INTRODUCTION

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Background

A pneumothorax refers to a collection of gas in the pleural space resulting in collapse of the lung on the affected side. A tension pneumothorax is a life-threatening condition caused by air within the pleural space that is under pressure; displacing mediastinal structures and compromising cardiopulmonary function. A traumatic pneumothorax results from blunt or penetrating injury that disrupts the parietal or visceral pleura. Mechanisms include injuries secondary to medical or surgical procedures.

Pathophysiology

A tension pneumothorax results from any lung parenchymal or bronchial injury that acts as a one-way valve and allows free air to move into an intact pleural space but prevents the free exit of that air. In addition to this mechanism, the positive pressure used with mechanical ventilation therapy can cause air trapping.

As pressure within the intrapleural space increases, the heart and mediastinal structures are pushed to the contralateral side. The mediastinum impinges on and compresses the contralateral lung.

Hypoxia results as the collapsed lung on the affected side and the compressed lung on the contralateral side compromise effective gas exchange. This hypoxia and decreased venous return caused by compression of the relatively thin walls of the atria impair cardiac function. The decrease in cardiac output results in hypotension and, ultimately, in hemodynamic collapse and death to the patient, if untreated.

Frequency

United States

A study conducted from 1959-1978 involving a US community with an average of 60,000 residents reported an incidence of primary spontaneous pneumothorax of 7.4 cases per 100,000 persons per year for men and 1.2 cases per 100,000 persons per year for women. When these figures are extrapolated, about 8,600 individuals develop primary spontaneous pneumothorax in the United States per year.

Tension pneumothorax is a complication in approximately 1-2% of the cases of idiopathic spontaneous pneumothorax. Until the late 1800s, tuberculosis was a primary cause of pneumothorax development. A 1962 study showed a frequency of pneumothorax of 1.4% in patients with tuberculosis.

Undoubtedly, the incidence of pneumothorax and/or tension pneumothorax in US hospitals has increased as intensive care treatment modalities have become increasingly dependent on positive-pressure ventilation, central venous catheter placement, and other causes that potentially induce iatrogenic pneumothorax.

Mortality/Morbidity

The clinician should assume that a tension pneumothorax results in hemodynamic instability and death, unless immediately treated.

Sex

The male-to-female ratio is about 6:1 for primary spontaneous pneumothorax development.

• In men, the risk of spontaneous pneumothorax is 102 times higher in heavy smokers than in nonsmokers. Spontaneous pneumothorax most frequently occurs in tall, thin men aged 20-40 years.
• Catamenial pneumothorax is a rare phenomenon that generally occurs in women aged 30-50 years. It frequently begins 1-3 days after menses onset. Its etiology may be primarily related to associated diaphragmatic defects.

Age

Pneumothorax occurs in 1-2% of all neonates. The incidence of pneumothorax in infants with neonatal respiratory distress syndrome is higher. In one study, 19% of such patients developed a pneumothorax.

CLINICAL

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History

The signs and symptoms produced by tension pneumothorax are usually more impressive than those seen with a simple pneumothorax. Unlike the obvious patient presentations oftentimes used in medical training courses to describe a tension pneumothorax, actual case reports include descriptions of the diagnosis of the condition being missed or delayed because of subtle presentations that do not always present with the classically described clinical findings of this condition.

Symptoms and signs of tension pneumothorax may include the following:

• Chest pain (90%)
• Dyspnea (80%)
• Anxiety
• Acute epigastric pain (a rare finding)
• Fatigue

Physical

Findings at physical examination may include the following:

