container to remove air and re-expand the lung.

Chest tube insertion can effectively re-expand a collapsed lung even when there is continuous air leakage, and, if necessary, a suction device can be connected to improve the treatment effect, so it is the most widely used treatment for pneumothorax.

The indications for chest tube insertion are as follows.

· When faster treatment is desired compared with 'rest and oxygen therapy' · When the size of the pneumothorax is large (20% or more)

· When there is tension pneumothorax · When there are symptoms such as shortness of breath · When there is disease in the opposite lung

· When the size of the pneumothorax is gradually increasing on chest X-ray

3. Chemical pleurodesis

In cases of persistent or recurrent spontaneous pneumothorax, chemical pleurodesis is used to fundamentally block air leakage and prevent recurrence by administering chemicals into the pleura to make it adhere.

The most commonly used agents for pleurodesis are tetracycline antibiotics or asbestos-free medical talc powder. The agents administered through a chest tube or thoracoscope cause inflammation in the pleura and lead to pleural adhesion, thereby eliminating the pleural cavity (chest cavity) itself, which is the space where pneumothorax occurs.

4. Surgery

In 40–50% of patients who experience spontaneous pneumothorax for the first time, pneumothorax recurs in the same lung or the opposite lung, and the probability of recurrence again in patients who have already been treated for recurrent pneumothorax is very high, at over 80%. In addition, the probability of recurrence on the same side is 75%, and most recurrences occur within 2 years after the first episode.

Non-surgical treatments such as chest tube insertion can be very effective for treating pneumothorax that has already occurred, but they have the limitation of not preventing recurrence. Therefore, in patients with recurrent pneumothorax, the principle is to perform surgical treatment to remove the causative blebs and induce pleural adhesion.

Cases in which surgery should be performed

· When the air leakage is severe and does not improve with chest tube insertion alone, or when the air leakage continues for 7–10 days or more

· When recurrent pneumothorax occurs on the same side · When there is a history of pneumothorax in the opposite lung in the past

· When pneumothorax occurs on both sides at the same time · When a large bulla is seen on chest X-ray

· When the person has a job that makes pneumothorax more likely, such as airline pilot or diver · When there are complications such as hemothorax or empyema

· When it would be problematic if pneumothorax recurred because the person does not have easy access to medical facilities, such as someone living in a remote area

In the past, surgery was performed through thoracotomy, but in recent years thoracoscopic surgery, which minimizes wounds by using video-assisted thoracoscopy, has mainly been used. Compared with thoracotomy, thoracoscopic surgery has the advantage of leaving less scarring because the incision is only about 1–1.5 cm, causing less postoperative pain and allowing for faster recovery. However, because special instruments must be used during surgery, the disadvantage is that the surgical cost is relatively high.

So far, I have explained the diagnosis and treatment of pneumothorax.

In the next installment, we will learn about hypotension.

Source: Korea Disease Control and Prevention Agency National Health Information Portal