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Spontaneous pneumothorax

A pneumothorax is an abnormal collection of air in the pleural space that causes an uncoupling of the lung from the chest wall. Symptoms typically include sudden onset of sharp, one sided, chest pain and shortness of breath. In a minority of cases the amount of air in the chest increases when a one-way valve is formed by an area of damaged tissue, leading to a tension pneumothorax. This condition can cause a steadily worsening oxygen shortage and low blood pressure. Unless reversed by effective treatment, it can result in death. Very rarely both lungs may be affected by a pneumothorax. It is often called a collapsed lung, although that term may also refer to atelectasis.

A primary pneumothorax is one that occurs without an apparent cause and in the absence of significant lung disease, while a secondary pneumothorax occurs in the presence of existing lung disease. Smoking increases the risk as do lung diseases including COPD, asthma, and tuberculosis. A pneumothorax can also be caused by physical trauma to the chest (including a blast injury), or as a complication of a healthcare intervention; in which case it is called a traumatic pneumothorax.

Diagnosis of a pneumothorax by physical examination alone can be difficult (particularly in smaller pneumothoraces). A chest X-ray, computed tomography (CT) scan, or ultrasound is usually used to confirm its presence. Other conditions that can result in similar symptoms include a hemothorax (buildup of blood in the pleural space), pulmonary embolism, and heart attack. A large bullae may look similar on a chest X-ray.

A small spontaneous pneumothorax will typically resolve without treatment and requires only monitoring. This approach may be most appropriate in people who have no underlying lung disease. In a larger pneumothorax, or if there is shortness of breath, the air may be removed with a syringe or a chest tube connected to a one-way valve system. Occasionally, surgery may be required if tube drainage is unsuccessful, or as a preventive measure, if there have been repeated episodes. The surgical treatments usually involve pleurodesis (in which the layers of pleura are induced to stick together) or pleurectomy (the surgical removal of pleural membranes). About 17–23 cases of pneumothorax occur per 100,000 people per year. They are more common in men than women.

Signs and symptoms
Illustration depicting a collapsed lung or Pneumothorax
A primary spontaneous pneumothorax (PSP) tends to occur in a young adult without underlying lung problems, and usually causes limited symptoms. Chest pain and sometimes mild breathlessness are the usual predominant presenting features. People who are affected by PSPs are often unaware of potential danger and may wait several days before seeking medical attention. PSPs more commonly occur during changes in atmospheric pressure, explaining to some extent why episodes of pneumothorax may happen in clusters. It is rare for PSPs to cause tension pneumothoraces.

Secondary spontaneous pneumothoraces (SSPs), by definition, occur in individuals with significant underlying lung disease. Symptoms in SSPs tend to be more severe than in PSPs, as the unaffected lungs are generally unable to replace the loss of function in the affected lungs. Hypoxemia (decreased blood-oxygen levels) is usually present and may be observed as cyanosis (blue discoloration of the lips and skin). Hypercapnia (accumulation of carbon dioxide in the blood) is sometimes encountered; this may cause confusion and - if very severe - may result in comas. The sudden onset of breathlessness in someone with chronic obstructive pulmonary disease (COPD), cystic fibrosis, or other serious lung diseases should therefore prompt investigations to identify the possibility of a pneumothorax.