• Respiratory distress (considered a universal finding) or respiratory arrest
• Unilaterally decreased or absent lung sounds (a common finding; but decreased air entry may be absent even in an advanced state of the disease)
• Adventitious lung sounds (crackles, wheeze; an ipsilateral finding)
• Lung sounds transmitted from the nonaffected hemithorax are minimal with auscultation at the midaxillary line
• Tachypnea; bradypnea (as a preterminal event)
• Hyperresonance of the chest wall on percussion (a rare finding; may be absent even in an advanced state of the disease)
• Hyperexpansion of the chest wall
• Increasing resistance to providing adequate ventilation assistance
• Cyanosis (a rare finding)
• Tachycardia (a common finding)
• Hypotension (should be considered as an inconsistently present finding; while hypotension is typically considered as a key sign of a tension pneumothorax, studies suggest that hypotension can be delayed until its appearance immediately precedes cardiovascular collapse)
• Pulsus paradoxus
• Jugular venous distension
• Cardiac apical displacement (a rare finding)
• Tracheal deviation (an inconsistent finding; while historic emphasis has been placed on tracheal deviation in the setting of tension pneumothorax, tracheal deviation is a relatively late finding caused by midline shift)
• Mental status changes, including decreased alertness and/or consciousness (a rare finding)
• Abdominal distension (from increased pressure in the thoracic cavity producing caudal deviation of the diaphragm and from secondary pneumoperitoneum produced as air dissects across the diaphragm through the pores of Kohn)
• When examining a patient for suspected tension pneumothorax, helpful indications of subtle thoracic size and thoracic mobility differences may be elicited by performing careful visual inspection along the line of the thorax. In a supine patient, by lowering oneself to be in level with the patient.
• Tension pneumothorax may be a difficult diagnosis to make and may present with considerable variability in signs presented. Respiratory distress and chest pain are generally accepted as being universally present in tension pneumothorax. Tachycardia and ipsilateral air entry are also common findings.
• The development of tension pneumothorax in patients who are ventilated will generally be of faster onset with immediate, progressive arterial and mixed venous oxyhemoglobin saturation decline and immediate decline in cardiac output.

Causes

A wide variety of disease states and circumstances increase the patient's risk of a pneumothorax. If a pneumothorax is complicated by a one-way valve effect, tension pneumothorax may result.

• Infants requiring ventilatory assistance and those with meconium aspiration have a particularly high risk for tension pneumothorax. Aspirated meconium may serve as a one-way valve and produce a tension pneumothorax.
• Trauma may cause a pneumothorax.
• • Tension pneumothorax may be the result of blunt trauma with or without associated rib fractures.
  • Incidents that may cause tension pneumothoraces include unrestrained head-on motor vehicle accidents, falls, and altercations involving laterally directed blows.
  • Any penetrating wound that produces an abnormal passageway for gas exchange into the pleural spaces and that results in air trapping may produce a tension pneumothorax.
  • In a recent study, 12% of patients with asymptomatic chest stab wounds had a delayed pneumothorax or hemothorax.
• Many procedures performed in an intensive care or emergency setting can result in an iatrogenic pneumothorax and tension pneumothorax. Examples of these procedures include incorrect chest tube insertion, mechanical ventilation therapy, central venous cannulation; cardiopulmonary resuscitation; hyperbaric oxygen therapy; needle, transbronchial, or transthoracic lung biopsy; liver biopsy or surgery; and neck surgery.
• Secondary or spontaneous tension pneumothorax is possible in many medical conditions.
• • Pneumothorax is associated with asthma, chronic obstructive pulmonary disease, pneumonia (especially with Staphylococcus, Klebsiella, Pseudomonas, and Pneumocystis species), pertussis, tuberculosis, lung abscess, and cystic fibrosis.
  • In pulmonary disorders such as asthma and emphysema, hyperexpansion disrupts the alveoli.
  • Increased pulmonary pressure due to coughing with a bronchial plug of mucus or phlegm bronchial plug may play a role.
  • Marfan syndrome is associated with an increased risk of pneumothorax.
  • Individuals may inherit a predisposition for primary spontaneous pneumothorax.

