Spontaneous pneumothorax especially common in teenagers caused for example by a rupture of a small lung bubble without common lung disease.
Risk of recurrence is 16% after the first and 80% after the third episode.
Pneumothorax may be caused a trauma (lung injured by broken ribs), a penetrating chest wall injury (sucking chest wound), an injury of the tracheobronchial tree, a severe asthmatic attack, pulmonary infections with development of an air fistula, artificial ventilation, resuscitation, or by a congenital cystic lung disease.
Induced by a vale – like mechanism, tension pneumothorax is caused by an increasing accumulation of air within the pleural cavity leading to a mediastinal shift (dangerous situation).
In cases of mild spontaneous pneumothorax mild or no symptoms.
Chest pain and shortness of breath, varying degrees of respiratory distress.
Reduced or missing breath sounds on the side of the pneumothorax.
In patients suffering from tension pneumothorax (beside the respiratory insufficiency) hemodynamic deterioration (neck vein distension in normovolemic patients) occurs.
Thoracic X-ray (do not confuse up the medial margin of the scapula with the lung surface), eventually CT scan.
Observation in cases of minimally closed stable pneumothorax. Supplemental oxygen may be necessary.
If significant symptoms occur insert a chest tube (2nd or 3rd intercostal space in the medioclavicular line (classic technique) or in the medioaxillary line at the level of the breast nipples) to provide a water – seal drainage (Bülau drainage).
- Perform a small skin incision after local (general) anaesthesia.
- With the tip of a clamp slowly perforate the intercostal space via the upper edge of the rib.
- Remove the clamp and insert the chest tube (reinforced by a trocar) through the prepared canal.
- Remove the trocar and fix the tube with sutures (size: 3-0 to 1). A second suture is placed to close the skin after the chest tube removal.
- Connect the chest tube to the water – sealed drainage system (Bülau system).
- Induced by breathing movements, air bubbles should pass the water sealed drainage system.
Surgical therapy should be considered if the air leak is persistent over a period of one week of water – sealed drainage, if the CT scan shows an underlying lung disease, if we have to deal with the second episode and if full lung expansion is not possible.
- Surgical methods: closure of the air leak (suture or stapling with bleb resection) and/or parietal pleurectomy (apical and anteriolateral areas) via thoracotomy or thoracoscopic surgery. By using only the thoracoscopic approach pulmonary blebs may be overlooked.
In cases of multiple recurrences, intrapleural instillation of tetracycline (Vibravenoes® and for pain control: e.g. 2% lidocaine administration into the chest tube 30 minutes before instillation) to obliterate the pleural cavity (pleurodesis) may be indicated.
Chest tubes may be removed if the lung is fully expanded and drainage volumes decrease below 20 to 50cc during a 24 hours period.
Start respiratory exercises beginning as soon as possible.
Some element of lung function may be permanently lost if the lung is not completely reexpanded.
Children younger than 9 years of age are unlikely to develop a recurrence.
After simple drainage therapy older children have a mean recurrence rate of about 50% (16% after the first, 80% after the third episode).
Thoracotomy, resection of the blebs and sometimes pleurectomy is the most suitable surgical method to avoid recurrence.