We break down pneumothorax: risks, diagnosis, and management pearls.
Hosts:
Christopher Pham, MD
Brian Gilberti, MD
https://media.blubrry.com/coreem/content.blubrry.com/coreem/Pneumothorax.mp3
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Tags:
Chest Trauma,
Pulmonary,
Trauma
Show Notes
Risk Factors for Pneumothorax
* Secondary pneumothorax
* Trauma: rib fractures, blunt chest trauma (as in the case).
* Iatrogenic: central line placement, thoracentesis, pleural procedures.
* Primary spontaneous pneumothorax
* Young, tall, thin males (10–30 years).
* Connective tissue disorders: Marfan, Ehlers-Danlos.
* Underlying lung disease: COPD with bullae, interstitial lung disease, CF, TB, malignancy.
* Technically, anyone is at risk.
Symptoms & Differential Diagnosis
* Typical PTX presentation: Dyspnea, chest pain, pleuritic discomfort.
* Exam clues: unilateral decreased breath sounds, focal tenderness/crepitus.
* Red flags (suggest tension PTX):
* JVD
* Tracheal deviation
* Hypotension, shock physiology
* Severe tachycardia, hypoxia
* Differential diagnoses:
* Pulmonary: asthma, COPD, pneumonia, pulmonary edema (SCAPE), ILD, infections.
* Cardiac: ACS, CHF, pericarditis.
* PE and other acute causes of dyspnea.
Diagnostics
* Bloodwork: limited role, except type & screen if intervention likely.
* EKG: reasonable given chest pain/shortness of breath.
* Imaging:
* POCUS (bedside ultrasound)
* High sensitivity (86–96%) & specificity (97–100%).
* Signs:
* Seashore sign: normal lung sliding.
* Barcode sign: absent lung sliding.
* Lung point: most specific for PTX.
* CXR
* Sensitivity ~70–90% for small PTX.
* May show pleural line, hyperlucency.
* CT chest (gold standard)
* Defines size/severity.
* Rules out mimics (bullae, pleural effusion, hemothorax).
* Guides intervention choice.
Management
* First step for all: Oxygen supplementation (non-rebreather if possible).
* Accelerates resorption of pleural air.
* Stable vs. unstable decision point:
* Unstable/tension PTX
* Immediate needle thoracostomy (14-g angiocath, 2nd ICS midclavicular).
* Temporizing until chest tube/pigtail placed.
* Stable, small PTX (<2 cm on O₂)
* Observation, supplemental O₂, conservative management.
* Stable, larger PTX or symptomatic
* Chest tube or pigtail catheter insertion.
* Pigtail catheters: less invasive,