DIFFERENTIALS

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Other Problems to be Considered

Airway obstruction
Hemothorax

WORKUP

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Lab Studies

• ABG analysis does not replace physical diagnosis nor should treatment be delayed while awaiting results if symptomatic pneumothorax is suspected. However, ABG analysis may be useful in evaluating the following:
• • Hypoxia
  • Hypercarbia and respiratory acidosis

Imaging Studies

• Translumination: In neonatal patients, one may notice increased transmission of light through the chest on the affected side.
• Chest radiography: Historical dogma has included the recommendation that a chest radiograph of tension pneumothorax is a film that should never be taken. More recent suggestions advise a risk-benefit analysis in which the time taken to obtain the radiograph is balanced against the expected clinical course with decompression preceding chest radiography in ventilated patients who are prone to rapid decompensation.
  • In a select subset of patients, it may be preferable to radiologically confirm and localize tension pneumothorax before subjecting the patient to potential morbidities arising from decompression. However, this consideration should be limited to a subset of patients who are awake, stable, not in advanced stages of tension and when an immediate chest film can be obtained, with a continuously accompanying practitioner ready to perform urgent decompression should the need arise.
• • Although the initial chest radiograph may show no evidence of pneumothorax, consider the possibility of delayed traumatic pneumothorax development in any penetrating chest wound. Obtain serial chest radiographs every 6 hours the first day after injury to rule this out. Some authors advocate the acquisition of only one or two serial examinations every 4-6 hours.
  • Air in the pleural cavity, with contralateral deviation of mediastinal structures, is evidence of a tension pneumothorax. Tension pneumothorax chest radiographic findings may include increased thoracic volume, increased rib separation, heart border ipsilateral flattening, contralateral mediastinal deviation, and hemidiaphragmatic depression.
  • Pneumothorax chest radiograph findings include ipsilateral lung edge seen parallel to the chest wall, increased lucency, and a deep sulcus sign (deep lateral costophrenic angle).
  • When evaluating the chest radiograph for pneumothorax, assess rotation. Rotation can obscure a pneumothorax and mimic a mediastinal shift.
  • In evaluating the radiograph for rotation, compare the symmetry and shape of the clavicles. Also, look at the relative lengths of the ribs in the middle lung fields on each side on the anteroposterior or posteroanterior views. On an image with rotation, the ribs on each side often have unequal lengths.
  • In a nonloculated pneumothorax, air rises to the nondependent portion of the pleural cavity. Therefore, carefully examine the apices of an upright chest radiograph, and scrutinize the costophrenic and cardiophrenic angles on a supine chest radiograph.
  • A skin fold can be mistaken for a pneumothorax. Unlike pneumothoraces, skin folds usually continue beyond the chest wall, and lung markings can be seen peripheral to the skin fold line. Viewing the film under the hot lamp may be necessary to discern obscure peripheral lung markings.
  • In evaluating the chest radiograph, first impressions of pneumothorax size can be misleading. To assist in determining the size of pneumothorax on the radiograph, a 2.5-cm margin of gas peripheral to the collapsing lung corresponds to a pneumothorax of about 30%. Complete collapse of the lung is a 100% pneumothorax.
• Chest CT scanning
• • Collapse of the lung, air in the pleural cavity, and deviation of mediastinal structures are present in tension pneumothorax.
  • A CT scan is more sensitive than a chest radiograph in the evaluation of small pneumothoraces and pneumomediastinum, although the clinical significance of these occult pneumothoraces is unclear, particularly in the stable nonintubated patient.
  • A CT scan may allow for further evaluation of underlying pulmonary disease or injury.
• Ultrasonography
• • Use of bedside ultrasonography in the diagnosis of pneumothorax is a relatively recent development. In some trauma centers, pneumothorax detection is included as part of their FAST (focused abdominal sonography for trauma) examination. However, at the present time, the role of bedside ultrasonography, while promising, is still in development.
  • Ultrasonographic features used in the diagnosis of pneumothorax include absence of lung sliding (high sensitivity and specificity), absence of comet-tail artifact (high sensitivity, lower specificity), and presence of lung point (high specificity, lower sensitivity).
  • In one study, ultrasonography had 95.5% sensitivity and 100% specificity for pneumothorax detection compared with chest radiography. In another study, ultrasonography performed on patients with blunt thoracic trauma had 94% sensitivity and 100% specificity for pneumothorax detection compared with spiral CT scanning.

