PNEUMOTHORAX

Patient Information: Secondary Spontaneous Pneumothorax (SSP)
 

This information sheet is designed to help you understand Secondary Spontaneous Pneumothorax (SSP), a type of collapsed lung that occurs in individuals with pre-existing lung conditions.
 

What is a Pneumothorax?
 

A pneumothorax occurs when air leaks into the space between your lung and your chest wall (this space is called the pleural space). This air pushes on the outside of your lung, making it collapse. A collapsed lung cannot inflate properly, which can cause breathing difficulties and chest pain.

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What is Secondary Spontaneous Pneumothorax (SSP)?
 

"Secondary" means the pneumothorax occurs as a complication of an underlying lung disease.
 

"Spontaneous" means it happens suddenly, without an obvious external cause like an injury to the chest (though the underlying lung disease is the predisposing factor).
 

SSP is generally considered more serious than Primary Spontaneous Pneumothorax (PSP) because patients often have less respiratory reserve due to their existing lung condition.
 

What Underlying Lung Diseases Can Cause SSP?
 

Many lung conditions can increase the risk of SSP. Some of the most common include:

• Chronic Obstructive Pulmonary Disease (COPD): This is the most common cause of SSP, particularly emphysema, where air sacs (bullae) can rupture.

• Cystic Fibrosis: Thick mucus and chronic infections can damage lung tissue.

• Tuberculosis (TB): Can cause cavities and damage to lung tissue.

• Lung Cancer: Tumours can weaken lung tissue or directly cause air leaks.

• Asthma (severe cases): Though less common, severe asthma can sometimes lead to SSP.

• Interstitial Lung Diseases: Conditions like idiopathic pulmonary fibrosis, sarcoidosis, or Langerhans cell histiocytosis can scar and damage lungs.

• Pneumonia: Certain types of pneumonia, especially necrotizing pneumonia (which destroys lung tissue), can lead to SSP.

• Marfan Syndrome and Ehlers-Danlos Syndrome: Connective tissue disorders that can affect lung integrity.

• HIV-related Lung Infections: Such as Pneumocystis jirovecii pneumonia (PJP).
   

What are the Symptoms of SSP?
 

Symptoms of SSP can be similar to PSP but are often more severe and can develop more rapidly due to the reduced lung function from the underlying disease. Symptoms include:

• Sudden, sharp chest pain: Often on one side.

• Worsening shortness of breath: This may be a significant increase from the patient's usual baseline breathlessness.

• Rapid heart rate.

• Rapid breathing.

• Cough.

• Fatigue.

• Bluish tinge to the skin or lips (cyanosis): This is a sign of low oxygen and requires immediate medical attention.
   

Even a small pneumothorax can cause significant symptoms in someone with underlying lung disease.
 

How is SSP Diagnosed?
 

Diagnosis is similar to PSP but with added emphasis on understanding the context of the underlying lung disease:

• Medical History and Physical Examination: Your doctor will ask about your symptoms, existing lung conditions, and will listen to your chest.

• Chest X-ray: This is usually the first imaging test to confirm the presence of air in the pleural space and the degree of lung collapse.

• CT Scan (Computed Tomography Scan): Often used in SSP to get a more detailed view of the pneumothorax, identify the underlying lung disease contributing to it (e.g., bullae in COPD), and guide treatment.

• Arterial Blood Gas (ABG) test: May be done to check oxygen and carbon dioxide levels in your blood, especially if you are very unwell.

• Electrocardiogram (ECG): To rule out heart problems that can cause similar symptoms.
   

How is SSP Treated?
 

Treatment for SSP is generally more urgent and often more aggressive than for PSP due to the higher risk of respiratory failure. The goals are to remove the air from the pleural space, re-expand the lung, and prevent recurrence.
 

1. Oxygen Therapy: Supplemental oxygen is usually given immediately to improve oxygen levels.

2. Chest Drain (Tube Thoracostomy): This is the most common initial treatment for SSP, even for smaller pneumothoraces.

   • A small incision is made in your chest wall (under local anaesthetic).

   • A flexible plastic tube (chest drain) is inserted into the pleural space.

   • The tube is connected to a drainage system to remove the air and allow the lung to re-inflate.

   • Hospital admission is always required. The chest drain usually stays in place for several days until the air leak stops and the lung is fully expanded.

   Picture Placeholder: A diagram showing a chest drain inserted into the pleural space and connected to an underwater seal drainage system.

3. Needle Aspiration: Less commonly used as a primary treatment for SSP compared to PSP, as chest drains are often preferred due to higher success rates and lower recurrence with drains in this population. May be considered in very specific, stable cases.

4. Pleurodesis: This procedure is often recommended for SSP patients, even after a first episode, due to the high risk of recurrence and the serious consequences of recurrence in patients with underlying lung disease.

   • It aims to make the outer surface of the lung stick to the chest wall, preventing future collapses.

   • It can be done chemically (e.g., sterile talc, doxycycline) via the chest drain or during surgery.

5. Surgery (Video-Assisted Thoracoscopic Surgery - VATS or Thoracotomy):

   • Surgery is considered more frequently in SSP, especially for persistent air leaks or recurrent episodes.

