Joel E. Gallant, M.D., M.P.H. and Patrick R. Sosnay, M.D.
- No specific data on incidence/prevalence from Zambia or Africa, but expected causes primarily PCP , TB , pulmonary cryptococcosis, and LIP.
- As in other countries, Dx of PTX in Zambia based on CXR.
- Tube thoracostomy (chest tube) in Zambia usually reserved for large PTX or significant sx/respiratory compromise.
Zambia Information Author: David Riedel, M.D.
- Pneumothorax (PTX) defined by air in pleural space, either due to entry from outside chest wall or leakage from lung parenchyma.
- In HIV, occurs most often in setting of Pneumocystis pneumonia (PCP). Spontaneous PTX in AIDS pt should prompt workup for PCP.
PCP-associated PTX independently associated with greater mortality.
- Spontaneous PTX in pts with AIDS can also occur with TB, COPD, pulmonary cryptococcosis, and lymphoid interstitial pneumonitis.
- Iatrogenic causes: central venous line placement, thoracentesis, bronchoscopy
- Presenting Sx: pleuritic chest pain, dyspnea, cough
- PE: Tachycardia, tachypnea, hypoxia, hyper-resonance or decreased breath sounds over one lung field. Some pts may not have any signs or Sx beyond those of pneumonia.
- Higher incidence in males, cigarette smokers, pts on aerosolized pentamidine prophylaxis, pts w/ pneumatoceles on CXR, injection drug users, pts on mechanical ventilation.
- CXR line or rim of air seen at apex of lung, beyond which there are no lung markings.
- Dx can be difficult in pts w/ pre-existing lung disease, lateral decubitus x-rays or CT can increase yield.
- CT can distinguish PTX from bullous lung disease.
- Size of PTX can be estimated based on rim of air. >2 cm correlates with >50% of hemithorax
- Small PTX (<1 cm rim) can be observed in asymptomatic pt.
- Any chest pain or dyspnea requires evaluation.
- PTX in setting of PCP has higher morbidity and mortality; requires inpt management.
- Treatment with 100% oxygen can speed resolution of small PTX without chest tube.
- Needle or catheter aspiration less likely to succeed in pts with secondary PTX from underlying lung disease
- Intercostal tube thoracostomy (chest tube) should be performed by a qualified surgeon, emergency medicine physician, or trained critical care physician.
- Bubbling seen in a containment system is sign of continued air leak, and tube should be left in place.
- PTX should be followed with serial CXR.
- Tube can be removed when no air leak on water seal, and CXR shows no ongoing PTX.
- Steroids for treatment of PCP have been associated w/ longer time to resolution of PTX.
- Heimlich valve can be adapted to chest tube, which allows outpt management.
- Medical pleurodesis with talc or tetracycline can be performed at bedside through chest tube as non-operative means of managing a persistent BPF.
- Lowest recurrence rate w/ surgical pleurodesis/pleurodectomy for persistent BPF