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osis or other serious lung diseases should therefore prompt investigations to identify the possibility of a pneumothorax 15 18 traumatic pneumothorax most commonly occurs when the chest wall is pierced such as when a stab wound or gunshot wound allows air to enter the pleural space or because some other mechanical injury to the lung compromises the integrity of the involved structures traumatic pneumothoraces have been found to occur in up to half of all cases of chest trauma with only rib fractures being more common in this group the pneumothorax can be occult not readily apparent in half of these cases but may enlarge particularly if mechanical ventilation is required 16 they are also encountered in people already receiving mechanical ventilation for some other reason 16 upon physical examination breath sounds heard with a stethoscope may be diminished on the affected side partly because air in the pleural space dampens the transmission of sound measures of the conduction of vocal vibrations to the surface of the chest may be altered percussion of the chest may be perceived as hyperresonant like a booming drum and vocal resonance and tactile fremitus can both be noticeably decreased importantly the volume of the pneumothorax may not be well correlated with the intensity of the symptoms experienced by the victim 18 and physical signs may not be apparent if the pneumothorax is relatively small 16 18 tension pneumothorax edit tension pneumothorax is generally considered to be present when a pneumothorax primary spontaneous secondary spontaneous or traumatic leads to significant impairment of respiration and or blood circulation 19 this causes a type of circulatory shock called obstructive shock tension pneumothorax tends to occur in clinical situations such as ventilation resuscitation trauma or in people with lung disease 18 it is a medical emergency and may require immediate treatment without further investigations see treatment section 18 19 the most common findings in people with tension pneumothorax are chest pain and respiratory distress often with an increased heart rate tachycardia and rapid breathing tachypnea in the initial stages other findings may include quieter breath sounds on one side of the chest low oxygen levels and blood pressure and displacement of the trachea away from the affected side rarely there may be cyanosis altered level of consciousness a hyperresonant percussion note on examination of the affected side with reduced expansion and decreased movement pain in the epigastrium upper abdomen displacement of the apex beat heart impulse and resonant sound when tapping the sternum 19 tension pneumothorax may also occur in someone who is receiving mechanical ventilation in which case it may be difficult to spot as the person is typically receiving sedation it is often noted because of a sudden deterioration in condition 19 recent studies have shown that the development of tension features may not always be as rapid as previously thought deviation of the trachea to one side and the presence of raised jugular venous pressure distended neck veins are not reliable as clinical signs 19 cause edit a schematic drawing of a bulla and a bleb two lung abnormalities that may rupture and lead to pneumothorax primary spontaneous edit spontaneous pneumothoraces are divided into two types primary which occurs in the absence of known lung disease and secondary which occurs in someone with underlying lung disease 20 the cause of primary spontaneous pneumothorax is unknown but established risk factors include being of the male sex smoking family history of pneumothorax and a tall thin build 21 22 smoking either cannabis or tobacco increases the risk 3 the various suspected underlying mechanisms are discussed below 15 16 secondary spontaneous edit secondary spontaneous pneumothorax occurs in the setting of a variety of lung diseases the most common is chronic obstructive pulmonary disease copd which accounts for approximately 70 of cases 21 the following known lung diseases may significantly increase the risk for pneumothorax type causes diseases of the airways 15 copd especially when bullous emphysema is present acute severe asthma cystic fibrosis infections of the lung 15 pneumocystis pneumonia pcp tuberculosis necrotizing pneumonia interstitial lung disease 15 sarcoidosis idiopathic pulmonary fibrosis histiocytosis x lymphangioleiomyomatosis lam connective tissue diseases 15 rheumatoid arthritis ankylosing spondylitis polymyositis and dermatomyositis systemic sclerosis marfan s syndrome and ehlers danlos syndrome cancer 15 lung cancer sarcomas involving the lung miscellaneous 16 catamenial pneumothorax associated with the menstrual cycle and related to endometriosis in the chest in children additional causes include measles echinococcosis inhalation of a foreign body and certain congenital malformations congenital pulmonary airway malformation and congenital lobar