9/12/2019

1/18

Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 8e

Chapter 68: Pneumothorax Bret A. Nicks; David Manthey

INTRODUCTION AND EPIDEMIOLOGY

Pneumothorax occurs when free air enters the potential space between the visceral and parietal pleura.Primary pneumothoraces occur without clinically apparent lung disease, either spontaneously or frompenetration of the intrapleural space by trauma. Secondary pneumothoraces occur in patients withunderlying lung disease.

The incidence of primary spontaneous pneumothorax is 10 to 18 cases for men and 2 to 5 cases for women

per 100,000 population.1 Associated factors include cigarette smoking, male gender, mitral valve prolapse,Marfan's syndrome, and changes in ambient pressure. Familial patterns also suggest an inherited

association.2 Physical activity or exertion can precipitate but is not a common pneumothorax-triggeringfactor. Traumatic pneumothoraces are subdivided into iatrogenic and noniatrogenic. Noniatrogenicpneumothoraces will be further discussed in the chapter 261, "Pulmonary Trauma."

Causes of secondary spontaneous pneumothorax are listed in Table 68-1. Chronic obstructive pulmonary

disease remains the most common cause.3 Pneumothorax occurs in 5% of patients with acquiredimmunodeficiency syndrome, is associated with subpleural necrosis by Pneumocystis infection, and carries ahigh mortality. Because of necrosis of lung tissue and continued air leak, simple aspiration fails in this groupof patients. Hemopneumothorax occurs in 2% to 7% of patients with secondary pneumothorax and, if

associated with a large amount of blood in the pleural cavity, can be life threatening.4,5,6,7 Treating theunderlying disease may help decrease the risk of future pneumothorax.

9/12/2019

2/18

TABLE 68-1

Causes of Secondary Pneumothorax

Airway disease

Chronic obstructive pulmonary disease

Asthma

Cystic fibrosis (8%–20% will develop one in lifetime)

Interstitial lung disease

Sarcoidosis

Pulmonary fibrosis

Tuberous sclerosis

Infection

Human immunodeficiency virus infection, Pneumocystis pneumonia

Tuberculosis

Bacterial pneumonia, necrotizing

Lung abscess

Connective tissue disease

Marfan's syndrome

Ehlers-Danlos syndrome

Scleroderma

Rheumatoid arthritis

Cancer

Primary lung or metastatic disease

Catamenial pneumothorax

PATHOPHYSIOLOGY

Under normal conditions, the parietal and visceral pleura are in close apposition. The pleural space isnegatively pressured at –5 mm Hg with fluctuations of 6 to 8 mm Hg between inspiration and expiration. Theinherent tendency of the chest wall is to expand and for the lungs to collapse from elastic recoil. With the lossof the normal negative pressure in the pleural space that "adheres" the visceral pleura (lungs) to the parietalpleura (ribs), the a�ected lung collapses. A primary spontaneous pneumothorax occurs when a subpleuralbleb ruptures, disrupting pleural integrity. Rupture in primary spontaneous pneumothoraces usually involves

the lung apex.6,7,8 In secondary spontaneous pneumothoraces, disruption of the visceral pleura occurssecondary to underlying pulmonary disease processes.

9/12/2019

3/18

Once there is a break in the visceral pleura, air travels down a pressure gradient into the intrapleural space,until pressure equilibrium occurs with partial or total lung collapse. Altered ventilation–perfusionrelationships and decreased vital capacity contribute to dyspnea and hypoxemia. If air continues to enter thepleural space, intrapleural pressure becomes positive. Tension pneumothorax develops as inhaled airaccumulates in the pleural space but cannot exit due to a check-valve system. As intrathoracic pressure (>15to 20 mm Hg) increases, the great vessels and heart are compressed and shi�ed contralaterally, severelyrestricting venous return, diastolic filling, and cardiac output causing ventilation-perfusion mismatch, and

resulting in hypoxia and shock.8 Tension pneumothorax can develop in the presence of a chest tube if gasegress is obstructed, including from the adjacent lung.

