Pneumothorax: What is it?

Podcast Transcript

Announcer:

Welcome to Love Your Heart, brought to you by Cleveland Clinic's, Sydell and Arnold Miller Family Heart, Vascular and Thoracic Institute. These podcasts will help you learn more about your heart, thoracic and vascular systems, ways to stay healthy, and information about diseases and treatment options. Enjoy!

Natalie Salvatore, RN:

Hello, my name is Natalie Salvatore. I'm a registered nurse in the Heart, Vascular and Thoracic Institute in Cleveland Clinic, and I'm joined with Dr. Alex Bribriesco. And today we're going to talk about pneumothorax. So welcome Dr. Bribriesco.

Alejandro Bribriesco, MD:

Thank you. Thank you for having me.

Natalie Salvatore, RN:

First thing our patients might want to know is, what is a pneumothorax?

Alejandro Bribriesco, MD:

Pneumothorax, it technically means air around the lung. So pneumo means air and thorax means chest. Many patients may know this as a punctured lung or a collapsed lung.

Natalie Salvatore, RN:

What would be some different types?

Alejandro Bribriesco, MD:

The causes of pneumothorax are important to go through. So sometimes we don't know why a patient had a pneumothorax, there wasn't an event, an injury or anything of that nature. They just developed this collapsed lung or air around the lungs. Now that's called a spontaneous pneumothorax, meaning it happened without any kind of event, and that's different than a traumatic pneumothorax, meaning there was some kind of event or accident or situation that you can link to having that lung being collapsed or air around the lung.

Natalie Salvatore, RN:

Great, thanks so much for explaining that. And what would be some symptoms of a pneumothorax?

Alejandro Bribriesco, MD:

The most common symptoms of a pneumothorax of any type are a patient will get chest pain, on the affected side, or sometimes it can just be just dull chest pain that they're not really sure why it's happening. And then also shortness of breath or difficulty breathing. They feel them usually together as that air is starting to potentially build up and cause pressure within the chest.

Natalie Salvatore, RN:

So they come to you or they come to the emergency room because of these symptoms. What would be the next steps or what can a patient expect as far as diagnosing this? So what kinds of testing may they have? And then what would be the treatment based on those test results?

Alejandro Bribriesco, MD:

Most of the time because the chest pain and the shortness of breath is brand new and very startling to patients, they'll be going to the emergency department. But the next step after getting vital signs to make sure that their blood pressure and oxygen levels are all in a stable and safe range, they'll get a chest x-ray. So they'll take this picture of the chest to see exactly how large the pneumothorax is. Or stated another way, how much air is pushing on the lung. Depending on that, what is usually done next is a small tube will be put between the ribs into the air pocket to try to suck out all of the air to allow the lung to fully re-expand. And that's the most important initial treatment of a pneumothorax, regardless of what caused it. After that point, most of the time a patient will be admitted to the hospital for observation to ensure that the lung stays expanded.

One thing that I didn't talk about earlier is that often patients who are young and otherwise healthy, they can still have these spontaneous pneumothoraxes, and so during this observation period they may get an additional kind of imaging of their chest or a CT scan. It's also called a CAT scan. It's a more sensitive x-ray to see, is there really any underlying lung disease that may have predisposed them to having this lung collapse? Usually for younger patients, somewhere between the age of as early as 10 to up to 40 years old, sometimes these pneumothoraxes can just happen and we don't know exactly why, but more often there'll be some underlying lung disease that the patient just didn't know about and this is the first sort of manifestation or the first time it presented itself. And so that can be treated slightly differently.

But the big picture for the first time a patient has one of these collapsed lungs is to make sure that everything is stable. Place a drain into the air pocket with a small tube between the ribs, get the lung to re-expand and then see if there's any more air that's leaking from the lung. Because if the lung is able to fully expand and everything seals off, the tube can usually come out. The patient can be discharged home with a follow up with either a lung doctor or a lung surgeon like myself somewhere within seven days to 14 days to make sure everything is stable and safe.

Natalie Salvatore, RN:

Wow. So that sounds like it might be pretty scary for our patients. What would be a potential complication if they didn't get this treated?

Alejandro Bribriesco, MD:

Sure. No, it's definitely a very scary situation. Now over time, depending on what's causing the air leaking from the lung, the lung can continue to collapse further and further and that can put pressure not only on the lungs but on the heart as well. So this can be a life-threatening situation that should be addressed as early as possible.

