pneumothorax

Definition of pneumothorax

Acronym of PNX, pneumothorax is a benign pathological condition in which there is the presence of gas within the pleural cavity. In other words, the pneumothorax is an expression of an abnormal accumulation of air within the space that separates the lung from the chest wall. A similar condition can cause serious breathing disorders: by exerting a marked pressure on the lung, the air accumulated in situ prevents it from expanding normally, thus causing dyspnea and pain during the respiratory act.

To understand...

Under physiological conditions, a pressure lower than the atmospheric pressure is exerted on the external surfaces of the lungs. In this way, the lung is perfectly capable of fulfilling its function. In the case of pneumothorax, this pressure difference is absent, therefore the elastic feedback of the lung is favored; failing to expand, the lung is destined to collapse on itself (like a punctured ball)

• The air penetrated into the pleural cavity hinders the adhesion between the lung and the internal thoracic walls. By shrinking, the lung reduces its volume and causes dyspnea.

Causes

The pneumothorax recognizes various causes and it is precisely on the basis of the trigger that different pathological forms can be identified:

1. Spontaneous pneumothorax: the collapse of the lung appears suddenly, without a precise and observable motive. Spontaneous pneumothorax is divided into two variants: primary and secondary. The primary (or primitive) form begins in young subjects without any underlying pulmonary disorder; the secondary variant, on the other hand, occurs when a patient has severe lung dysfunction, and represents a more serious condition than the previous one.
2. Traumatic pneumothorax: the pathology is the result of traumatic injuries, such as gunshots to the chest, stabbings in the back, fractures of the ribs or surgical errors. The disease assumes the connotation of hemo-pneumothorax when blood accumulates in addition to gas in the pleural cavity.
3. Iatrogenic pneumothorax: direct expression of invasive therapeutic / diagnostic maneuvers, such as pleural biopsy, central venous catheterization and trans-thoracic needle-aspirate.

It has been observed that pneumothorax occurs most frequently among males of young age, especially if they are long-limbed. However, other risk factors that predispose a subject to the appearance of this lung disease have also been identified.

The main factors predisposing to pneumothorax are listed below:

• Acute asthma
• COPD (chronic obstructive pulmonary disease)
• Lung cancer
• Emphysema
• Cystic fibrosis
• Idiopathic pulmonary fibrosis
• Lung infections (sustained by bacteria or parasites)
• Histiocytosis (abnormal and uncontrolled proliferation of histiocytes in the blood and tissues, responsible for cancer)
• Connective tissue disorders (eg Marfan syndrome, rheumatoid arthritis, ankylosing spondylitis)
• Pertussis
• Sarcoidosis
• Sarcoma
• smoking
• Tuberculosis

Incidence

From medical statistics, interested results have emerged regarding the incidence of pneumothorax. It is estimated that the spontaneous variant of the disease appears more frequently in male boys from the age of 20, while those in their forties are rarely affected; the statistics instead show different data regarding secondary spontaneous pneumothorax: in this case, the target is men aged between 60 and 65 years.

It is estimated that 18 males per 100, 000 men are affected annually by pneumothorax. As for the female sex, it is observed that every year only 6 out of 100, 000 women complain of this discomfort.

Another element analyzed by statesmen is the frequency with which pneumothorax manifests itself in relapsing form. It is believed that 30% of patients admitted for primary spontaneous pneumothorax are again affected by the same problem within 6 months to 3 years after the first acute episode. On the other hand, spontaneous secondary pneumothorax recurs in 45% of affected patients. The risk of relapse seems to increase with aging, with the smoking habit and in the presence of pulmonary fibrosis.

Moreover, in the case of AIDS and COPD, the risk of relapses of pneumothorax and poor prognosis increases excessively.

• Quitting smoking minimizes the risk of relapses

Symptoms

The symptoms that accompany the pneumothorax can be vague and doubtful, especially in mild forms. In the more serious variants, however, the prodromes can be particularly accentuated: in similar situations, the pneumothorax constitutes a medical emergency in all respects.

The symptoms that characterize most forms of pneumothorax are: dyspnea, hypoxia, chest pain and intrascapular pain (perceived as a sort of vibration or crackling during inspiration). Depending on the severity of the condition, the affected patient may also complain of fatigue, altered blood pressure, cyanosis (due to lack of oxygen), pain at the carotid artery, leg, arm and mouth paresthesia, chest tightness, tachycardia and vertigo.

Diagnosis

Often times, simple physical examination is not sufficient to confirm the diagnosis of pneumothorax. CT (computed tomography) or chest radiography are generally the two most widely used diagnostic techniques for the confirmation of the pathology.

• A differential diagnosis must be made with pleural effusion, simple chest pain and pulmonary embolism

Care

The goal of treatment for pneumothorax is to alleviate the pressure exerted on the lung in order to ensure its re-expansion. The choice of a therapy option rather than another depends on the form in which the pathology is manifested.

Not all pneumothorax variants require immediate medical treatment. When it runs asymptomatically, pneumothorax tends to resolve spontaneously over a period of about ten days. A similar therapeutic approach can only be considered in the absence of underlying severe lung injury. Even when only a portion of the lung has collapsed, the doctor may choose not to subject the patient to any invasive treatment; however, the client's monitoring is essential.

Different discourse needs to be addressed for the more aggressive variants: in such circumstances, the patient is subjected to chest drainage . This medical practice consists of inserting a hollow needle or tube between the ribs, precisely in the pleural space filled with air that presses on the collapsed lung. The tube is connected to a suction system capable of constantly removing the air that has accumulated in situ. This particular device can be removed after a few hours or a few days, depending on the severity of the condition.

Surgery can be recommended both when the drainage has not produced satisfactory results, and as a precautionary form to avoid relapses:

1. Pleurodesis: encourages lung adhesion to the chest wall. Pleurodesis can be surgical (surgery in all respects) or medical (instillation of sclerosing drugs by pleural catheter)
2. Pleurectomy: partial excision of the parietal pleura

There is no way to avoid pneumothorax; however, quitting smoking can significantly reduce the chances of relapse.