emphysema 23 11 5 of people with a spontaneous pneumothorax have a family member who has previously experienced a pneumothorax several hereditary conditions marfan syndrome homocystinuria ehlers danlos syndromes alpha 1 antitrypsin deficiency which leads to emphysema and birt hogg dubé syndrome have all been linked to familial pneumothorax 24 generally these conditions cause other signs and symptoms as well and pneumothorax is not usually the primary finding 24 birt hogg dubé syndrome is caused by mutations in the flcn gene located at chromosome 17p 11 2 which encodes a protein named folliculin 23 24 flcn mutations and lung lesions have also been identified in familial cases of pneumothorax where other features of birt hogg dubé syndrome are absent 23 in addition to the genetic associations the hla haplotype a 2 b 40 is also a genetic predisposition to psp 25 26 traumatic edit a traumatic pneumothorax may result from either blunt trauma or penetrating injury to the chest wall 16 the most common mechanism is the penetration of sharp bony points at a new rib fracture which damages lung tissue 21 traumatic pneumothorax may also be observed in those exposed to blasts even when there is no apparent injury to the chest 11 traumatic pneumothoraces may be classified as open or closed in an open pneumothorax there is a passage from the external environment into the pleural space through the chest wall when air is drawn into the pleural space through this passageway it is known as a sucking chest wound a closed pneumothorax is when the chest wall remains intact 27 pneumothorax was reported as an adverse event caused by misplaced nasogastric feeding tubes avanos medical s feeding tube placement system the cortrak 2 eas was recalled in may 2022 by the fda due to adverse events reported including pneumothorax leading to 60 injuries and 23 people dying as communicated by the fda 28 medical procedures such as inserting a central venous catheter into one of the chest veins or taking biopsy samples from lung tissue may also lead to pneumothorax the administration of positive pressure ventilation either mechanical ventilation or non invasive ventilation can result in barotrauma pressure related injury leading to a pneumothorax 16 divers who breathe from an underwater apparatus are supplied with breathing gas at ambient pressure which results in their lungs containing gas at higher than atmospheric pressure divers breathing compressed air such as when scuba diving may develop a pneumothorax as a result of barotrauma from ascending just 1 metre 3 ft while breath holding with their lungs fully inflated 29 an additional problem in these cases is that those with other features of decompression sickness are typically treated in a diving chamber with hyperbaric therapy this can lead to a small pneumothorax rapidly enlarging and causing features of tension 29 newborn infants edit pneumothorax is more common in neonates than in any other age group the incidence of symptomatic neonatal is estimated to be around 1 3 per 1000 live births prematurity low birth weight and asphyxia are the major risk factors and a majority of newborn infant cases occur during the first 72 hours of life 30 31 17 artificial pneumothorax edit in the late 1800s and early 1900s physicians namely carlo forlanini a physician from italy began experimenting with intentionally collapsing the lungs of patients infected with tuberculosis 32 the goal of treatment was to deprive the oxygen dependent mycobacterium of the resources it requires to multiply and spread 32 although this method fell out of common practice following the advent of pharmaceutical advancements some research shows that in cases where medications are not effective ap has successful results 33 however the same complications that arise with other mechanisms may still apply leading to questions of risk vs benefit 33 mechanism edit the thoracic cavity is the space inside the chest that contains the lungs heart and numerous major blood vessels on each side of the cavity a pleural membrane covers the surface of lung visceral pleura and also lines the inside of the chest wall parietal pleura normally the two layers are separated by a small amount of lubricating serous fluid the lungs are fully inflated within the cavity because the pressure inside the airways intrapulmonary pressure is higher than the pressure inside the pleural space intrapleural pressure despite the low pressure in the pleural space air does not enter it because there are no natural connections to air containing passages and the pressure of gases in the bloodstream is too low for them to be forced into the pleural space 16 therefore a pneumothorax can only develop if air is allowed to enter through damage to the chest wall or to the lung itself or occasionally because microorganisms in the pleural space produce gas 16 once air enters the pleural cavity the intrapleural pressure increases resulting in the difference between the intrapulmonary pressure and the