Procedures

• Needle thoracostomy is performed as follows:
• • Locate puncture site. The second intercostal space in the midclavicular line on the affected side immediately superior to the rib is most commonly recommended site.
  • Prepare the puncture site with Betadine and/or alcohol scrubs.
  • Insert a large-bore Angiocath (14-gauge in an adult, 18-gauge or 20-gauge in an infant) into the desired intercostal space over the top of the rib and perpendicular to the chest wall. Listen for a rush of air.
  • Remove the needle.
  • Secure the Angiocath in place, and establish a water seal or flutter valve.
  • Immediately prepare to insert a chest tube.
  • Listen for a rush of air on insertion to confirm the diagnosis of tension pneumothorax. Note this finding on the patient's chart. In an area with high ambient noise, the escape of air may not be detected.
  • Needle thoracostomy requires follow-up placement of a chest tube.
  • Potential morbidity associated with needle thoracostomy includes pneumothorax (with potential to tension later), cardiac tamponade, hemorrhage (which can be life-threatening), loculated intrapleural hematoma, atelectasis, pneumonia, arterial air embolism (when needle thoracostomy is performed and no tension pneumothorax is present), and pain to patient.
• Tube thoracostomy is performed as follows:
• • If the patient is hemodynamically stable, consider conscious sedation with careful titration of a short-acting narcotic and benzodiazepine. However, use of a local anesthetic often is adequate.
  • Place the patient in a 30-60° reverse Trendelenburg position, scrub the site with Betadine and/or alcohol, and anesthetize the site with lidocaine.
  • Make a 3-4-cm incision over the fifth or sixth rib in the midaxillary line.
  • Use a curved hemostat to puncture the intercostal muscles and parietal pleura immediately superior to the rib border, avoiding damage to the underlying lung. Then, slide a finger over the clamp to maintain the formed tract.
  • Perform a digital examination to assess the location and to evaluate pulmonary adhesions. Sweep the finger in all directions, and feel for the diaphragm and possible intra-abdominal structures. To avoid losing the desired tract, keep the finger in place until tube is inserted.
  • Insert the chest tube along side of the finger, using a clamp on the tube, if desired.
  • Direct the chest tube posteriorly and inferiorly, and insert it until it is at least 5 cm beyond the last hole of the tube.
  • Attach the tube to a water seal and vacuum device (eg, Pleur-Evac). Look for respiratory variation and bubbling of air through the water seal. Document the amount of blood or other fluids that may drain.
  • Suture the site, and secure the tube. A variety of anchoring and closure techniques exist, all of which are probably equivalent. Cover the site with Vaseline-impregnated gauze, and apply a suitable dressing.
  • Follow-up chest radiography is required to confirm tube placement and lung reexpansion.
  • Complications of tube thoracostomy include death, injury to lung or mediastinum, hemorrhage (usually from intercostal artery injury), neurovascular bundle injury, infection, bronchopleural fistula, and subcutaneous or intraperitoneal tube placement.

TREATMENT

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Prehospital Care

Attention to the ABCs is mandatory for all patients with thoracic trauma. Evaluate the patency of the airway and the adequacy of the ventilatory effort. Assess the circulatory status and the integrity of the chest wall.

