inpatient / pulmonology and critical care


Last Updated: 1/21/2023

# Pneumothorax

-- ABCs: 
stable vs unstable (tension physiology) - page thoracic surgery, consider needle decompression
-- HPI Intake: *** dyspnea, chest pain, prev PTX, smoking, h/o COPD, other primary lung dx
-- Can't Miss: tension PTX
-- Admission Orders: *** telemetry, continuous pule ox
-- Initial Treatment to Consider: oxygen, pain management, avoid NIPPV

-- History: *** prev PTX, smoking, emphysema, M>F, height, recent thoracic procedure
-- Clinical: *** hypoxia, hypotension, chest pain, dyspnea
-- Exam: *** ipsilateral absence of breath sounds, hyper-resonant percussion, distended neck veins
-- Data: *** CXR
-- Etiology/DDx: ***  spontaneous (primary vs secondary to lung dx like emphysema), traumatic, iatrogenic (CVC, intubation, barotrauma, bronch, thoracentesis)

The patient's HPI is notable for ***. Exam showed ***. Labwork and data were notable for ***. Taken together, the patient's presentation is most concerning for ***, with a differential including ***.

-- Chest tube vs conservative management
-- O2 with goal *** >92-94%
-- Set chest tube to *** water seal,
-- CXR daily and after changes in settings
-- Pleurodesis in refractory cases

Chest tube placed on *** by *** is currently set to *** (suction, water seal / gravity, clamped), with/without appropriate tidaling, with/without air leak ***

Get Template PDF

PDF coming soon!

If You Remember Nothing Else

A pneumothorax can either be treated conservatively (watch and wait) if the air space is small, the patient is asymptomatic, and is otherwise healthy. Otherwise, a patient will need to have the air drained via a chest tube. In emergency situations, including tension pneumothorax, a needle decompression should be attempted at bedside as a bridge to a chest tube. In general, avoid NIPPV.

Clinical Pearls

  • Spontaneous PTX is 6x more common in men, and is most often seen in those 16-25 years old
  • Can consider treating conservatively if 18-50yo, apex-to-cupula on CXR <3cm, and no dyspnea with regular activity on room air
  • In general, you should try to avoid NIPPV in PTX
  • If ventilated, you will likely see evidence of decreased lung compliance (increased Pplat >30)
  • Upright CXR can detect PTX of 50cc, supine and portable may only be able to detect PTX of 500cc or more - try ultrasound in the case where the patient can’t sit up
  • When reviewing CXR, don’t let the medial border of the scapula or a skin fold fool you
  • POCUS - M-mode can be used to assess for lung sliding - absence c/f PTX; barcode sign (loss of the seashore sign” is 91% sensitive and 98% specific and is superior to CXR in diagnosing PTX
  • Tension PTX is one of the H’s and T’s for a reversible cause of cardiac arrest
  • Emergency needle decompression - 16G at the 5th intercostal space, mid-axillary line, above the rib

Other Resources

  • Assessing for Lung Sliding and PTX on POCUS - YouTube Video - MedCram
  • Demystifying Chest Drain Management (chest tubes) - YouTube Video - American Thoracic Society
  • The Basics of Chest Tube Management - YouTube Video - ICU Advantage
  • Chest Tube Physiology - YouTube Video - ICU Advantage