Diagnosis of pneumothorax in critically ill adults

Abstract

The diagnosis of pneumothorax is established from the patients' history, physical examination and, where possible, by radiological investigations. Adult respiratory distress syndrome, pneumonia, and trauma are important predictors of pneumothorax, as are various practical procedures including mechanical ventilation, central line insertion, and surgical procedures in the thorax, head, and neck and abdomen. Examination should include an inspection of the ventilator observations and chest drainage systems as well as the patient's cardiovascular and respiratory systems.Radiological diagnosis is normally confined to plain frontal radiographs in the critically ill patient, although lateral images and computed tomography are also important. Situations are described where an abnormal lucency or an apparent lung edge may be confused with a pneumothorax. These may arise from outside the thoracic cavity or from lung abnormalities or abdominal viscera inside the chest. (Postgrad Med J 2000;76:399-404)

The diagnostic performance of chest ultrasonography in the up-to-date work-up of the critical care setting

“…It is well known that pneumothorax is a frequently entertained diagnosis in the ICU (33). Its bedside diagnosis is extremely important in ICU patients (20).…”

Iatrogenic pneumothorax related to mechanical ventilation

“…Reduction in tidal volume during pressure controlled ventilation and increased airway pressure with volume controlled ventilation might be found from ventilators. A pulsus paradoxus on the arterial trace and increased central venous pressure from central venous catheterization may be observed [8,9,46,47] . It should be noted that many of the above findings are nonspecific and have not been a reliable indicator of pneumothorax given that dyspnea severity can be out of proportion to the size of the pneumothorax.…”

“…It should be noted that many of the above findings are nonspecific and have not been a reliable indicator of pneumothorax given that dyspnea severity can be out of proportion to the size of the pneumothorax. The radiographic data thus remains the gold standard for the diagnosis of pneumothorax [8] . The chest radiograph may show radiolucent hemithorax with apparent lung edge and absent lung marking.…”

“…Pneumothorax is rare in intubated patients with normal lungs and most patients with pneumothorax related to mechanical ventilation (PRMV) have underlying lung diseases that range from primary obstructive lung disease to secondary pneumonia and acute respiratory distress syndrome (ARDS) [4][5][6] . In critical illness, pneumothoraces may be difficult to diagnose when they have different clinical presentations and their locations are atypical and complicated by other disease processes in unconscious patients [7,8] . Prompt recognition and treatment of pneumothorax is important to minimize morbidity and mortality [9] because if pneumothorax is not diagnosed quickly, once tension pneumothorax ensues, it usually has a malignant course leading to death if untreated [10] .…”

Pneumothorax Related to Mechanical Ventilation: Silent Enemy

“…5,6 Unrecognized pneumothorax in patients on mechanical ventilation could rapidly progress to tension pneumothorax which is more common in this patient population, occurring in 30%-97% of all pneumothoraces. [7][8][9] .…”