CLINICAL FEATURES

Classic symptoms of primary spontaneous pneumothorax are sudden onset of dyspnea and ipsilateral,pleuritic chest pain. The pleuritic component of the pneumothorax may resolve within the first 24 hours.Profound dyspnea is rare, unless the patient has poor reserve due to underlying parenchymal disease ordevelops a tension pneumothorax. Sinus tachycardia is the most common physical finding. Because manypneumothoraces are small, other classic findings like ipsilateral decreased breath sounds, hyperresonance topercussion, and decreased or absent tactile fremitus are absent. In traumatic pneumothorax, the positive

predictive value of ipsilateral decreased breath sounds is 86% to 97% for the diagnosis.9 Cough and

exertional complaints are not common signs or symptoms.2 Except for trauma, physical exam alone is notsensitive enough to exclude the diagnosis.

The clinical hallmarks of tension pneumothorax are tracheal deviation away from the involved side,

hyperresonance of the a�ected side, hypotension, and significant dyspnea.8

DIAGNOSIS

Pneumothorax is an important di�erential consideration in patients with chest pain, especially in those withunderlying lung disease. Patients with pleurisy, pleural e�usions, infiltrates, or shingles can present with painsimilar to those with pneumothorax.

IMAGING

Chest X-Ray

A standard erect posteroanterior chest radiograph is the usual initial test and demonstrates loss of lungmarkings in the periphery and a pleural line that runs parallel to the chest wall (Figure 68-1). Ensure that theline does not extend outside of the chest cavity, suggesting a confluence of shadows or skin line. A lateral

radiograph will identify a pneumothorax in an additional 14% of cases.10 An expiratory radiograph does notidentify many additional pneumothoraces. The sensitivity of anteroposterior chest radiography, whencompared with CT, was 75.5% (95% confidence interval, 61.7% to 86.2%), with a specificity of 100% (95%

9/12/2019

4/18

confidence interval, 97.1% to 100%).10,11,12 In critically ill patients, when they cannot be moved to an erectposition, look for the deep sulcus sign, a deep lateral costophrenic angle, on the a�ected side.

FIGURE 68-1.

Spontaneous hemopneumothorax. Upright chest radiograph of a 19-year-old male college student withspontaneous hemopneumothorax. Note the large air-fluid level in the inferior portion of the right hemithoraxin addition to the complete collapse of the entire right lung.

Large bullae in patients with chronic obstructive pulmonary disease may look like a pneumothorax, althougha pneumothorax pleural line will run parallel with the chest wall, whereas bullae will have a medially concaveappearance. Pneumothoraces usually cross more than one lung segment, whereas bullae are limited to asingle lobe. A chest CT can di�erentiate the two. A thoracostomy with the chest tube inserted into a bullamistaken for a pneumothorax results in a large pneumothorax, associated bronchopulmonary fistula, and its

complications.12 Pleural adhesions cement the visceral and parietal pleura together, changing theappearance of the pneumothorax.

Pneumothorax size may be calculated by the Light index or Collins or Rhea methods, but most published

formulae show only a modest correlation to actual pneumothorax size.13,14,15,16 The American College ofChest Physicians supports a method of measurement from the apex of the lung to the cupula of the thoracic

cavity on an upright posteroanterior film.17 A measurement of less than 3 cm in this cephalad area isconsidered a small pneumothorax. Another method is to measure the interpleural distance at the level of the

hilum; in this area, a distance of 2 cm correlates with a pneumothorax of approximately 50% by volume.18

9/12/2019

5/18

The British Thoracic Society defines a small pneumothorax as one with a <2-cm rim between the lung edge

and chest wall and a large pneumothorax as one with a ≥2-cm rim.18

US

US detects traumatic pneumothorax, with a reported sensitivity of 98.1% (95% confidence interval, 89.9% to

99.9%) and specificity of 99.2% (95% confidence interval, 95.6% to 99.9%).13 The movement of the lung(ocean) against the stationary chest wall (shore) is o�en referred to as the "seashore." In a normal lung, thereis commonly a sonographic reverberation distal to the pleura that looks like a comet tail and a sliding sign ofthe movement of the visceral pleura along the parietal pleura (Figure 68-2). In the presence of intrapleural air,pleural adhesions, e�usions, and parenchymal disease, small pneumothoraces may be loculated, andtherefore, the sliding sign and the comet tail reverberation are lost, limiting the specificity for

pneumothorax.14,15

FIGURE 68-2.

