Pneumothorax: Causes, Symptoms & Treatment

Pneumothorax is an accumulation of air in the space between the lungs and the chest. It leads to functional limitations of the lungs and, as a result, oxygen deprivation.

What is a pneumothorax?

A pneumothorax is said to occur when air has accumulated in the area called the pleural space. The pleural space is a narrow space between the lungs and the chest. Both the outside of the lungs and the inner wall of the chest are lined with the pleura, a thin layer of skin. Normally, there is a negative pressure between the two layers of skin that keeps the lungs attached to the rib cage and prevents them from collapsing. In a pneumothorax, air enters the pleural space and the negative pressure is relieved. As a result, the lung no longer expands along with the rib cage when breathing and therefore takes in less oxygen. There are different gradations of pneumothorax, from mild reduction in breathing volume to total collapse of the lung lobes, and both or only one lung can be affected.

Causes

Several causes of pneumothorax are possible. Depending on the trigger, a distinction is made between idiopathic and symptomatic spontaneous pneumothorax, tension or valvular pneumothorax, and traumatic pneumothorax. In idiopathic spontaneous pneumothorax, there is no clear cause. All that is known is that approximately 90% of patients are smokers and men are more commonly affected than women. Idiopathic spontaneous pneumothorax results from a tear in the lung tissue. Symptomatic pneumothorax forms in people with pre-existing lung disease and occurs as an additional symptom. The two types described are also called closed pneumothorax because the air that enters comes from inside the body. Traumatic pneumothorax, on the other hand, is an open type because air enters the pleural space from the outside due to an injury. Another open type is tension pneumothorax or valvular pneumothorax, which is the most dangerous variant. In this case, as with a valve, only air can flow in but no longer out. In this pneumothorax, there is a lot of pressure on the lungs and heart, which causes serious circulatory problems and can lead to a life-threatening condition.

Symptoms, complaints, and signs

Pneumothorax has different symptoms depending on its severity. If only a small amount of air has entered the pleural space, the lung will remain distended and the patient will experience almost no discomfort. However, if the lung has collapsed, distinct symptoms can be noted. Typical is the sudden onset of accelerated breathing caused by shortness of breath. The affected person begins to pant and thus tries to increase the air supply. In addition, there is pain in the chest, which may radiate to the shoulder. This symptom is often interpreted as a heart attack, which can trigger strong feelings of anxiety. Furthermore, dry irritating cough may occur, which also causes pain. If the pneumothorax is caused by an injury, skin emphysema may develop at the site of the injury; this is a clearly visible accumulation of air in the subcutis. If a tension pneumothorax develops later, the above symptoms worsen and there is a danger to life. Shortness of breath increases and the skin and mucous membranes turn blue due to the lack of oxygen. The heart begins to race and beats only very shallowly. Since the blood circulation no longer functions, the blood pressure drops rapidly. The blood becomes congested. Without treatment, total failure of lung function eventually occurs and the cardiovascular system collapses.

Diagnosis and progression

Symptoms of pneumothorax can vary. If only a small amount of air has entered the pleural space, the respiratory volume is not excessively reduced and the patient experiences little discomfort. However, if the lung has completely collapsed, there is shortness of breath. Pain occurs in the chest and abdomen and in the heart region, radiating to the shoulder. In the dangerous tension pneumothorax, blood pressure drops extremely and the heart begins to race (tachycardia). The physician will already recognize the first signs of a pneumothorax by the symptoms present.When tapping (percussion) the chest, darker tapping sounds can be detected due to the increase in pressure, and when listening with the stethoscope (auscultation), altered breathing sounds can be heard. Furthermore, the skin may be bluish in color due to lack of oxygen, the blood pressure may be low, and the pulse may be higher than normal. Blood tests are used to check the oxygen level in the blood. Another diagnostic measure is X-ray, which can be used to see the collapsed lungs and the heart and diaphragm displaced by the pressure.

Complications

Pneumothorax always carries the risk of a life-threatening complication. Whether this occurs depends on its severity. Tension pneumothorax is considered the most dangerous complication. It represents an acute life-threatening emergency that can only be resolved by immediate emergency measures. Tension pneumothorax is caused by a thoracic injury, which can increase the pressure in the pleural cavity via a valve effect to such an extent that the thoracic organs are compressed. This results in, among other things, displacement of the heart to the opposite side and squeezing of the superior and inferior vena cava. The injury acts like a lip valve, which only allows air to enter the pleural space but not to escape. As a result, more and more air is drawn in with each thoracic movement. The tension continues to increase. The squeezing of the vena cavae and the displacement of the mediastinal pleura causes increasing respiratory distress and leads to a drop in blood pressure. On exhalation, the chest on the affected side no longer lowers. Plump neck veins indicate venous influence congestion due to increased pressure in the chest cavity. Even after ventilation, the patient does not recover. In order to ensure oxygen supply to the organism, there is a strong increase in heart rate. Eventually, the body can no longer be adequately supplied with oxygen. If left untreated, death then occurs due to circulatory arrest.