   • The aims are to treat the source of the air leak (e.g., remove or staple bullae) and perform pleurodesis.

   • VATS is a keyhole approach. A thoracotomy (larger incision) may be needed in some complex cases or if VATS is not feasible.

6. Management of the Underlying Lung Disease: Optimising treatment for the underlying lung condition is crucial in managing SSP and preventing future episodes.
    

What Can I Expect After Treatment?
 

• Hospital Stay: SSP usually requires a longer hospital stay compared to PSP.

• Recovery: Recovery will depend on the severity of the SSP, the treatment received, and your underlying lung condition. It can be a lengthy process.

• Pain Management: Chest discomfort is common and will be managed with medication.

• Follow-up: Close follow-up with your respiratory specialist is essential. This will include chest X-rays and management of your underlying lung disease.

• Pulmonary Rehabilitation: May be recommended to improve lung function and overall fitness.

• Flying and Diving: Similar to PSP, discuss restrictions with your doctor. Air travel should be avoided until cleared, and scuba diving is generally permanently contraindicated.
   

Can SSP Happen Again?
 

SSP has a higher risk of recurrence compared to PSP. The underlying lung disease means the lung remains vulnerable. This is why preventative measures like pleurodesis or surgery are often recommended earlier and more frequently in SSP.

When to Seek Urgent Medical Attention

If you have an underlying lung condition and experience sudden worsening of breathlessness or new chest pain, seek urgent medical attention immediately, as this could indicate an SSP.
 

Key Points to Remember
 

• SSP is a collapsed lung that occurs due to an underlying lung disease.

• It is generally more serious than PSP due to reduced lung reserve.

• Common causes include COPD, cystic fibrosis, and TB.

• Symptoms include sudden worsening of shortness of breath and chest pain.

• Chest drain insertion is the most common initial treatment.

• Procedures to prevent recurrence (pleurodesis, surgery) are often recommended.

• Managing the underlying lung disease is vital.

Disclaimer: This information sheet provides general guidance and is not a substitute for professional medical advice, diagnosis, or treatment. Always discuss your specific condition, underlying lung disease, and treatment options with your doctor or healthcare team. They can provide information tailored to your individual circumstances.

Patient Information: Traumatic Pneumothorax

This information sheet is designed to help you understand Traumatic Pneumothorax, a type of collapsed lung that occurs as a result of an injury to the chest.
 

What is a Pneumothorax?
 

A pneumothorax occurs when air leaks into the space between your lung and your chest wall (this space is called the pleural space). This air pushes on the outside of your lung, making it collapse. A collapsed lung cannot inflate properly, which can cause breathing difficulties and chest pain.
 

What is a Traumatic Pneumothorax?
 

A "Traumatic" pneumothorax means the collapsed lung is caused by some form of injury or trauma to the chest. This is different from a spontaneous pneumothorax, which happens without an obvious injury.
 

Traumatic pneumothoraces can be caused by:
 

• Penetrating Trauma: This is when an object pierces the chest wall, such as:

  • A stab wound from a knife or other sharp object.

  • A gunshot wound.

  • Injury from shrapnel.

• Blunt Trauma: This is when the chest sustains a forceful impact, but the skin is not necessarily broken, such as:

  • A car accident (e.g., hitting the steering wheel, seatbelt injury).

  • A fall from a height.

  • A direct blow to the chest during sports or an assault.

  • Rib fractures that puncture the lung.

• Medical Procedures (Iatrogenic Pneumothorax): Sometimes, a pneumothorax can occur as an unintended complication of certain medical procedures, such as:

  • Lung biopsy.

  • Insertion of a central venous line (catheter) into a large vein in the neck or chest.

  • Mechanical ventilation (being on a breathing machine).

  • Cardiopulmonary resuscitation (CPR), especially if rib fractures occur.
     

What are the Symptoms of a Traumatic Pneumothorax?
 

Symptoms usually develop at the time of the injury or shortly afterward. The severity can depend on the size of the pneumothorax and the extent of other injuries. Symptoms include:
 

• Sudden, sharp chest pain: Often localized to the site of injury, which may worsen with breathing or coughing.

• Shortness of breath or difficulty breathing.

• Rapid breathing.

• Rapid heart rate.

• Cough (may sometimes produce blood if the lung is injured).

• Bruising, tenderness, or an open wound on the chest.

• Low blood pressure and signs of shock (e.g., pale, clammy skin, confusion) if the pneumothorax is large or associated with significant bleeding (this is a medical emergency).

• Subcutaneous emphysema: Air leaking into the tissues under the skin, causing a crackling sensation when the skin is touched.

• Bluish tinge to the skin or lips (cyanosis): Indicates low oxygen and is a serious sign.
   

A Tension Pneumothorax is a life-threatening type of traumatic pneumothorax where air continues to enter the pleural space with each breath and cannot escape. This builds up pressure, collapsing the lung completely, pushing the heart and major blood vessels to the other side of the chest, and severely impairing breathing and circulation. This requires immediate emergency treatment.
 

How is a Traumatic Pneumothorax Diagnosed?
 