Natalie Salvatore, RN:

Great. So the recommendation would be to seek help as soon as possible?

Alejandro Bribriesco, MD:

Definitely.

Natalie Salvatore, RN:

Now, after a patient comes and gets this treated, what does the future look like?

Alejandro Bribriesco, MD:

Sure, so to kind of split folks up into a couple of groups, first group would be patients who are young, otherwise healthy and had this for the very first time. The outlook is generally very favorable, in that the chances of it recurring are up to about 30 percent at one year. Meaning that with no further treatment and just observation, they may never have another problem. One of the biggest risk factors for recurrence is smoking. And some of our studies have shown that smoking increases your risk of having this happen again, more than four times the risk of a normal person. And so counseling and quitting smoking would be a big part of that particular group.

Now, if it does happen again in patients like that, then it would be the same process as the first time presenting to the emergency department, placing the tube to re-expand the lung to make sure everything is safe and steady. Then we would consider doing a surgical intervention, a minimally invasive surgery to try to make sure that this doesn't happen again. What that involves is putting special medicine on the inside of the chest so that the lung will stick to the inside of the chest wall and it will prevent this pneumothorax from happening again. So that's one group.

The second group are patients who have lung disease already, and the pneumothorax or the collapsed lung is due to that disease. For example, patients who have emphysema or COPD, their lung is already diseased from that process, so the tissue is weaker and more likely to rupture or burst and cause this pneumothorax. Those particular patients, we recommend doing that minimally invasive surgical procedure after the very first time that this pneumothorax happens. And that's because their chances of it happening again are much higher than the first group of patients without lung disease. The first group may be 30 percent at one year. The second group, it's more like 50 percent, it's much higher risk. And in addition, their lungs are already not very good, so they may die from the pneumothorax as opposed to a younger person with normal lungs who can tolerate that and have more time to have the interventions needed. So that second group we'll usually recommend having the surgery surgical procedure.

The final group, and this traumatic sort of pneumothorax, meaning something happened to cause the lung injury. Typically the lungs underneath are okay, you don't need to do any additional things, you just treat the injury to the lung that first time around. And the outlook is very good from that perspective, usually without the need for the extra chest procedure to cause the lung to stick to the chest wall.

Natalie Salvatore, RN:

Great. And if you had to counsel a patient on questions to ask either before their appointment or this happens more emergently or spontaneous as you mentioned, so if they were going to the emergency room, what kind of questions might a patient ask? Or if they were coming to a follow-up, so this happened and now they're coming to their first appointment after the initial pneumothorax, what questions would you suggest that our patients ask their providers?

Alejandro Bribriesco, MD:

Sure. So one of the important questions would include, how large was the pneumothorax the first time around? Was it small, was it large? And the care provider can tell you what they consider large or small, and that's an important detail because if a patient presents with a large pneumothorax or their lung is very collapsed, that actually can be a sign that the chances of it happening again are higher. So asking how large the pneumothorax was would be one thing. The second thing to ask would be, do they have any idea as to what possibly caused this? And that's excluding someone who had a car accident or some kind of trauma where you know exactly what caused it. Because separating a patient who has essentially normal lungs and just had this spontaneous lung collapse, versus one who has underlying lung disease and then had this pneumothorax, those are two very different groups of people.

And so that'd be an important thing for a patient to understand if they do have underlying lung disease, which would require further follow up just on that part in and of itself. And then if the patient is either in the hospital or in the outpatient, the questions to ask would be what are the options for treatment? What are the risks and the benefits, and how do those compare to other possible treatments? Things like observation, versus surgery, versus attempting other procedures that maybe don't require surgery but may not be as effective. So that's all important information gathering that patients should feel empowered to do so they can help make the best decision.

Natalie Salvatore, RN:

Thank you so much for all of your insight as to what a pneumothorax is and how we manage it here at Cleveland Clinic. Anything else that you want to leave our patients with?

Alejandro Bribriesco, MD:

So I really appreciate the opportunity to talk with you about this. Again, this can be a very scary situation that happens. But really staying calm, understanding the steps and getting to a healthcare provider as soon as you can are the biggest things. And then really as a lung doctor and lung surgeon, just encouraging people to stop smoking. That's probably the biggest message for all that.

Natalie Salvatore, RN:

Great, thank you so much.

Alejandro Bribriesco, MD:

Thank you very much.

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