History and exam

Key diagnostic factors

common

chest pain

Typically pleuritic.[8]

Some patients with primary spontaneous pneumothorax may experience shoulder tip pain instead.[8]

dyspnoea

More prominent in secondary spontaneous pneumothorax.[8]

ipsilateral reduced breath sounds

This is the most common sign in tension pneumothorax but may also be present in a non-tension pneumothorax.

ipsilateral hyperinflation of the hemithorax with hyper-resonance on percussion

Hyperinflation may be difficult to detect clinically in a tension pneumothorax, however, and is not present in a pneumothorax ex vacuo (commonly known as ‘trapped lung’).[40]​​

hypoxia

Generally a late sign. More common in tension pneumothorax and secondary spontaneous pneumothorax.[40][46]

presence of risk factors

Smoking​[8]

  • This is the most important risk factor; men who smoke increase their risk of a first pneumothorax 22-fold and women 9-fold compared with non-smokers.[7]

Family history of pneumothorax

  • A risk factor for pneumothorax.[9]

Tall and slender body build

  • Increases the risk of pneumothorax.[8]

Male sex

  • A risk factor for pneumothorax.[8]

Young age

  • However, secondary spontaneous pneumothorax is more common in people aged >55 years.[8]

Presence of underlying lung disease

  • Lung disease that increases the risk of pneumothorax includes:

    • COPD

    • Severe asthma

    • Tuberculosis

    • Pneumocystis jirovecii infection

    • Cystic fibrosis.

  • In particular, acute presentations of asthma and bullous COPD, or long standing lung disease such as cystic fibrosis, bronchiectasis, fibrotic lung diseases, or lung cancer may increase the risk of a tension pneumothorax.[43]​​

Structural abnormalities

  • These include Marfan syndrome and Ehlers-Danlos syndrome.[10]

Recent invasive medical procedures

  • These include drainage of pleural effusion or CT-guided lung biopsy.[13][14] 

Trauma

  • Penetrating chest wounds and cardiopulmonary resuscitation are a particular risk factor for a tension pneumothorax.[12][43]​​​

Homocystinuria

  • A risk factor for pneumothorax.[9]

Menstruation

  • Catamenial pneumothorax occurs in recurrent episodes within 72 hours before or after the start of menstruation. Suspect this in women with recurrent pneumothorax and a history of endometriosis. It is rare but thought to be underdiagnosed.[8][11]

Ventilated patients

  • A risk factor for a tension pneumothorax.[43]​​

Blocked chest drain

  • A risk factor for a tension pneumothorax.[43]​​

Non-invasive ventilation (NIV)

  • A risk factor for a tension pneumothorax.[43]​​

Hyperbaric oxygen treatment

  • A risk factor for a tension pneumothorax.[41]

uncommon

cardiopulmonary deterioration

This is a feature of a tension pneumothorax and is typically sudden in onset. It includes:​[8][40]

  • Hypotension; this suggests imminent cardiac arrest

  • Respiratory distress

  • Low oxygen saturations

  • Tachycardia

  • Shock

  • Loss of consciousness.

trachea shifted to the contralateral side

This is a feature of a tension pneumothorax.

sweating

This is a feature of a tension pneumothorax.​[8][40]

Other diagnostic factors

uncommon

cough

Sometimes present in pneumothorax ex vacuo (commonly known as ‘trapped lung’).[44]

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