Pneumothorax

A pneumothorax, commonly called a collapsed lung, occurs when air leaks into the space between your lung and chest wall, causing the lung to deflate and leading to sudden chest pain and breathing difficulties that require immediate medical attention.

Table of contents

• What is a pneumothorax?
• Types of pneumothorax
• Symptoms
• Causes and risk factors
• Diagnosis
• Treatment
• Recovery and outlook
• Prevention

What is a pneumothorax?

A pneumothorax happens when air gets into the space between your lung and chest wall, called the pleural space^[1]. Normally, your lung sits right next to the inner surface of your chest wall, with only a thin membrane between them. When air builds up in this space, it pushes against the outside of your lung and makes it collapse, either partially or completely^[2].

The condition is sometimes referred to as a “collapsed lung” or “punctured lung”^[2]. The amount of air that accumulates determines how serious the pneumothorax is and what symptoms you will experience. In most cases, only some of the lung collapses^[7].

• Lungs
• Pleural space
• Chest wall

Types of pneumothorax

There are several different types of pneumothorax, classified based on what causes them and how they develop.

Spontaneous pneumothorax occurs without any external injury or trauma. This type is further divided into two categories^[2]:

• Primary spontaneous pneumothorax happens in people who have no known lung disease. It most commonly affects young, tall, thin adults, particularly men. This occurs when abnormal air pockets in the lung, called blebs, break apart and release air^[2].
• Secondary spontaneous pneumothorax develops in people who already have lung disease. The underlying condition weakens the lung, making it more likely to tear. This happens when the lung is blocked, causing bulging areas called bullae that can burst^[2].

Traumatic pneumothorax results from injury to the chest or medical procedures^[3]. This includes:

• Injury-related pneumothorax from blunt force trauma, fractured ribs, knife wounds, or gunshot wounds^[2].
• Iatrogenic pneumothorax occurs when the lung is punctured during medical procedures such as lung biopsy, central venous line insertion, or mechanical ventilation^[2].

Tension pneumothorax is a serious medical emergency that occurs when air can get into your lungs but cannot escape. This one-way valve effect causes pressure to build up inside your chest, which can squash your heart and other lung, making them stop working properly^[2]. This requires immediate treatment.

Other rare types include catamenial pneumothorax, which can affect people with endometriosis. In this condition, tissue growing outside the uterus can form cysts that bleed into the pleural space, causing lung collapse^[2].

Symptoms

The main symptoms of pneumothorax are sudden, sharp chest pain and shortness of breath^[1]. The severity of symptoms depends on how much of the lung has collapsed.

Common symptoms include^[2]:

• Sudden, sharp stabbing pain on one side of the chest, which gets worse when breathing in
• Difficulty breathing or shortness of breath
• Cough
• Fast breathing
• Fast heart rate
• Fatigue
• Bluish skin, lips, or nails (a condition called cyanosis)

In severe cases, particularly with tension pneumothorax, symptoms can become life-threatening and may include severe distress, fast and shallow breathing, sweating, and low blood pressure^[5].

A small pneumothorax may cause few or no symptoms at all. Some people only discover they have a pneumothorax when it shows up on a chest X-ray done for another reason^[5].

If you experience sudden chest pain and difficulty breathing, call emergency services immediately. A pneumothorax can be a medical emergency^[1].

Causes and risk factors

Pneumothorax has three main causes: medical conditions, injuries, and lifestyle factors^[2].

Medical conditions that can lead to pneumothorax include^[2]:

• Chronic obstructive pulmonary disease (COPD)
• Asthma
• Pneumonia
• Tuberculosis
• Cystic fibrosis
• Emphysema
• Lung cancer
• Idiopathic pulmonary fibrosis
• Acute respiratory distress syndrome (ARDS)

Injuries that can cause traumatic pneumothorax include blunt force trauma from car accidents or falls, penetrating injuries like stab or gunshot wounds, and fractured ribs^[2]. Medical procedures can also accidentally puncture the lung, including lung biopsies, central venous line placement, and mechanical ventilation^[3].

Lifestyle and risk factors that increase your chances of developing pneumothorax include^[2]:

• Smoking tobacco or cannabis
• Vaping
• Drug use, especially inhaled drugs
• Flying that involves drastic changes in air pressure
• Scuba or deep-sea diving

Certain characteristics also make pneumothorax more likely. Primary spontaneous pneumothorax most commonly occurs in tall, thin young men between ages 20 and 40^[3]. About 1 in 10 people who experience pneumothorax have a family member who has also had one, a pattern called familial pneumothorax^[22].

In some cases, pneumothorax occurs for no obvious reason^[1].

Diagnosis

Diagnosis of pneumothorax begins with your doctor asking about your symptoms and medical history, including any recent chest injuries or lung conditions^[5]. Your doctor will examine you, focusing on your vital signs such as blood pressure, pulse, breathing rate, and temperature, as well as listening to your lungs^[8].

