Spontaneous or trauma pneumothorax: symptoms and causes


Causes of pneumothorax

There are three types of pneumothorax, depending on the cause:

  1. Primary spontaneous pneumothorax, there is no confirmed cause and the affected person is healthy.
  2. Secondary spontaneous pneumothorax, is caused by lung diseases or diseases of other organs.
  3. Traumatic pneumothorax, the cause is trauma.

Primary spontaneous pneumothorax

People who don’t have lung disease may develop this disorder.
Primary spontaneous pneumothorax, or PSP, mainly affects young people and occurs in people under 40 years of age (15-34 years of age).
Especially young and tall slim men have a higher chance of developing this disorder.
Familial predisposition may be a risk factor for spontaneous pneumothorax.

In most young people who develop spontaneous pneumothorax, it forms on the apical segment or tip of the lung through small air pockets or blebs lined with visceral pleural mesothelium.
These blebs communicate with one or more terminal bronchioles, thus there is a unidirectional connection with the airways. The air:

  • may occur,
  • can no longer escape due to the flap mechanism.

Scientists do not know why the bubbles form, although there are some theories about this.
For example, increased elasticity in lean, predisposed people can lead to dilation of the pleura and thus to the development of a bladder.
The pneumothorax occurs when one or two air bubbles burst.
The rupture process of the bubbles is related to the increase in air pressure inside, which causes excessive increase in size.

The result is a reduction in the blood flow to the mesothelial cells and thus:

  • Death
  • tearing.

The rupture of the bubbles does not depend on:

  • physical exertion,
  • an increase in pressure in the airways.

Other causes of primary spontaneous pneumothorax include:

  1. smoking as the main cause in about 80% of cases,
  2. Change in air pressure (for example, when diving or flying).

Secondary spontaneous pneumothorax

A person suffering from any lung disease may be affected by this type of lung collapse.
Chronic obstructive bronchopathy (COPD) is the most common cause of secondary spontaneous pneumothorax.
People older than 60 years are most affected by this condition. Lung diseases that can cause these disorders include:

  1. Lung cancer
  2. Tuberculosis
  3. Pneumonia
  4. Emphysema (a risk factor)
  5. Cystic fibrosis
  6. Marfan syndrome
  7. Asthma
  8. Interstitial lung diseases (for example, sarcoidosis or idiopathic pulmonary fibrosis).

Catalenial pneumothorax occurs in women between 30 and 40 years of age who suffer from endometriosis.
Symptoms begin within 48 hours of menstrual onset.
The exact cause of this type of pneumothorax is still unclear and researchers suspect that it is caused by the tissue of the endometrium (in the uterus) that has developed elsewhere in the body, in this case:

  • In the diaphragm: This causes the formation of small openings or holes that allow air to pass from the abdomen into the chest.
  • In the visceral pleura: This disorder is known as thoracic endometriosis. The result is a narrowing of the bronchi and a higher pressure in the alveoli, which can form blisters and pneumothorax.

Trauma pneumothorax

An injury to the lungs or chest can cause traumatic pneumothorax.
This may be a consequence of:

Iatrogenic pneumothorax (caused by the doctor): may be caused intentionally for diagnostic purposes or accidentally, for example during thoracoscopy. Symptoms depend on the patient’s age, underlying medical conditions, and the amount of air trapped.

Symptoms of pneumothorax

The symptoms of pneumothorax depend on the amount of air trapped outside the lungs.

Complications and consequences of pneumothorax

Hemopneumothorax is a complication of spontaneous pneumothorax.
It can occur if:

  • Blood and air fill the pleural cavity without previous trauma or lung disease.
  • There is serious damage to the lungs or thoracic vessels.

If the pleural effusion consists of at least 1000 ml of blood in the pleural cavity, it is called a massive hematothorax.

The pneumomediastinum is a complication of pneumothorax that affects the mediastinum, which is the area between the lungs (the center of the thorax) where the heart and large blood vessels are located.
The collapsed lung shifts the mediastinum and trachea towards the healthy lungs.
As a result, there is a sharp reduction in the amount of blood, which:

  1. returns to the heart (venous return),
  2. flows from the heart (cardiac output).

First, the heart tries to compensate for this situation by increasing the heart rate.
If a pneumothorax is not treated early enough, it can lead to death.

Diagnosis of pneumothorax

Objective investigation

After reviewing the clinical picture, the doctor examines the breathing process. This clinical examination is usually sufficient for the diagnosis of pneumothorax.

In the first phase of the examination, a stethoscope is used to check:

  • The movements of the thorax and lungs during inhalation. This shows whether the expansion of the chest occurs normally during breathing. In pneumothorax, one area of the chest expands more than the other area when inhaled by the patient.
  • The tympanic knocking sound, which is louder due to the air present.
  • Auscultation, in which the vesicular breathing sound has disappeared.

Device diagnostics
To make a reliable diagnosis of spontaneous pneumothorax, a chest X-ray in two standard projections is sufficient:

  • anterior-posterior,
  • Latero-lateral

The chest X-ray is prescribed for:

  • Confirmation of diagnosis,
  • knowledge of the enclosed air volume,
  • Monitoring of lung development during treatment.

In the case of a tension pneumothorax, the X-ray (right figure) shows:

  • A dark spot at the level of the collapsed lung.
  • The trachea and heart shift to the healthy side.
  • The diaphragm becomes flat and concave.

In the case of a spontaneous pneumothorax, the X-ray shows:

  • The line of the pleura visceralis.
  • The affected space between the lung margin and the parietal pleura shows the severity of lung collapse.
  • You don’t see an air bronchogram (area corresponding to the bronchi), but only air because the lungs have collapsed.

Treatment of pneumothorax

Guidelines of the University of Modena

Procedure in patients with spontaneous pneumothorax
The patient enters the emergency room and the X-ray shows a small apical layer of air (located at the tip of the lung) in pneumothorax.
The patient has no serious symptoms, he must:

  • remain in an observation room of the hospital,
  • lie on the side of the pneumothorax or in the supine position (abdomen upwards),
  • stay sober (can drink).

After three hours, another chest X-ray is taken to see the development of the pneumothorax.
If the shadow has increased, there is a deterioration.
Otherwise, if the symptoms have not changed, the X-ray (third) is repeated after 24 hours:

  • If the air layer has remained the same or decreased, the patient can be discharged, but he must return after a week for another X-ray to check the full expansion of the lungs.
  • If the air layer has increased or the patient has remained unchanged, but the lung tissue has collapsed by two-thirds, surgery is indicated.

How do you increase the pressure in the airways to unfold the lungs? The air pressure in the airways must rise above the pressure of the outside air so that ventilation can start again.

This can be done by mechanical ventilation with positive pressure in the intensive care unit.
If the amount of air trapped is too large, this can cause serious breathing problems. Thus, the removal of the air is absolutely indicated.
Thoracic drainage:

  • is the most commonly used therapy to remove excessive amounts of air or gas,
  • is carried out under local anesthesia.

The patient must be admitted to hospital.
The doctor inserts a small drainage tube into the chest. The air can be directed to the outside through the hose.

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