Prognosis Ft. DDx pneumothorax

8/9/2019 Prognosis Ft. DDx pneumothorax

1/5

This section reviews some important points to consider in the diagnosis ofpneumothoraces.

Spontaneous pneumothorax

Because patients with primary spontaneous pneumothorax (PSP) will have apicalemphysematous pulmonary disease on computed tomography (CT) scanning orthoracoscopy, they can e thought to have a congenital syndrome of mild acinaremphysema, whose expression is enhanced y environmental factors (eg, smo!ing)

"ust as it is in patients with alpha#$#antitrypsin deficiency and %typical% emphysema.

&olliculin gene disorders have een descried in familial spontaneous pneumothorax .

These patients may have pneumothorax as the presenting symptom of Birt#'ogg#uedisease.*+ Some authors recommend screening patients with a family history ofpneumothorax for the enign s!in tumors and renal cancers that arise from the disease.

Catamenial pneumothorax is a rare cause of recurrent pneumothorax in women. Prior torecurrence, this condition may initially e diagnosed as PSP.

Pneumonia is a possile cause of pneumothorax in the patient with humanimmunodeficiency virus infection ('-), Pneumocystis jiroveci pneumonia(PCP) , toxoplasmosis, and /aposi sarcoma need to e considered . 0 patient with '-can have spontaneous pneumothorax as the presenting symptom of their illness1 '-carries a lifetime ris! of 23 for pneumothorax, and aout 4*3 of that numer is relatedto PCP pneumonia.

The rare event of spontaneous pneumothorax leading to tension pneumothorax may emisdiagnosed as an asthma crisis or exaceration of chronic ostructive pulmonarydisease (C5P) in the patient presenting with tachycardia, sucutaneous emphysema,dyspnea, and shoc!.

Traumatic pneumothorax

0lways consider pneumothorax in the differential diagnosis of ma"or trauma. -n thepatient with lunt trauma and mental status changes, hypoxia, and acidosis, symptomsof a tension pneumothorax may e mas!ed y associated and similarly potentially lethalin"uries.

6hen assessing the trauma patient, e aware that clinical presentations of tensionpneumothorax and cardiac tamponade may e similar.

Tension pneumothorax

The diagnosis of a tension pneumothorax should largely e made ased on the historyand physical examination findings. 7ltrasonography in the emergency setting is eing


2/5

increasingly used as an ad"unct to the physical examination when there is doutregarding the diagnosis. Chest radiography or CT scanning should e used only inthose instances when the clinician is in dout regarding the diagnosis and when thepatient8s clinical condition is hemodynamically stale. 5taining such imaging studieswhen the diagnosis of tension pneumothorax is not in 9uestion causes an unnecessary

and potentially lethal delay in treatment.

0 tension pneumothorax is a life#threatening condition and re9uires immediate action(eg, needle thoracostomy or chest tue insertion). 'owever, the clinician should e waryof prematurely diagnosing a tension pneumothorax in a patient without respiratorydistress, hypoxia, hypotension, or cardiopulmonary compromise. -f the patient8s clinicalpresentation is 9uestionale and if the patient appears stale, the clinician shouldreexamine the patient and use edside ultrasonography or re9uest immediate portalechest radiography (or reexamine the chest radiographs if they have already eenotained) to confirm the diagnosis.

0 high index of suspicion for tension pneumothorax is recommended in patients onmechanical ventilation with acute onset of hemodynamic instaility, difficult ventilationwith high inspiratory pressures, and worsening hypoxemia and:or hypercapnia, evenwith a functioning chest tue in place. Patients at greatest ris! of a pneumothoraxand:or tension pneumothorax include those with C5P who are using ventilators thosewith acute respiratory distress syndrome (0;S) and those receiving a tidal volumegreater than $< m=:!g, a pea! airway pressure greater than 2> cm '


3/5

• Pulmonary @mpyema and 0scess

• Tuerculosis

Differential Diagnoses

• 0cute Coronary Syndrome

•

0cute ;espiratory istress Syndrome• 0ortic issection

• Congestive 'eart &ailure and Pulmonary @dema

• @sophageal ;upture and Tears

• ?yocardial -nfarction

• Pericarditis and Cardiac Tamponade

• Pulmonary @molism

• ;i &racture

Prognosis

Primary, secondary, and recurring spontaneous pneumothorax

Complete resolution of an uncomplicated pneumothorax ta!es approximately $> days.

PSP is typically enign and often resolves without medical attention. ?any affected

individuals do not see! medical attention for days after symptoms develop. This trend is

important, ecause the incidence of reexpansion pulmonary edema increases in

patients whose chest tues have een placed A or more days after the pneumothorax

occurred.

;ecurrences usually stri!e within the first 2 months to A years. The *#year recurrence

rate is


4/5

Bullous lesions found on computed tomography (CT) scan or at thoracoscopy and the

presence of emphysematousli!e changes in PSP are also not predictive of recurrence.

'owever, contralateral les were seen y CT scanning in higher fre9uency in the

patients with contralateral recurrence (AA patients $3) than those without a

contralateral recurrence in a retrospective study of


5/5

syndrome, even with surgical intervention. Traumatic mediastinum, although present in

up to 23 of patients does not portend serious in"ury .

Documents

Prognosis Ft. DDx pneumothorax