Physical examination may reveal signs such as decreased or absent breath sounds on the affected side, a hollow sound when tapping on the chest, rapid heart rate, and low blood oxygen levels^[8]. However, diagnosing pneumothorax by physical examination alone can be difficult, especially for smaller cases^[7].

A chest X-ray is the most common test used to confirm pneumothorax. The X-ray shows the collapsed lung as a dark area in the chest^[9]. This imaging test allows doctors to see how much of the lung has collapsed.

In some cases, additional tests may be needed^[9]:

• A computed tomography (CT) scan may be ordered to find a small collapsed area of lung or in people with extensive lung disease
• Ultrasound imaging can also be used to identify pneumothorax
• Your doctor may check oxygen levels in your blood using a handheld device called a pulse oximeter or by drawing blood from an artery
• An electrocardiogram (EKG) may be performed to check your heart function

Other conditions that can cause similar symptoms include blood buildup in the pleural space, pulmonary embolism, and heart attack, so accurate diagnosis is important^[7].

Treatment

The goal of treating pneumothorax is to relieve pressure on your lung, allowing it to re-expand, and to prevent the condition from happening again^[9]. Treatment depends on the cause, the severity of lung collapse, and your overall health.

Observation may be the only treatment needed for a small pneumothorax. If only a small portion of your lung has collapsed, your doctor may simply monitor your condition with chest X-rays until the excess air is completely absorbed and your lung re-expands on its own. This may take several weeks^[9]. You may receive supplemental oxygen therapy to speed air reabsorption and lung expansion^[9].

Needle aspiration involves inserting a hollow needle with a small flexible tube between the ribs into the air-filled space. The doctor then removes the needle, attaches a syringe to the tube, and pulls out the excess air. The tube may be left in place for a few hours to ensure the lung stays expanded^[9].

Chest tube insertion is used when a larger area of lung has collapsed. A tube is inserted between the ribs to continuously remove excess air from the pleural space and allow the lung to re-expand^[9]. The tube may need to stay in place for several days.

Pleurodesis is a procedure that prevents future pneumothorax by sealing the space between the lung and chest wall. This can be done through a chest tube using chemicals like talc or doxycycline, but surgical pleurodesis using video-assisted thoracoscopy (VATS) is the preferred approach for better results^[12]. During VATS, small incisions are made and instruments are used to create inflammation that causes the lung to stick to the chest wall.

Surgery may be recommended to prevent recurrence, especially after a second pneumothorax. Surgical options include video-assisted thoracoscopic surgery or, less commonly, open surgery called thoracotomy^[9]. Surgery is particularly important for people with lung conditions like LAM, where recurrence rates can be very high without preventive treatment^[12].

Emergency treatment for tension pneumothorax requires immediate needle decompression to release trapped air, followed by chest tube placement^[11].

Most patients experience less pain after treatment compared to the discomfort from recurrent pneumothorax episodes^[18].

Recovery and outlook

Once the cause of pneumothorax is treated, the lung usually returns to normal within 48 to 72 hours. However, full recovery may take up to several weeks^[17].

During recovery, it is important to^[17]:

• Get plenty of rest and sleep
• Take pain medication as prescribed
• Avoid exercise until your doctor approves
• Keep any bandages clean and dry
• Avoid flying in airplanes or scuba diving until cleared by your doctor
• Attend all follow-up appointments

The outlook after pneumothorax depends on its cause and type. For people with primary spontaneous pneumothorax who receive no preventive treatment, about 25% will experience a recurrence^[12]. However, for people with underlying lung disease like LAM, the recurrence rate can be as high as 65-75% without preventive treatment^[12].

After surgical treatment with pleurodesis, recurrence rates drop significantly, though they remain around 25-30% even with surgery in some patient groups^[12].

Most patients who undergo surgery find they can resume normal activities, including walking, exercising, and participating in sports. This improved physical ability leads to greater independence and better quality of life^[18].

Watch for signs of recurrence. Call emergency services immediately if you develop severe trouble breathing, severe chest pain, or cough up blood^[17].

Prevention

Most cases of collapsed lung cannot be prevented^[7]. However, there are steps you can take to reduce your risk:

Quit smoking. Smoking significantly increases the risk of primary spontaneous pneumothorax^[3]. If you smoke tobacco or cannabis, quitting is the most important step you can take. Avoiding vaping is also recommended^[22].

Manage underlying lung conditions. If you have a lung disease like COPD, asthma, or cystic fibrosis, work closely with your doctor to manage it properly. This can help reduce your risk of secondary spontaneous pneumothorax^[5].

Avoid activities that change air pressure rapidly if you have had a previous pneumothorax or are at high risk. This includes flying and scuba diving until your doctor clears you^[17].

Consider preventive treatment after your first pneumothorax. Because recurrence rates are high, especially in people with underlying lung disease, many doctors recommend pleurodesis after the first episode to prevent future occurrences^[12].

If you have a family history of pneumothorax, discuss this with your doctor, as you may be at higher risk and might have an underlying genetic condition^[22].