• Failure of the emergency medical service personnel and medical control physician to make a correct diagnosis of tension pneumothorax and to promptly perform needle decompression in the prehospital setting can result in rapid clinical deterioration and cardiac arrest.
• However, if an incorrect diagnosis of tension pneumothorax is made in the prehospital setting, the patient's life is endangered by unnecessary invasive procedures. Close cooperation and accurate communication between the physician and the emergency medical service personnel is of paramount importance.
• To prevent reentry of air into the pleural cavity after needle thoracostomy and decompression in the prehospital setting, a one-way valve should be attached to the distal end of the Angiocath. If available, a Heimlich valve may be used. If a commercially prepared valve is not available, attach a finger condom or the finger of a rubber glove with its tip removed to serve as a makeshift one-way valve device.
• Clothing covering a wound that communicates with the chest cavity can play a role in producing a one-way valve effect, allowing air to enter the pleural cavity but hindering its exit. Removing such clothing items from the wound may facilitate decompression of a tension pneumothorax.
• A tension pneumothorax is a contraindication to the use of military antishock trousers.

Emergency Department Care

For all patients with thoracic injury, immediate and careful attention to the ABCs is vital. Fully assess the patency of the airway and adequacy of the ventilatory effort. Carefully evaluate the cardiovascular system, because a tension pneumothorax and a pericardial tamponade can cause similar findings.

• If a tension pneumothorax is suspected, immediately administer 100% oxygen, and evaluate the patient for evidence of respiratory compromise, hemodynamic instability, or clinical deterioration. Place large-bore catheters, because hemothorax can be associated with pneumothorax, and the patient may, therefore, require immediate intravenous infusion.
  Upright positioning, if not inappropriate due to cervical spine or trauma concerns, may be beneficial.
• Immediately perform needle thoracostomy or chest tube placement if the clinical condition warrants such action. Once a needle thoracostomy has been performed, chest tube insertion must follow.
• If a hemothorax is associated with the pneumothorax, additional chest tubes may be needed to assist drainage of blood and clots. If the hemopneumothorax requires insertion of a second chest tube, the second tube should be directed inferiorly and should be posterior to the diaphragm.
• Chest tubes are attached to a vacuum apparatus that continual removes air from the pleural cavity. The collapsed lung re-expands and heals, thereby preventing continued air leakage. After air leaks have ceased for 24 hours, the vacuum may be decreased and the chest tube removed.
• The process of lung re-expansion and healing is not immediate and may be complicated by pulmonary edema. A chest tube is, therefore, usually left in place for at least 3 days unless the clinical condition warrants a longer placement.
• In general, traumatic pneumothoraces should be treated with insertion of a chest tube, particularly if the patient cannot be closely observed.
• • A subset of patients who have a small ( <15-20%), minimally symptomatic pneumothorax may be admitted, observed closely, and monitored by using serial chest radiographs.
  • In these patients, administration of 100% oxygen promotes resolution by speeding the absorption of gas from the pleural cavity into the pulmonary vasculature.

Consultations

• Treatment of tension pneumothorax should commence immediately after diagnosis, without waiting for further consultation and/or evaluation.
• A trauma or general surgeon should evaluate patients with trauma, and the patient should be admitted for observation.

MEDICATION

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A tension pneumothorax requires treatment with procedural modalities. Anesthetics and analgesics should be used if the patient is not in distress. Medication may be necessary to treat the pulmonary disorder that caused the pneumothorax. For example, intravenous antibiotics are included in the treatment of a pneumothorax that developed as a sequela of staphylococcal pneumonia. Also, studies suggest that the administration of prophylactic antibiotics after chest tube insertion may reduce the incidence of complications such as emphysema.

FOLLOW-UP

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Further Inpatient Care

• If the patient has had repeated episodes of pneumothorax or if the lung remains unexpanded after 5 days with a chest tube in place, surgery may be necessary. The surgeon may use treatment options such as thoracoscopy, electrocautery, laser treatment, resection of blebs or pleura, or open thoracotomy.
• In patients with repeated pneumothoraces who are not good candidates for surgery, sclerotherapy with talc or doxycycline may be necessary.