US with M-mode and B-mode imaging of normal (A) and abnormal (B) pleura. [Image used with permission ofCasey Glass, MD, Wake Forest School of Medicine.]

9/12/2019

6/18

Chest CT

Chest CT detects between 25% and 40% of pneumothoraces not visualized on a postprocedure chest

radiograph.12 CT can detect other pathology such as pulmonary blebs. If a chest radiograph does notdemonstrate pneumothorax but there is clinical suspicion for the condition (e.g., in symptomatic high-riskpatients, those with underlying lung disease or positive-pressure ventilation, or a�er lung biopsy), obtain achest CT (Figure 68-3).

FIGURE 68-3.

Secondary spontaneous pneumothorax. CT of a large, le�-sided secondary spontaneous pneumothorax.Note di�use bullous emphysema.

9/12/2019

7/18

TREATMENT

The ED treatment goal is the elimination of intrapleural air. Tension pneumothorax should be diagnosedclinically—before a radiograph—and immediately treated by needle decompression followed by tubethoracostomy.

Treatment options are oxygen, observation, needle or catheter aspiration (either single or sequentialaspirations), and tube thoracostomy (either small-size or standard chest tube) (see Tables 68-2 and 68-3).Oxygen administration (>28%) increases pleural air resorption three- to fourfold over the base 1.25%reabsorbed per day, by creating a nitrogen gas pressure gradient between the alveolus and trapped

air.19,20,21 Without supplemental oxygen, a 25% pneumothorax would take approximately 20 days to resolve.Recommended dosing ranges from 3 L/min nasal cannula to 10 L/min by mask and should be guided by thepatient's status. Monitor for hypercapnia in patients with chronic obstructive pulmonary disease.

Observation is appropriate for small, stable pneumothoraces only. If this option is selected, observe thepatient for at least 4 hours on supplemental oxygen, and then repeat the chest radiograph. If symptoms andchest radiograph improve, the patient should return in 24 hours for repeat examination. First-timespontaneous pneumothorax of <20% lung volume in a stable, healthy adult may be treated initially with

oxygen therapy and observation.19,20,21,22,23,24

Aspiration or tube thoracostomy is selected based on likelihood of recurrence and likelihood of spontaneousresolution. Pneumothoraces in patients with underlying pulmonary disease are likely to recur. Largepneumothoraces and those with an air leak are unlikely to resolve without drainage. Inability to return forcare or to tolerate any pneumothorax increase (i.e., those with poor cardiopulmonary reserve) shouldprompt drainage.

9/12/2019

8/18

When deciding to intervene procedurally on a pneumothorax, the stability of the patient, the degree ofsymptoms, the size and relative change in size over time, the cause of the pneumothorax, the degree ofunderlying lung disease, the likelihood of recurrence and resolution, and the need for positive-pressureventilation are factors to consider. In situations when the patient is clinically stable (Table 68-2), various

treatment approaches can be considered (Tables 68-3 and 68-4).18,19,20,21,22,23,24,25,26,27

TABLE 68-2

Criteria for Stable Patient with Pneumothorax

Respiratory rate <24 breaths/min

No dyspnea at rest, speaks in full sentences

Pulse >60 and <120 beats/min

Normal blood pressure for patient

Room air oxygen saturation >90%

Absence of hemothorax

9/12/2019

9/18

*The term "catheter" is used for a thin flexible tube; the term "chest tube" is used for a more rigid, larger tube. French

sizes represent tube or catheter diameter (1 French = 1/3-mm diameter), and the larger the French number, the larger

the device.