intrapleural pressure defined as the transpulmonary pressure to equal zero which cause the lungs to deflate in contrast to a normal transpulmonary pressure of 4 mm hg 34 chest wall defects are usually evident in cases of injury to the chest wall such as stab or bullet wounds open pneumothorax in secondary spontaneous pneumothoraces vulnerabilities in the lung tissue are caused by a variety of disease processes particularly by rupturing of bullae large air containing lesions in cases of severe emphysema areas of necrosis tissue death may precipitate episodes of pneumothorax although the exact mechanism is unclear 15 primary spontaneous pneumothorax psp has for many years been thought to be caused by blebs small air filled lesions just under the pleural surface which were presumed to be more common in those classically at risk of pneumothorax tall males due to mechanical factors in psp blebs can be found in 77 of cases compared to 6 in the general population without a history of psp 35 as these healthy subjects do not all develop a pneumothorax later the hypothesis may not be sufficient to explain all episodes furthermore pneumothorax may recur even after surgical treatment of blebs 16 it has therefore been suggested that psp may also be caused by areas of disruption porosity in the pleural layer which are prone to rupture 15 16 35 smoking may additionally lead to inflammation and obstruction of small airways which account for the markedly increased risk of psps in smokers 18 once air has stopped entering the pleural cavity it is gradually reabsorbed 18 tension pneumothorax occurs when the opening that allows air to enter the pleural space functions as a one way valve allowing more air to enter with every breath but none to escape the body compensates by increasing the respiratory rate and tidal volume size of each breath worsening the problem unless corrected hypoxia decreased oxygen levels and respiratory arrest eventually follow 19 diagnosis edit the symptoms of pneumothorax can be vague and inconclusive especially in those with a small psp confirmation with medical imaging is usually required 18 in contrast tension pneumothorax is a medical emergency and may be treated before imaging especially if there is severe hypoxia very low blood pressure or an impaired level of consciousness in tension pneumothorax x rays are sometimes required if there is doubt about the anatomical location of the pneumothorax 19 21 chest x ray edit a plain chest radiograph ideally with the x ray beams being projected from the back posteroanterior or pa and during maximal inspiration holding one s breath is the most appropriate first investigation 36 it is not believed that routinely taking images during expiration would confer any benefit 37 still they may be useful in the detection of a pneumothorax when clinical suspicion is high but yet an inspiratory radiograph appears normal 38 also if the pa x ray does not show a pneumothorax but there is a strong suspicion of one lateral x rays with beams projecting from the side may be performed but this is not routine practice 18 23 it is not unusual for the mediastinum the structure between the lungs that contains the heart great blood vessels and large airways to be shifted away from the affected lung due to the pressure differences this is not equivalent to a tension pneumothorax which is determined mainly by the constellation of symptoms hypoxia and shock 16 the size of the pneumothorax i e the volume of air in the pleural space can be determined with a reasonable degree of accuracy by measuring the distance between the chest wall and the lung this is relevant to treatment as smaller pneumothoraces may be managed differently an air rim of 2 cm means that the pneumothorax occupies about 50 of the hemithorax 18 british professional guidelines have traditionally stated that the measurement should be performed at the level of the hilum where blood vessels and airways enter the lung with 2 cm as the cutoff 18 while american guidelines state that the measurement should be done at the apex top of the lung with 3 cm differentiating between a small and a large pneumothorax 39 the latter method may overestimate the size of a pneumothorax if it is located mainly at the apex which is a common occurrence 18 the various methods correlate poorly but are the best easily available ways of estimating pneumothorax size 18 23 ct scanning see below can provide a more accurate determination of the size of the pneumothorax but its routine use in this setting is not recommended 39 not all pneumothoraces are uniform some only form a pocket of air in a particular place in the chest 18 small amounts of fluid may be noted on the chest x ray hydropneumothorax this may be blood hemopneumothorax 16 in some cases the only significant abnormality may be the deep sulcus sign in which the normally small space between the chest wall and the diaphragm appears enlarged due to the abnormal presence of fluid 19 computed tomography edit ct ...