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Chapter 405 Pneumothorax

Pneumothorax is the accumulation of extrapulmonary air within the chest, most commonly from leakage of air from within the lung. Air leaks can be primary or secondary and can be spontaneous, traumatic, iatrogenic, or catamenial (Table 405-1). Pneumothorax in the neonatal period is also discussed in Chapter 95.12.

Etiology and Epidemiology

A primary spontaneous pneumothorax occurs without trauma or underlying lung disease. Spontaneous pneumothorax with or without exertion occurs occasionally in teenagers and young adults, most frequently in males who are tall, thin, and thought to have subpleural blebs. Familial cases of spontaneous pneumothorax occur and have been associated with mutations in the folliculin gene. Patients with collagen synthesis defects, such as Ehlers-Danlos disease (Chapter 651) and Marfan syndrome (Chapter 693) are unusually prone to the development of pneumothorax.

A pneumothorax arising as a complication of an underlying lung disorder but without trauma is a secondary spontaneous pneumothorax. Pneumothorax can occur in pneumonia, usually with empyema; it can also be secondary to pulmonary abscess, gangrene, infarct, rupture of a cyst or an emphysematous bleb (in asthma), or foreign bodies in the lung. In infants with staphylococcal pneumonia, the incidence of pneumothorax is relatively high. It is found in ≈5% of hospitalized asthmatic children and usually resolves without treatment. Pneumothorax is a serious complication in cystic fibrosis (CF; Chapter 395). Pneumothorax also occurs in patients with lymphoma or other malignancies, and in graft versus host disease with bronchiolitis obliterans.

External chest or abdominal blunt or penetrating trauma can tear a bronchus or abdominal viscus, with leakage of air into the pleural space. Ecstasy (methylenedioxymethamphetamine) abuse has been associated with pneumothorax.

Iatrogenic pneumothorax can complicate transthoracic needle aspiration, tracheotomy, subclavian line placement, thoracentesis, or transbronchial biopsy. It may occur during mechanical or noninvasive ventilation, acupuncture, and other diagnostic or therapeutic procedures.

Catamenial pneumothorax, an unusual condition that is related to menses, is associated with diaphragmatic defects and pleural blebs.

Pneumothorax can be associated with a serous effusion (hydropneumothorax), a purulent effusion (pyopneumothorax), or blood (hemopneumothorax). Bilateral pneumothorax is rare after the neonatal period but has been reported after lung transplantation and with Mycoplasma pneumoniae