When should you go to the doctor?

Symptoms such as a sudden one-sided chest pain, coughing irritation or shortness of breath indicate a pneumothorax. A doctor should be consulted if the symptoms are acute and do not subside within a few minutes. Cold, clammy hands, anxiety and pale skin indicate a tension thorax, which should be clarified immediately by a physician. In case of acute shortness of breath, intense chest pain and palpitations, an emergency physician should be called immediately. Further treatment will be provided by a pulmonary specialist. Depending on the symptoms and the cause of the condition, oncologists, internists and ENT specialists may also be involved. If the symptoms occur in the context of a lung disease, the responsible physician should be informed first. People who are between 55 and 65 years old are at risk. Asthmatics, fibrosis patients and people with immune deficiency also belong to the risk groups and should go to the general practitioner or specialist quickly with the complaints mentioned. He or she can make the diagnosis and provide rapid relief of the symptoms through medication and other therapeutic measures.

Treatment and therapy

In a mild idiopathic spontaneous pneumothorax, the patient often requires only bed rest and the administration of oxygen. The air in the pleural space is usually absorbed by the body, and normal negative pressure is restored on its own. It takes between 2 and 4 weeks to return to normal. Because spontaneous pneumothorax is prone to recurrence, it is possible to inject a drug into the pleural space that glues the two layers of skin together to prevent air from entering. This is called pleurodesis. If the pneumothorax occurs as an accompanying symptom of an existing lung disease or if it was caused by an injury, a drain is often placed. This involves inserting a tube into the pleural space to drain the air and restore negative pressure. Life-threatening tension pneumothorax requires immediate emergency treatment, in which air is drained with a large cannula to equalize pressure.

Prevention

One can prevent idiopathic pneumothorax by abstaining from smoking. In case of existing lung diseases, one should consult the doctor at an early stage to prevent pneumothorax as an accompanying symptom.If the pneumothorax was treated with drainage and respiratory problems or chest pain subsequently recur, the patient must contact a physician immediately. Thus, there is a risk of respiratory failure with hypoxemia, so that there is a need for ventilation. Here, the risk depends on the extent of the lung collapse and how long the pneumothorax lasted before drainage.

Follow-up

During pneumothorax follow-up, there are several important things for the patient to keep in mind. For example, he or she must not stay at higher altitudes of 2,000 meters or more for a period of about four weeks, which is also something to consider after a surgical procedure. In addition, the affected person must take consistent physical rest for around two to four weeks. Normally, work can be resumed after pneumothorax treatment, which includes physical activities. However, sports activities that involve pronounced physical exertion should be avoided until the lungs have fully developed. After conservative therapy, it is advisable to refrain from flying until an X-ray examination has determined that the lung is fully expanded. This may take up to six months. The control examinations are mostly carried out by the general practitioner. For three months after a pneumothorax, the patient must not use a blowing instrument. Diving should also be avoided.

What you can do yourself

In a pneumothorax, air collects between the lungs and the chest. Breathing should be done without excitement or rush despite the discomfort. Anxiety and panic worsen the health condition of the affected person and aggravate the existing respiratory distress. The consumption of harmful substances such as nicotine, drugs, smoking with an e-cigarrette or a hookah pipe should be absolutely refrained from. They have a negative impact on the organism and the patient’s breathing. Places where people smoke should be widely avoided, as passive smoking also leads to impairment of respiratory activity. In addition, rooms should be regularly supplied with sufficient oxygen. Night sleep in particular should be well monitored. Regular ventilation leads to the enrichment of stuffy air with oxygen. Daily exposure to fresh air strengthens the patient and promotes good health. Overexertion of any kind should be avoided. The affected person needs rest and should not expose himself to unnecessary stress. Physical activities should be well controlled to avoid overexertion. Stress, hectic activity and conflicts should be avoided. Agitation can reduce well-being and worsen breathing. Sports activities as well as leisure time activities are to be adapted to the body’s possibilities. If the affected person notices the first irregularities, he should take a break so that sufficient regeneration takes place.