History and exam

Key diagnostic factors

common

chest pain

Chest pain occurs on the same side as the pneumothorax and is typically pleuritic in nature.[35][39]

dyspnea

The degree of dyspnea depends on the hypoxia caused and presence and severity of pre-existing lung disease. It does not necessarily correlate to the size of the pneumothorax.[1]

hyperexpanded ipsilateral hemithorax

The degree of hyperexpansion depends on the size of the pneumothorax and whether a tension pneumothorax develops.[1]

hyper-resonant ipsilateral hemithorax

Hyper-resonance on percussion of the affected side.

ipsilateral absent or diminished breath sounds

Diminished or absent breath sounds on the affected side.

uncommon

extreme breathlessness

Associated with tension pneumothorax and significant pre-existing lung disease.[1]

trachea shifted to contralateral side

Associated with tension pneumothorax. This is an important clinical finding in the evaluation of patients with pneumothorax.[1]

Risk factors

strong

cigarette smoking

The estimated lifetime risk of developing a pneumothorax in healthy smoking men is approximately 12%, compared with 0.1% in nonsmokers. Small-airway inflammation from tobacco smoke may contribute to the development of subpleural blebs.​[12][26]

family history of pneumothorax

There seems to be a familial tendency for primary spontaneous pneumothoraces. There may be either autosomal-dominant with incomplete penetrance or X-linked recessive inheritance.[15][16]

tall and slender body build

Patients with primary spontaneous pneumothoraces are usually taller and thinner than control patients. The alveoli at the lung apex are subjected to a greater mean distending pressure in taller patients, leading to the development of subpleural blebs and other abnormalities.[13][27]

age <40 years

The peak age for primary spontaneous pneumothorax is 20 years at the first episode. Primary spontaneous pneumothoraces rarely occur after 40 years of age.[13]

recent invasive medical procedure

Invasive procedures such as transcutaneous needle aspiration of lung lesions, thoracentesis, bronchoscopic transbronchial biopsy, central venous catheter placement, and positive pressure ventilation are associated with iatrogenic pneumothoraces.

chest trauma

Pneumothoraces are seen in as many as 40% to 50% of chest trauma victims.[9][10][11]

acute severe asthma

The air trapping associated with airway inflammation during an asthmatic attack can cause rupture of alveolar sacs leading to the development of a pneumothorax.[1]

COPD

This is the leading cause of secondary spontaneous pneumothoraces and is due to rupture of subpleural emphysematous blebs.[18]

tuberculosis

Secondary spontaneous pneumothoraces occur in 1.5% of cases of active pulmonary tuberculosis. Ruptures of subpleural tuberculous cysts are thought to be responsible.[21]

AIDS-related Pneumocystis jirovecii infection

Pneumocystis jirovecii necrotic subpleural cyst may cause pneumothorax in patients with a history of HIV infection and AIDS.[27]

About 2% to 5% of patients with AIDS develop a secondary spontaneous pneumothorax.[27]

cystic fibrosis

Secondary spontaneous pneumothorax is a frequent occurrence in cystic fibrosis and is associated with more severe disease. About 16% to 20% of patients with cystic fibrosis >18 years of age will experience a pneumothorax at some time in their lives. Recurrent contralateral pneumothoraces occur in 40% of patients.[28][29]

lymphangioleiomyomatosis

A multisystem disease of women, characterized by cystic lung destruction that can result in recurrent pneumothoraces.[30]

Birt-Hogg-Dube syndrome

An autosomal dominant inheritable disease characterized by pulmonary cysts, spontaneous pneumothoraces, benign skin lesions, and renal cancers. Mutations in the gene that encodes for folliculin have been identified in individuals with this familial spontaneous pneumothorax.[31]

pulmonary Langerhans cell histiocytosis

This is a smoking-related interstitial lung disease, characterized by the development of cystic changes in the lung that predisposes to pneumothorax.[32]

Erdheim-Chester disease

A rare disease characterized by disseminated non-Langerhans cell histiocytosis involving multiple organs. Pulmonary involvement is uncommon but the lung can become infiltrated by lipid-laden histiocytes, resulting in diffuse interstitial cystic changes and pneumothorax.[33]

weak

Marfan syndrome

There are reports of families afflicted with Marfan syndrome whose members suffered multiple bilateral episodes of primary spontaneous pneumothoraces. In this population, primary spontaneous pneumothoraces are attributed to pulmonary tissue fragility related to defective fibrillin.[14]

homocystinuria

There have been a few case reports of primary spontaneous pneumothoraces in patients with homocystinuria. The pathophysiology of this association is unknown.[17]

primary lung cancer and metastatic cancer to the lungs

Pneumothorax can occur in bronchogenic carcinomas and in a variety of cancers that have metastasized to the lungs. The pneumothoraces can develop following chemotherapy. It is postulated that necrosis of the peripherally located cancer causes the tumor to rupture into the pleural space, resulting in a pneumothorax.[19][20]

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