TABLE 68-3

Aspiration and Thoracostomy Devices*

Single aspiration Insertion of a needle or catheter, aspiration of air using an attached syringe, and

immediate removal of the device

Needle aspiration 18-gauge needle (provided in kits as an 8-French catheter over an 18-gauge needle)

Small-size

catheter

≤14 French

Small-size chest

tube

10–14 French

Pigtail catheter 14 French, placement using Seldinger technique

Moderate-size

chest tube

16–22 French

Large-size chest

tube

24–36 French

9/12/2019

10/18

TABLE 68-4

Treatment of Pneumothorax

Condition Treatment Options

Small primary pneumothorax

(<20% or 3 cm apex-cupula and

asymptomatic)

Observation for >3 h on oxygen, repeat chest x-ray, discharge if no

symptoms, and return for check if symptoms recur or in 24 h

Or

Small-size catheter aspiration with immediate catheter removal, then

observe for >3 h, discharge if no symptoms, and return for check if

symptoms recur or in 24 h

Or

Small-size catheter aspiration or small-size chest tube insertion,

Heimlich valve, or water seal and admission

Small secondary pneumothorax Small-size catheter or small-size chest tube insertion, Heimlich valve, or

water seal and admission

Large pneumothorax, either

primary or secondary, or bilateral

pneumothoraces

Moderate-size chest tube and admission; large-size chest tube if fluid or

hemothorax present; water seal and admission

Tension pneumothorax Immediate needle decompression followed by moderate or large-size

chest tube insertion, water seal drainage, and admission; immediate

chest tube placement ideal

The selection of catheter or chest tube size is based on the flow rate of air that the device can accommodate.Select large-bore tubes for anticipated big leaks, as from mechanical ventilation. Tension pneumothorax candevelop if a large air leak develops, and small-bore tubes or catheters cannot handle the air flow. Every chesttube has a proximal hole, called the sentinel eye, which is visible radiographically and helps ensure that alldrainage holes are inside the pleural cavity. Table 68-3 provides definitions for terms and various devices

used to treat pneumothorax.26,27,28,29,30

NEEDLE DECOMPRESSION

To decompress, wear protective clothing or at least a mask to prevent material from squirting onto theoperator. Use a 14-gauge needle for adults and an 18-gauge needle for children. Select a needle at least 2inches (5 cm) long to penetrate the pleural cavity. Two locations are recommended: into the second or thirdintercostal space just above the rib (to avoid the intercostal artery) at the midclavicular line, or in the fourthor fi�h intercostal space just above the rib and at the anterior axillary line (Figure 68-4). One small

9/12/2019

11/18

postmortem study analyzing both approaches reported only a 59% success rate in entering the pleural

cavity.31 If the needle is inserted medial to the midclavicular line, mediastinal vessels can be injured. A fingercot cut at its distal end can then be placed over the needle to fabricate a one-way valve. The Heimlich valve isstill occasionally used for ambulatory treatment of pneumothorax, and serious complications with its use are

rare.32

FIGURE 68-4.

Needle placement for decompression of a right-sided tension pneumothorax. A site for a needlethoracostomy is the second intercostal space in the midclavicular line. [Reproduced with permission fromReichman EF, Simon RR: Emergency Medicine Procedures. © 2004, McGraw-Hill, New York.]

NEEDLE OR CATHETER ASPIRATION

Needle or catheter aspiration is as e�ective as thoracostomy for treating the first episode of small primary or

secondary spontaneous pneumothorax,25 with success ranging from 37% to 75%, or higher in those with

primary spontaneous pneumothorax.26 Techniques include simple one-time aspiration with a large-gaugeneedle or a small-bore catheter, repeated aspirations through a small-size catheter, or chest tube attached to

9/12/2019

12/18

a one-way valve or water seal drainage. The catheter technique has the advantages of both aspiration and

chest tube placement.27

Small-Size Catheters

The catheter technique involves placing a small catheter either into the second anterior intercostal space inthe midclavicular line or laterally at the fourth or fi�h intercostal space in the anterior axillary line a�er localanesthesia and sterile preparation. Attach a three-way stopcock, and use a 60-mL syringe to aspirate thepleural space until resistance is met, o�en triggering a cough. Close the stopcock, secure the tube, andobtain a follow-up chest radiograph to ensure lung reexpansion. Aspiration of more than 4 L suggestscontinued air leak and failure of simple aspiration. Failure of the lung to fully expand warrants anotheraspiration attempt or formal tube thoracostomy and admission.

Pigtail Catheters Using Seldinger Technique

Advantages of this technique are a smaller incision, less tissue dissection, and smaller scar.

