Journal of Cardiovascular Nursing

Vol. 20, No. 4, pp 251-253 I © 2005 Lippincon Williams & Wikins, Inc.

eumothorax
Assessment and Diagnostic
Testing
Beverly Ryan, MSN, RN, ACNP

Acute pneumothorax and the presence of air in the pleural space, is a relatively common and
potentially life-threatening cause of chest pain. Early recognition and treatment are essential in
decreasing the morbidity and mortality from this condition. Knowledge of the diseases and
procedures associated with an increased risk for pneumothorax, as well as the frequent signs
and symptoms upon presentation, will assist the clinician in its early identification.
KEYWORDS: chest pain, dyspnea, pneumothorax

T he differential diagnosis of chest pain includes

pneumothorax, a potentially life-threatening
event. Pneumothorax is rhe presence of free air in the
pleural space resulting in partial or total lung col-
lapse. The parietal and visceral pleurae lie next to
each other, forming a pleural space in which the nor-
mal pressure is less than atmospheric pressure—this
negative pressure maintains lung expansion. A dis-
ruption of either of the pleura linings allows for the
introduction of air into this potential space, altering
the pressure gradient and causing a loss of the nega-
tive pressure and resultant partial or total collapse of
the lung. Knowledge of the risk factors, signs, and
symptoms of a pneumothorax will lead to prompt
recognition and decrease complications and mortal-
ity from this condition.
Pneumothorax is either spontaneous or trau-
matic. A spontaneous pneumothorax occurs without
a precipitating cause and may be either primary or
secondary. A traumatic pneumothorax occurs from
either blunt or penetrating trauma. Spontaneous
pneumothorax affects an estimated 20,000 patients
per year in the United States.' In some geographic
areas, more than 21% of pneumothoraces seen are
due to use of illicit drugs, through attempts to inject
Beverly Ryan. MSN, RN, ACNP
Acute Care Nurse Practitioner and Clinical Lung Transplant
Coordinator, University of Virginia, Charlottesville
Corresponding author
Beverly Ryan. MSN, RN, ACNP. University of Virginia. Box 800191,
Charlottesvtile, VA 22908 (e-mail: bjb6d®v)rginia.edu).
drugs into the subclavian or jugular vein." Iatrogenic
pneumothoraces are considered traumatic, and
result from a complication of medical treatments or
procedures such as lung biopsy, thoracentesis, liver
biopsy, nasogastric tube placement, and central-line
insertion.
Incidence
A primary spontaneous pneumothorax (PSP) is not
associated with underlying pulmonary disease;
however, 48% to 79% of patients who have recur-
rent PSP are found to have blehs or bullae during
thorascopy.' The ratio of PSP in men to women is
approximately 6:1, with the annual rate estimated
at 7.4 cases per 100,000 men and 1.2 cases per
100,000 women. Sixty-five percent of cases of PSP
occur in young adults, especially tall, thin men,
between the ages of 20 and 40 years."* Recurrence is
common with greater than one third of patients
having a second episode within several years.
Patients who have PSP are more likely to have a his-
tory of smoking, the risk increasing with the
amount smoked.
Secondary spontaneous pneumothorax (SSP)
occurs in association with an underlying pul-
monary disease that weakens the alveolar-pleural
barrier. The annual incidence of SSP also has a
male predominance, estimated at 6.3 cases per
100,000 men and 2.0 cases per 100,000 women.''
Chronic obstructive pulmonary disease (COPD) is
the leading cause of SSP. Other causes of SSP

