What Is The Difference Between Pneumothorax And Tension Pneumothorax?
Pneumothorax can be divided in to spontaneous primary pneumothorax, spontaneous secondary pneumothorax, traumatic open pneumothorax, traumatic closed pneumothorax and iatrogenic pneumothorax. All of these pneumothoraxes can progress into tension pneumothorax when the respiration and blood circulation is significantly affected. Out of this traumatic and iatrogenic are the main reasons for tension pneumothorax. Pneumothorax and tension pneumothorax cannot be clearly diagnosed by clinical features, but the presence of hypoxemia, hypotension and loss of consciousness is more suggestive of tension pneumothorax. Tension pneumothorax is a clinical diagnosis.
Pneumothorax is air in the pleural space. Pneumothorax is a broad category, it can be further subdivided into:
Pneumothorax is air in the pleural space.
Pneumothorax is a broad category, it can be further subdivided into:
- Primary spontaneous pneumothorax. Primary spontaneous pneumothorax (PSP) is defined as the spontaneously occurring of air in the pleural space in patients without any clinically apparent underlying lung disease.
- Secondary spontaneous pneumothorax. Secondary spontaneous pneumothorax (SSP) is defined as spontaneous occurring of air in the pleural space in patients with underlying lung disease.
- Open (penetrating) In an open pneumothorax there is an opening in the chest wall connecting the external environment and pleural space. When air is drawn into the pleural space through this passageway, it is known as a sucking chest wound.
- Closed (non-penetrating) The chest wall remains intact
Pneumothorax which occur due to a complication in a surgery, medical treatment or investigation.
There are several causes/risk factors for each category of pneumothorax.
Primary spontaneous pneumothorax
- Tall, thin healthy people
- Marfan syndrome
Secondary spontaneous pneumothorax
- Cystic fibrosis
- Severe asthma
- Interstitial lung disease
- Connective tissue disorders
Open traumatic pneumothorax
Penetrative injuries to the chest with an open wound
Closed traumatic pneumothorax
Blunt injury to the chest wall without any open wound in the chest (e.g. blunt trauma causing rib fracture which lacerates the pleura).
- Central vein cannulation (subclavian more commonly so than internal jugular vein)
- Pleural tap or biopsy
- Transbronchial biopsy
- Fine needle aspiration
- Mechanical intubation – positive pressure ventilation
Symptoms and signs of pneumothorax
The clinical status depends on the extent of the pneumothorax
- Shortness of breath,
- Sudden onset chest pain – severe and/or stabbing pain, radiating to the ipsilateral shoulder and increases with inspiration (pleuritic).
- Hyper resonance of the chest wall on the affected side
- Diminished breath sounds on the affected side.
- Other symptoms can be present depending on the secondary diseases.
- Some patients can be asymptomatic if it’s a simple pneumothorax.
- Chest X-ray
- Visceral pleural white line
- Absence of lung markings
- Displacement of mediastinum
- Air-fluid level in pleural space on erect chest radiograph
- CT scan of the chest
- Ultrasound scan of the chest
Tension pneumothorax is the progressive built-up of air within the pleural space. A tension pneumothorax develops when a ‘one-way valve ‘is created and air leak occurs either from the lung or through the chest wall. Due to the valve effect air will be stuck inside the pleural space without any means of escape.
Spontaneous, traumatic and iatrogenic pneumothorax can progress into tension pneumothorax when the respiration and blood circulation is significantly impaired.
All the causes of pneumothorax can cause tension pneumothorax, common causes are traumatic and iatrogenic pneumothorax.
Same symptoms and signs of pneumothorax will be present, but the symptoms and signs are more remarkable and patient is severely ill.
There can be more symptoms and signs present other than the ones mentioned
- Decreased level of consciousness
- Tracheal deviation toward the contralateral side (this is an inconsistent finding)
- Pulsus paradoxus
- Cardiac apical displacement
- Distension of neck veins (may not be present if hypotension is severe)
It is really difficult clearly demarcate what are the clinical features of pneumothorax and tension pneumothorax. But if the patient has hypoxemia, hypotension and decreased level of consciousness it is more suggestive of tension pneumothorax.
Tension pneumothorax is a clinical diagnosis and treatment can be continued without any investigations in a strongly suspected tension pneumothorax in order to save the patient’s life. However, investigations can be done if readily available (e.g. chest X ray). Displacement of the mediastinum usually indicates tension pneumothorax.
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