Insert the needle into the pleural space, making sure placement is in the "triangle of safety" (Figure 68-

5).29,32 Aspirate fluid or air to verify location in the pleural space, and advance a guidewire through theneedle. Place a dilator over the guidewire until the pleural space is entered. Remove the dilator and place thechest tube over the wire into the pleural space. Remove the stylet, secure the tube, and attach to suction.

FIGURE 68-5.

Safe location of chest tube, within a triangle bordered by the fi�h intercostal space, pectoralis major, andlatissimus dorsi.

9/12/2019

13/18

Tube Thoracostomy

Chest tube thoracostomy is used to treat a large pneumothorax, recurrent or bilateral pneumothorax, orcoexistent hemothorax, or if there are abnormal vital signs or dyspnea. A chest tube is used in smallspontaneous secondary pneumothoraces where large air leak is anticipated or noted. Standard chest tubethoracostomy with underwater seal drainage is the most commonly used approach, with a low complication

rate and a success rate of 95%.24,25 Most guidelines suggest a small 10- to 14-French chest tube fornontrauma, reserving larger 14- to 22-French chest tubes if a large air leak is probable, such as frommechanical ventilation or with underlying pulmonary disease.

The technique of tube thoracostomy is described in the chapter 261, "Pulmonary Trauma."

There is no clear di�erence between simple aspiration and intercostal tube drainage in overall short- and

long-term outcomes,24 and simple aspiration is as safe and e�ective as tube thoracostomy for small-volume

air leak primary spontaneous pneumothorax.25

TREATMENT COMPLICATIONS

9/12/2019

14/18

Complications of the pneumothorax itself can include those due to hypoxia, hypercapnia, and hypotension.Reexpansion lung injury is uncommon and seen more o�en when there is collapse of the lung for greaterthan 72 hours, a large pneumothorax, rapid reexpansion, or negative pleural pressure suction of greater than

20 cm.3,8 Most patients need no treatment for re-expansion injury aside from observation or oxygen, with

virtually no adverse outcomes.30

Intervention complications include intercostal vessel hemorrhage, lung parenchymal injury, empyema, andtube malfunction (development of an air leak or tension pneumothorax). Pleurodesis for recurrenceprevention is used in those with first spontaneous pneumothorax with a persistent air leak, second ipsilateralspontaneous pneumothorax, first contralateral pneumothorax, bilateral spontaneous pneumothoraces, first

episode of a secondary pneumothorax, or recurrent high-risk activities (flying or diving).3,8

SPECIAL CONSIDERATIONS

IATROGENIC PNEUMOTHORAX

Iatrogenic pneumothorax is a subset of traumatic pneumothorax and occurs more o�en than spontaneouspneumothorax. Transthoracic needle procedures (needle biopsy and thoracentesis) account forapproximately half of iatrogenic pneumothoraces, and subclavian vein catheterization accounts for onefourth. Given that one central venous line is placed every minute in the United States and that pneumothoraxoccurs a�er 0.5% to 3.0% of subclavian line attempts, iatrogenic pneumothorax is common, underdetected,

and underreported.28 Factors associated with the increasing frequency of iatrogenic pneumothorax includethe patient population, underlying disease, body habitus, and experience of the operator. US guidance forcentral venous catheter insertion for thoracentesis reduces the pneumothorax complication rate.

Although it is routine to obtain a chest radiograph a�er central line placement or transthoracic needleprocedures, chest radiograph may not identify a pneumothorax if supine or if there is inadequate time for the

pneumothorax to develop, with up to one third detected later.28

Treatment for iatrogenic pneumothorax is generally the same as that for spontaneous pneumothorax.Patients with a small pneumothorax a�er a needle puncture and those not requiring positive-pressureventilation can be observed or initially treated with simple catheter aspiration (with or without a Heimlich

valve), which is adequate for 60% to 80% of patients.28 Long-term recurrence is not a concern with iatrogenicpneumothorax.

AIR TRANSPORT WITH PNEUMOTHORAX

Increased elevation causes an increase in gas volume (Boyle's law), increasing the risk for tensionpneumothorax in air transport patients with pneumothorax, particularly when transported in fixed-wing

vehicles (airplane) given the altitudes reached.21 High-altitude flying is not recommended for at least 7 to 14days a�er pneumothorax resolution.