In an emergency setting following trauma, doctors will assess you quickly.
 

• Clinical Examination: Your doctor will examine your chest, listen to your breathing sounds, check your vital signs (blood pressure, heart rate, oxygen levels), and look for signs of injury.

• Chest X-ray: This is a common initial test to confirm the presence of air in the pleural space and assess the size of the pneumothorax and any associated injuries like rib fractures.

• FAST Scan (Focused Assessment with Sonography for Trauma): An ultrasound scan performed at the bedside in emergency situations can quickly detect a pneumothorax.

• CT Scan (Computed Tomography Scan): Provides more detailed images of the chest, lungs, and surrounding structures. It is often used in trauma patients to assess the full extent of injuries, including smaller pneumothoraces not visible on X-ray, lung contusions (bruising), and injuries to other organs.
   

How is a Traumatic Pneumothorax Treated?
 

Treatment depends on the size of the pneumothorax, your symptoms, your overall stability, and any other injuries you have sustained. The primary goal is to remove the air from the pleural space, allow the lung to re-expand, and manage associated injuries.
 

1. Observation: Very small traumatic pneumothoraces in stable patients with no breathing difficulty might be managed with close observation and supplemental oxygen, with follow-up X-rays.

2. Oxygen Therapy: Supplemental oxygen is usually given to help the body absorb the leaked air more quickly and to improve oxygen levels.

3. Needle Decompression (for Tension Pneumothorax): This is an emergency, life-saving procedure. A large needle is inserted into the chest to immediately release trapped air and relieve pressure. This is followed by chest drain insertion.

4. Chest Drain (Tube Thoracostomy): This is the most common treatment for most traumatic pneumothoraces.

   • Under local anaesthetic (or during surgery for other injuries), a flexible plastic tube is inserted through the chest wall into the pleural space.

   • The tube is connected to a drainage system that allows air (and sometimes blood, if there's bleeding – known as a haemopneumothorax) to escape, allowing the lung to re-inflate.

   • You will be admitted to the hospital. The chest drain usually remains in place for several days until the air leak stops, any fluid drainage is minimal, and the lung is fully expanded.

5. Pain Management: Injuries to the chest can be very painful. Adequate pain relief is essential to help you breathe comfortably and cough effectively (to clear secretions and prevent chest infections).

6. Addressing Other Injuries: Treatment will also focus on managing any other injuries sustained during the trauma (e.g., repairing wounds, stabilising fractures, surgery for internal injuries).

7. Surgery (Video-Assisted Thoracoscopic Surgery - VATS or Thoracotomy): Surgery may be needed in cases of:

   • Persistent large air leak from the lung.

   • Failure of the lung to re-expand with a chest drain.

   • Significant bleeding into the chest (haemothorax).

   • Recurrent pneumothorax after initial treatment.

   • To repair significant lung or airway damage.

     VATS is a minimally invasive (keyhole) approach. A thoracotomy involves a larger incision and may be necessary for more extensive injuries.
      

What Can I Expect After Treatment?
 

• Hospital Stay: The length of your hospital stay will depend on the severity of your pneumothorax, other injuries, and the treatment required.

• Recovery: Recovery can take several weeks to months, depending on the extent of your trauma.

• Pain: Pain from the injury and chest drain site is common and will be managed with medication.

• Breathing Exercises: You may be taught breathing exercises by a physiotherapist to help re-expand your lung fully and prevent complications like chest infections.

• Follow-up: You will have follow-up appointments with your doctor, which will likely include chest X-rays.

• Activity Restrictions: Your doctor will advise you on when it's safe to return to normal activities, work, and exercise. Strenuous activities and contact sports will need to be avoided for a period.

• Flying and Diving: Similar to other types of pneumothorax, discuss restrictions with your doctor. Air travel should be avoided until your lung is fully healed and stable. Scuba diving may be permanently contraindicated or require specialist assessment.
   

Potential Complications
 

Besides the pneumothorax itself, complications can include:

• Infection (e.g., pneumonia, infection around the chest drain site).

• Persistent air leak.

• Failure of the lung to re-expand.

• Bleeding into the chest (haemothorax).

• Chronic pain.

• Complications related to associated injuries.
   

When to Seek Medical Attention After Discharge
 

After being discharged from the hospital, contact your doctor or seek medical attention if you experience:

• Increasing shortness of breath.

• Sudden or worsening chest pain.

• Fever or chills (signs of infection).

• Redness, swelling, or discharge from any wound or chest drain site.

• Coughing up blood.
   

Key Points to Remember
 

• Traumatic pneumothorax is a collapsed lung caused by an injury to the chest.

• Symptoms include chest pain and shortness of breath, often appearing immediately after the trauma.

• A Tension Pneumothorax is a life-threatening emergency.

• Treatment usually involves a chest drain to re-expand the lung and management of other injuries.

• Recovery time varies depending on the severity of the trauma.
   

Disclaimer: This information sheet provides general guidance and is not a substitute for professional medical advice, diagnosis, or treatment. If you have sustained an injury and have symptoms, seek immediate medical attention. Always discuss your specific condition, injuries, and treatment plan with your doctor or healthcare team.