Deterrence/Prevention

• Advise patients to wear safety belts and passive restraint devices while driving.
• Encourage smoking cessation.
• The incidence of iatrogenic tension pneumothorax may be decreased with prophylactic insertion of a chest tube in patients with a simple pneumothorax that requires positive pressure ventilation.
• When subclavian vein cannulation is required, use the supraclavicular approach rather than the infraclavicular approach when possible to help decrease the likelihood of pneumothorax formation.
• Prompt recognition and treatment of bronchopulmonary infections decreases the risk of progression to a pneumothorax.

Complications

• Respiratory distress and/or arrest
• Cardiac arrest
• Pulmonary edema (following lung re-expansion)
• Empyema
• Persistent bronchopulmonary fistula
• Pneumomediastinum
• Pneumopericardium
• Pneumoperitoneum
• Pyopneumothorax
• Hemopneumothorax

Prognosis

• The prognosis is generally good with appropriate therapy, but it varies depending on the etiology.

MISCELLANEOUS

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Medical/Legal Pitfalls

• The diagnosis of a tension pneumothorax should be made based on the history and physical examination findings. A chest radiograph or CT scan should be used only in those instances when the clinician is in doubt regarding the diagnosis and when the patient's clinical condition is sufficiently stable. Obtaining such imaging studies when the diagnosis of tension pneumothorax is not in question causes an unnecessary and potentially lethal delay in treatment.
• A tension pneumothorax is a life-threatening condition and requires immediate action (eg, needle thoracostomy or chest tube insertion). However, the clinician should be wary of prematurely diagnosing a tension pneumothorax in a patient without respiratory distress, hypoxia, hypotension, or cardiopulmonary compromise. If the patient's clinical presentation is questionable and if the patient appears stable, the clinician should reexamine the patient and request immediate portable chest radiography (or reexamine the chest radiographs if they have already been obtained) to confirm the diagnosis.
• Consider the diagnosis of a pneumothorax and/or tension pneumothorax with blunt and penetrating trauma. In the patient blunt trauma and mental status changes, hypoxia, and acidosis, symptoms may be attributed to a suspected intracerebral injury rather than a tension pneumothorax. Portable chest radiography should always be included in the initial radiographic evaluation of major trauma.
• When assessing the trauma patient, be aware that clinical presentations of tension pneumothorax and myocardial rupture with tamponade may be similar.
• A significant number of patients have a larger chest wall than can be penetrated by a catheter length of 5 cm. Although thinner patients requiring thoracostomy can be treated using shorter catheter lengths, patients with a body habitus suggestive of a wider chest wall may need a catheter longer than 5 cm to reliably penetrate into the pleural space. In one recent study, a catheter length of patients at an American Level 1 Trauma Center showed that a catheter length of 5 cm would reliably penetrate the pleural space in only 75% of patients.
• Maintain a high index of suspicion for a tension pneumothorax in patients using ventilators who have a rapid onset of hemodynamic instability or cardiac arrest, particularly if they require increasing peak inspiratory pressures. Patients at greatest risk of a pneumothorax and/or tension pneumothorax include those with COPD who are using ventilators; those with acute respiratory distress syndrome; and those requiring a tidal volume greater than 12 mL/kg, a peak airway pressure greater than 60 cm H₂O, or a positive end-expiratory pressure greater than 15 cm H₂O.
• Avoid assuming that a patient with a chest tube does not have a tension pneumothorax if he or she has respiratory or hemodynamic instability. Chest tubes can become plugged or malpositioned and cease to function. Also, improper attachment of a one-way valve to the chest tube may produce tension pneumothorax.
• A 2005 study of emergency physicians used a sampling of 25 emergency physicians, 21 of which had completed ATLS training. When attempting to correctly locate the needle thoracostomy site on a human volunteer, only 60% were able to correctly identify the second intercostal space, and all placed the thoracentesis needle medial to the midclavicular line. In this same study, 8% of participants inappropriately identified the site used for needle pericardiocentesis and 4% inappropriately identified the fifth intercostal space in the anterior axillary line.
• Related to the development of apparent life-threatening hemorrhage after decompression in the second intercostal space at the anterior, midclavicular line in patients with no initial evidence of hemothorax on presentation, it has been suggested that a potentially safer option is to decompress a pneumothorax in the fifth intercostal space at the anterior axillary line, similar to recommendations for chest drain insertion.