251
252 Journal of Cardiovascular Nursing | July/August 2005
include infections, interstitial lung diseases, and
pulmonary malignancies, which may also cause a
pneumothorax (Table 1).
Either blunt trauma or penetrating wounds may
cause disruption of the pleural space and pneumoth-
orax. Rib fractures may or may not he present in
patients with a blunt trauma pneumothorax. Force
applied at full inspiration with the glottis closed may
lead to pneumothorax due to increased intra-alveolar
pressure and rupture of the alveoli. Mechanical ven-
tilation has an overall associated incidence of pneu-
mothorax of 5%. This incidence increases dramati-
cally in patients with underlying lung diseases, such
as COPD, inflammatory lung disease, and acute res-
piratory distress syndrome (ARDS). Central-line
insertions are associated with a 3% to 6% incidence
of pneumothorax.
All types of pneumothorax may progress to ten-
sion pneumothorax, a life-threatening complica-
tion. Tension pneumothorax occurs in 1% to 3% of
spontaneous pneumothoraces and can occur at any
stage of treatment.^ Disruption of the alveolar-pleu-
ral interface creates a 1-way valve, allowing air to
enter the pleural space and preventing its exit.
Progressive accumulation of trapped air creates
increased pressure within the space, causing total
collapse of the lung on the affected side. Eventually
the increased pressure causes a shift of the medi-
astinum and compression of the contralateral lung,
heart, and great vessels. Without treatment,
decreased venous return, decreased cardiac output,
and cardiovascular collapse lead to death. As ten-
sion pneumothorax is a rapidly progressive condi-
tion, early identification is essential and requires
immediate decompression.
Causes of Secondary Spontaneous
Pneumothorax
Lung diseases
Chronic obstructive pulmonary disease
Asthma
Cystic fibrosis
Sarcoidosis
Lymphangioleiomyomatosis
Histiocytosis X
Idiopathic pulmonary fibrosis
infectious causes
Pneumocystis pneumonia
Tuberculosis
Necrotizing pneumonia
Others
Malignancy
Pulmonary infarction
Catameniai
Marfan syndrome
Radiation therapy
Assessment
The 2 most common symptoms produced by a pneu-
mothorax are sudden onset chest pain and dyspnea,
usually while the patient is at rest. Patients typically
describe the chest pain associated with a pneumoth-
orax as sharp and pleuritic in nature, increasing with
deep inspiration, and occurring on the ipsilateral
side. The intensity of the pain is not necessarily asso-
ciated with the size of the pneumothorax. With time,
the pain may change to a dull steady ache and com-
pletely resolve within 24 to 72 hours without treat-
ment. As many as 30% of patients may have very
mild or vague nonspecific symptoms such as malaise,
and delay treatment for days.'''''
The severity of the dyspnea is dependent on the
presence of underlying lung disease and, to a lesser
extent, the size of the pneumothorax. Lack of pul-
monary reserve may lead to severe dyspnea with even
minimal-sized pneumothoraces. As does the chest
pain associated with a pneumothorax, dyspnea may
also resolve within several days without treatment.
Physical Examination
The most common physical finding on examination
of the patient with a pneumothorax is a moderate
sinus tachycardia, with a heart rate usually less than
140 beats per minute (hpm). Depending on the size of
the pneumothorax, decreased breath sounds, hyper-
resonance to percussion, and absent tactile fremitus
on the affected side may be present. The affected side
may appear larger on inspection and move less during
respiration. Detection of a pneumothorax of less than
20% on clinical examination is often not possible.
Subcutaneous emphysema from the introduction of
air into the tissue around the chest, neck, and face
may occur. Signs of this include swelling in the
affected area and crepitus upon auscultation and pal-
pation. Hypoxia is most common in patients with
underlying pulmonary disease, and in those with
pneumothorax greater than 25%. Patients who have
a large degree of intrapulmonary shunting and perfu-
sion of the nonventilated portion of the lung will also
be relatively more hypoxic.''''' Diagnosis of a pneu-
mothorax by physical examination in patients with
underlying lung disease is difficult, in that physical
findings such as decreased breath sounds and dyspnea
are present due to their disease process.
The signs and symptoms of a tension pneumotho-
rax are more dramatic. Patients present with severe
respiratory distress, cyanosis, absent breath sounds
on the affected side, sinus tachycardia with a rate
more than 140 bpm, jugular venous distension, and
pulsus paradox. A later sign is tracheal deviation,
resulting from the midline shift. Hypotension and

TABLE 2 Physical Findings in Pneumothorax
Respiratory
Tachypnea
Use of accessory respiratory muscles
Asymmetric chest expansion
Diminished or absent breath sounds
Hyperresonance to percussion
Decreased vocal fremitus
Deviation of trachea to contralaterai side
Subcutaneous emphysema
Increased peak airway pressure in ventilated patients
Cardiovascular
Jugular venous distention
Cyanosis
Distant heart sounds
Tachycardia
Hypertension
Hypotension
Pulsus paradox
ECG changes
Neurological
Restlessness
Agitation
Confusion
Obtundation
mental status changes occur because of decreased
cardiac output. The diagnosis of tension pneumotho-
rax is a clinical one, and patients presenting with the
classic signs and symptoms of a tension pneumotho-
rax must receive immediate treatment (Table 2).
Diagnostic Tests
For those patients who are stable, the mainstay of
diagnosis is the chest radiograph. The upright posi-
tion is preferred because air rises to the nondepen-
dent portion of the pleura, and the pneumothorax
becomes evident in the apex of the affected lung. The
radiograph shows a separation of the visceral pleural
line from the chest wall by an avascular zone.
Diagnosis of pneumothorax by radiograph is made
more difficult by coexisting conditions such as bul-
lous emphysema. In questionable cases, expiratory
films may be helpful in diagnosis. During expiration,
the volume of gas in a pneumothorax remains con-
stant while the size of the hemithorax decreases,
accentuating the appearance of the pleural air. Supine
films are recommended only for those patients too
unstable to obtain upright views. They are often dif-
ficult to interpret, as the pleural air rises and collects
anteriorly and at the base of the lung. Anterolaterai
air may increase the radiolucency at the costophrenic
sulcus, causing the deep sulcus sign, diagnostic of a
pneumothorax.'^ Lateral decuhitus films may also
improve recognition of the air collection, as the air
will rise up along the lateral chest wall. In the criti-
cally ill patient, a chest computed tomographic scan
Pneumothorax 253
may be necessary to diagnose a pneumothorax if
erect or decubitus films cannot be obtained.
Chest x-ray findings of a tension pneumothorax
include total or partial lung collapse, mediastinal shift,
and depression of the diaphragm. Often the rib cage is
expanded because of the large volume of air present in
the chest. Tension pneumothorax may be present
without total collapse of the lung due to underlying
lung disease that prevents collapse.'' Tension pneu-
mothorax is a clinical diagnosis, and treatment should
not be delayed to obtain a chest x ray.
Electrocardiogram changes can occur in patients
with a left tension pneumothorax. These may include
a rightward shift of the QRS axis, reduced precordial
R-wave voltage, decreased QRS amplitude, electrical
alternans, and precordial T-wave inversions. These
changes are related to the shift in the position of the
heart within the thoracic cavity and do not indicate
cardiac ischemia or injury.'''"'
In summary, more than 20,000 patients per year are
affected by PSP and SSP,' a potentially life-threatening
condition. This diagnosis must be considered in the
differential diagnosis of nonischemic chest pain as
early recognition and treatment are essential in
decreasing the morbidity and mortality from this
condition. A high index of suspicion based on the
knowledge of the frequent signs and symptoms and
diseases associated with pneumothorax will help
improve outcomes.
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