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Pneumothorax (Ptx) is defined as gas in the pleural space. Spontaneous Ptx occurs without trauma to the thorax. Primary spontaneous Ptx occurs in the absence of underlying lung disease and typically results from apical pleural blebs. Simple aspiration may be adequate treatment for an initial primary spontaneous Ptx, but recurrence typically requires thoracoscopic intervention. Secondary spontaneous Ptx occurs in the setting of underlying lung disease, most commonly chronic obstructive pulmonary disease. Chest tube placement is typically required for secondary spontaneous Ptx; thoracoscopy and/or pleurodesis (with pleural abrasion or a sclerosing agent) should also be considered.
Traumatic Ptx, resulting from either penetrating or nonpenetrating chest trauma, usually requires chest tube placement. Iatrogenic Ptx can occur from transthoracic needle biopsy, thoracentesis, placement of a central venous catheter, or transbronchial biopsy. Treatment with O2 or aspiration is often adequate for iatrogenic Ptx, but chest tube placement may be required. Tension Ptx can result from trauma or mechanical ventilation. Positive pleural pressure in mechanical ventilation can rapidly lead to a tension Ptx with reduced cardiac output. Urgent treatment is required, either with a chest tube or, if not immediately available, with a large-bore needle inserted into the pleural space through the second anterior intercostal space.