MULTIMEDIA

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Media file 1:  Pneumothorax, Tension and Traumatic.
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Media file 2:  Pneumothorax, Tension and Traumatic.
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Media file 3:  Pneumothorax, Tension and Traumatic.
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Media file 4:  Pneumothorax, Tension and Traumatic.
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Media file 5:  Pneumothorax, Tension and Traumatic.
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Media file 6:  Pneumothorax, Tension and Traumatic.
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REFERENCES

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• Bense L, Eklund G, Wiman LG. Smoking and the increased risk of contracting spontaneous pneumothorax. Chest. Dec 1987;92(6):1009-12. [Medline].
• Chan SS. Emergency bedside ultrasound to detect pneumothorax. Acad Emerg Med. Jan 2003;10(1):91-4. [Medline].
• Dulchavsky SA, Schwarz KL, Kirkpatrick AW, et al. Prospective evaluation of thoracic ultrasound in the detection of pneumothorax. J Trauma. Feb 2001;50(2):201-5. [Medline].
• Ferrie EP, Collum N, McGovern S. The right place in the right space? Awareness of site for needle thoracocentesis. Emerg Med J. Nov 2005;22(11):788-9. [Medline].
• Givens ML, Ayotte K, Manifold C. Needle thoracostomy: implications of computed tomography chest wall thickness. Acad Emerg Med. Feb 2004;11(2):211-3. [Medline].
• Gordon R. The deep sulcus sign. Radiology. Jul 1980;136(1):25-7. [Medline].
• Greene R, McLoud TC, Stark P. Pneumothorax. Semin Roentgenol. Oct 1977;12(4):313-25. [Medline].
• Holloway VJ, Harris JK. Spontaneous pneumothorax: is it under tension?. J Accid Emerg Med. May 2000;17(3):222-3. [Medline].
• Leigh-Smith S, Davies G. Tension pneumothorax: eyes may be more diagnostic than ears. Emerg Med J. Sep 2003;20(5):495-6. [Medline].
• Leigh-Smith S, Harris T. Tension pneumothorax--time for a re-think?. Emerg Med J. Jan 2005;22(1):8-16.
• Ludwig J, Kienzle GD. Pneumothorax in a large autopsy population. A study of 77 cases. Am J Clin Pathol. Jul 1978;70(1):24-6. [Medline].
• Melton LJ, Hepper NG, Offord KP. Incidence of spontaneous pneumothorax in Olmsted County, Minnesota: 1950 to 1974. Am Rev Respir Dis. Dec 1979;120(6):1379-82. [Medline].
• Ogata ES, Gregory GA, Kitterman JA. Pneumothorax in the respiratory distress syndrome: incidence and effect on vital signs, blood gases, and pH. Pediatrics. Aug 1976;58(2):177-83. [Medline].
• Rawlins R, Brown KM, Carr CS, Cameron CR. Life threatening haemorrhage after anterior needle aspiration of pneumothoraces. A role for lateral needle aspiration in emergency decompression of spontaneous pneumothorax. Emerg Med J. Jul 2003;20(4):383-4.
• Soldati G, Iacconi P. The validity of the use of ultrasonography in the diagnosis of spontaneous and traumatic pneumothorax. J Trauma. Aug 2001;51(2):423. [Medline].
• Wilder RJ, Beacham EG, Ravitch MM. Spontaneous pneumothorax complicating pulmonary tuberculosis. J Thorac Cardiovasc Surg. 1962;46:331.

Article Last Updated: Aug 28, 2006