9/12/2019

15/18

1. 

2. 

3. 

4. 

5. 

6. 

7. 

DIVING

Similarly, due to Boyle's law, development of a pneumothorax at depth may lead to a tension pneumothoraxwith ascent. Current guidelines suggest that a history of spontaneous pneumothorax is a contraindication to

underwater diving unless treated by surgical pleurectomy and normal lung function exists.21

DISPOSITION

Patients with a primary spontaneous pneumothorax who have been treated with observation or withcatheter aspiration can be discharged if the pneumothorax does not increase in size over 3 to 6 hours andsymptoms resolve or do not worsen. The remaining patients are observed longer or admitted, with thatdecision based on the size, therapy, and clinical condition.

REFERENCES

Gupta  D, Hansell  A, Nichols  T  et al.: Epidemiology of pneumothorax in England. Thorax 55: 666, 2000. [PubMed: 10899243]  

Abolnik  IZ: On the inheritance of primary spontaneous pneumothorax. Am J Med Genet 40: 155, 1991. [PubMed: 1897568]  

Guo  Y, Xie  C, Rodriguez  RM, Light  RW: Factors related to recurrence of spontaneous pneumothorax.Respirology 10: 378, 2005. [PubMed: 15955153]  

Hsu  NY, Shih  CS, Hsu  CP, Chen  PR: Spontaneous hemopneumothorax revisited: clinical approach andsystemic review of the literature. Ann Thorac Surg 80: 1859, 2005. [PubMed: 16242469]  

Ng  CS, Lee  TW, Wan  S, Yim  AP: Video assisted thoracic surgery in the management of spontaneouspneumothorax: the current status. Postgrad Med J 82: 179, 2006. [PubMed: 16517799]  

Sahn  SA, He�ner  JE: Spontaneous pneumothorax. N Engl J Med 342: 868, 2000. [PubMed: 10727592]  

Norris  RM, Jones  JG, Bishop  JM: Respiratory gas exchange in patients with spontaneous pneumothorax.Thorax 23: 427, 1968. [PubMed: 5664705]  

9/12/2019

16/18

8. 

9. 

10. 

11. 

12. 

13. 

14. 

15. 

16. 

17. 

18. 

Subotich  D, Mandarich  D: Accidentally created tension pneumothorax in a patient with primaryspontaneous pneumothorax—confirmation of the experimental studies, putting into question the classicalexplanation. Med Hypotheses 64: 170, 2005. [PubMed: 15533636]  

Chen  SC, Markmann  JF, Kauder  DR, Schwab  CW: Hemopneumothorax missed by auscultation inpenetrating chest injury. J Trauma 42: 86, 1997. [PubMed: 9003263]  

O'Connor  AR, Morgan  WE: Radiological review of pneumothorax. BMJ 330: 1493, 2005. [PubMed: 15976424]  

Seow  A, Kazerooni  EA, Pernicano  PG, Neary  M: Comparison of upright inspiratory and expiratory chestradiographs for detecting pneumothoraces. Am J Roentgenol 166: 313, 1996. [PubMed: 8553937]

Rowan  KR, Kirkpatrick  AW, Liu  D  et al.: Traumatic pneumothorax detection with thoracic US: correlationwith chest radiography and CT—initial experience. Radiology 225: 210, 2002. [PubMed: 12355007]  

Blaivas  M, Lyon  M, Duggal  S: A prospective comparison of supine chest radiography and bedsideultrasound for the diagnosis of traumatic pneumothorax. Acad Emerg Med 12: 844, 2005. [PubMed: 16141018]  

Goodman  TR, Traill  ZC, Phillips  AJ  et al.: Ultrasound detection of pneumothorax. Clin Radiol 54: 736,1999. [PubMed: 10580763]  

Lichtenstein  DA: Ultrasound in the management of thoracic disease. Crit Care Med 35: S250, 2007. [PubMed: 17446785]  

Hoi  K, Turchin  B, Kelly  AM: How accurate is the Light index for estimating pneumothorax size? AustralasRadiol 51: 196, 2007. [PubMed: 17419871]  

Baumann  MH, Strange  C, He�ner  JE  et al.: Management of spontaneous pneumothorax: an AmericanCollege of Chest Physicians Delphi consensus statement. Chest 119: 590, 2001. [PubMed: 11171742]  

Henry  M, Arnold  T, Harvey  J  et al.: BTS guidelines for the management of spontaneous pneumothorax.Thorax 58: ii39, 2003.

