Diagnosis>Organ System>

CLINICAL

• Pneumothorax (PTX) defined by air in pleural space, either due to entry from outside chest wall or leakage from lung parenchyma.
• In HIV, occurs most often in setting of Pneumocystis pneumonia (PCP). Spontaneous PTX in AIDS pt should prompt workup for PCP.
• PCP-associated PTX independently associated with greater mortality.
• Spontaneous PTX in pts with AIDS can also occur with TB, COPD, pulmonary cryptococcosis, and lymphoid interstitial pneumonitis.
• Iatrogenic causes: central venous line placement, thoracentesis, bronchoscopy
• Presenting Sx: pleuritic chest pain, dyspnea, cough
• PE: Tachycardia, tachypnea, hypoxia, hyper-resonance or decreased breath sounds over one lung field. Some pts may not have any signs or Sx beyond those of pneumonia.
• Higher incidence in males, cigarette smokers, pts on aerosolized pentamidine prophylaxis, pts w/ pneumatoceles on CXR, injection drug users, pts on mechanical ventilation.

DIAGNOSIS

• CXR line or rim of air seen at apex of lung, beyond which there are no lung markings.
• Dx can be difficult in pts w/ pre-existing lung disease, lateral decubitus x-rays or CT can increase yield.
• CT can distinguish PTX from bullous lung disease.
• Size of PTX can be estimated based on rim of air. >2 cm correlates with >50% of hemithorax

TREATMENT

• Small PTX (<1 cm rim) can be observed in asymptomatic pt.
• Any chest pain or dyspnea requires evaluation.
• PTX in setting of PCP has higher morbidity and mortality; requires inpt management.
• Treatment with 100% oxygen can speed resolution of small PTX without chest tube.

• Needle or catheter aspiration less likely to succeed in pts with secondary PTX from underlying lung disease
• Intercostal tube thoracostomy (chest tube) should be performed by a qualified surgeon, emergency medicine physician, or trained critical care physician.
• Bubbling seen in a containment system is sign of continued air leak, and tube should be left in place.
• PTX should be followed with serial CXR.
• Tube can be removed when no air leak on water seal, and CXR shows no ongoing PTX.

• Steroids for treatment of PCP have been associated w/ longer time to resolution of PTX.
• Heimlich valve can be adapted to chest tube, which allows outpt management.
• Medical pleurodesis with talc or tetracycline can be performed at bedside through chest tube as non-operative means of managing a persistent BPF.
• Lowest recurrence rate w/ surgical pleurodesis/pleurodectomy for persistent BPF

Drug Comments

REFERENCES