9/12/2019

17/18

19. 

20. 

21. 

22. 

23. 

24. 

25. 

26. 

27. 

28. 

[PubMed: 12728149]  

Marquette  CH, Marx  A, Leroy  S  et al.: Simplified stepwise management of primary spontaneouspneumothorax: a pilot study. Eur Respir J 27: 470, 2006. [PubMed: 16507845]  

Baumann  MH: Management of spontaneous pneumothorax. Clin Chest Med 27: 369, 2006. [PubMed: 16716824]  

Currie  GP, Allrui  R, Christie  GL, Legge  JS: Pneumothorax: an update. Postgrad Med J 83: 461, 2007. [PubMed: 17621614]  

Noppen  M, Alexander  P, Driesen  P: Manual aspiration versus chest tube drainage in first episodes ofprimary spontaneous pneumothorax. Am J Respir Crit Care Med 165: 1240, 2002. [PubMed: 11991872]  

Hassani  B, Foote  J, Borgundvaag  B: Outpatient management of primary spontaneous pneumothorax inthe emergency department of a community hospital using a small-bore catheter and a Heimlich valve. AcadEmerg Med 16: 513, 2009. [PubMed: 19438414]  

Wakai  A, O'Sullivan  RG, McCabe  G: Simple aspiration verses intercostal tube drainage for primaryspontaneous pneumothorax in adults. Cochrane Database Syst Rev 1: CD004479, 2007. [PubMed: 17253510]  

Zehtabchi  S, Rios  CL: Management of emergency department patients with primary spontaneouspneumothorax: needle aspiration or tube thoracostomy. Ann Emerg Med 51: 91, 2008. [PubMed: 18166436]  

Reed  MF, Lyons  JM, Luchette  FA  et al.: Preliminary report of a prospective randomized trial ofunderwater seal for spontaneous and iatrogenic pneumothorax. J Am Coll Surg 204: 84, 2007. [PubMed: 17189116]  

Mahmood  K, Wahidi  M: Straightening out chest tubes: what size, what type, and when. Clin Chest Med34: 63, 2013. [PubMed: 23411057]  

Massongo  M, Leroy  S, Scherpereel  A  et al.: Outpatient management of primary spontaneouspneumothorax: a prospective study. Eur Respir J June 13, 2013. [PubMed: 23766331]

9/12/2019

18/18

29. 

30. 

31. 

32. 

Kulvatunyou  N, Vijayasekaran  A, Hansen  A  et al.: Two-year experience of using pigtail catheters to treattraumatic pneumothorax: a changing trend. J Trauma 71: 1104, 2011. [PubMed: 22071915]  

Harche  H, Mabry  RL, Mazuchowski  EL: Needle thoracentesis decompression: observations frompostmortem computed tomography and autopsy. J Spec Oper Med 13: 53, 2013. [PubMed: 24227562]  

Morioka  H, Takada  K, Matsumoto  S: Reexpansion pulmonary edema: evaluation of risk factors in 173episodes of spontaneous pneumothorax. Respir Investig 51: 35, 2013. [PubMed: 23561257]  

Brims  FJ, Maskell  NA: Ambulatory treatment in the management of pneumothorax: a systematic reviewof the literature. Thorax 68: 664, 2013. [PubMed: 23515437]  

USEFUL WEB RESOURCES

An American College of Chest Physicians Delphi Consensus Statement—http://journal.publications.chestnet.org/article.aspx?articleid=1079496

British Thoracic Society guidelines for the management of spontaneous pneumothorax—http://thorax.bmj.com/cgi/content/full/58/suppl_2/ii39

McGraw HillCopyright © McGraw-Hill EducationAll rights reserved.Your IP address is 75.148.241.33 Terms of Use   •  Privacy Policy   •  Notice   •  Accessibility

Access Provided by: Brookdale University Medical CenterSilverchair