Talk:Pneumothorax

This may be the wrong time to be offering this, but I saw the suggestion at FAC that "In special populations" might be included. The following is a draft of a section dealing with pneumothorax in scuba divers. Please feel free to use it, modify it, or put it on the shelf for some future time. --RexxS (talk) 18:28, 6 January 2012 (UTC)

Thanks for writing that. Where do you think it should be inserted? It is also not entirely clear how arterial gas embolism leads to pneumothorax. JFW | T@lk 10:48, 8 January 2012 (UTC)

Well, I suspect it belongs in "Special populations", as it only applies to those who are breathing compressed gases. I'm sorry I wasn't able to make the point clearer, but Bennett and Elliott only indicate possible mechanisms. AGE and pneumothorax are comorbidities (is that the right word?) of an expansion injury to the lung, rather than one causally related to the other. It's probably clearer for you if I quote the relevant sentences (with apologies for copyvio):

• "It is not clear the exact pathway that air follows to produce this lesion. Clearly air can dissect to the visceral pleura and either at the site of weakness, a bleb, or an adhesion to the chest wall rupture, causing a clinical PTX. It is also possible, however, that air dissecting along perivascular sheaths can dissect to the root of the lung and then rupture the parietal pleura causing a PTX. A diving related PTX needs to be recognised early because if it occurs in association with an AGE, recompression treatment could theoretically cause a simple communicating PTX to be converted into a tension PTX during the ascent phase of treatment." - Bennett & Elliott, page 561.

I'd be more than happy if you can use that to clarify my efforts. I must admit I was trying to be as concise a possible, because the low incidence of diving related PTX suggested to me that more would be WP:UNDUE. I'll also drop User:Gene Hobbs a line and ask if he can improve it. --RexxS (talk) 15:59, 8 January 2012 (UTC)

Thanks for the clarification. I wonder if we shouldn't list the mechanism of PTX in divers in "Mechanism", but then there is a risk that the whole thing will get fragmented. JFW | T@lk 18:07, 8 January 2012 (UTC)

Well, I would actually argue for consideration of splitting the barotrauma up a little with a few additional points (Maybe one sentence each):

Under causes - trauma, List exposure to changes in atmospheric pressure such as those seen in scuba diving, submarine escape, uncontrolled decompression (altitude) and undiagnosed with HBO tx.

Epidemiology, add a shorter version of the information RexxS listed above as a summary of risk to divers or all of it under a subheading.

History, Mention spontaneous PTX as contraindication to scuba and debate around that for fitness to dive as well as SET operational changes made due to risk of pulmonary barotrauma (including PTX).

Maybe use a reference or two that have more public access. ;)

Just my 2c... Looks GREAT! --Gene Hobbs (talk) 00:12, 9 January 2012 (UTC)

Thanks Gene. Do you have a source (per WP:MEDRS) that discusses atmospheric pressure shifts in extenso? That might be helpful when we think about adding the above causes.

The BTS guideline has some content on the importance of securing the pleura in people with previous PTX prior to diving.

The history content would again need a source. JFW | T@lk 01:03, 9 January 2012 (UTC)

Barotrauma refs:

• Diving - Moon, RE; Stolp, BW title=Diving and the lung. (1997). South Pacific Underwater Medicine Society (SPUMS) Journal. 27 (4) http://archive.rubicon-foundation.org/6092. Retrieved 2012-01-08. {{cite journal}}: Missing or empty |title= (help); Missing pipe in: |author= (help)CS1 maint: multiple names: authors list (link)

• Spontaneous PTX as contraindication to diving - Taylor, DMcD; O’Toole, KS; Ryan, CM (2002). "Experienced, recreational scuba divers in Australia continue to dive despite medical contra-indications". South Pacific Underwater Medicine Society (SPUMS) Journal. 32 (4). Retrieved 2012-01-08.{{cite journal}}: CS1 maint: multiple names: authors list (link)
• AND Vorosmarti J, Linaweaver PG (eds). (1987). "Fitness to Dive. 34th Undersea and Hyperbaric Medical Society Workshop. UHMS Publication Number 70(WS-WD)5-1-87". Undersea and Hyperbaric Medical Society. Retrieved 2012-01-08. {{cite journal}}: Cite journal requires |journal= (help)
• Not absolute contraindication - Francis, TJR (2001). "Pulmonary fitness to dive". South Pacific Underwater Medicine Society (SPUMS) Journal. 31 (4). Retrieved 2012-01-08.

• Submarine escape - Walker, Robyn (2002). "Lung assessment for submarine escape training". South Pacific Underwater Medicine Society Journal (32). Retrieved 2012-01-08. {{cite journal}}: More than one of |number= and |issue= specified (help)
• Uncontrolled decompression - Bason R, Yacavone DW (1992). "Loss of cabin pressurization in U.S. Naval aircraft: 1969-90". Aviat Space Environ Med. 63 (5): 341–5. PMID 1599378. {{cite journal}}: Unknown parameter |month= ignored (help)

These may be a good start, I can pull more tomorrow if needed. --Gene Hobbs (talk) 02:34, 9 January 2012 (UTC)

Gene, thanks for identifying two free references. Unfortunately both have the format of case discussions, which are less suitable as sources for medical articles (see WP:MEDRS). The Vorosmarti source would be good, but is now 24 years old; is there no more recent consensus guidance on the subject? JFW | T@lk 22:07, 23 January 2012 (UTC)

No worries, just giving you options. <g> Jim's article is a good one and it is the last workshop on the topic by any of the three major societies worldwide. The only real change to those guidelines was one on diabetes anyway. Asthma may see some changes in the next few years but pressure and volume still act the same so nothing new on this topic anytime soon...

I just noticed you have not been using first names when they are available. I am a more info in the reference is better guy but please revert that one as well if it does not meet your needs.

I do think that should be moved down to the traumatic section. Thanks! --Gene Hobbs (talk) 22:18, 23 January 2012 (UTC)

I will have a look at moving the content to the "traumatic" section. With regards to first names, I try to keep the reference formatting consistent. The journal articles use only initials. I might have a further look at the Vorosmarti source, seeing that it pretty much seems to be the final word in this area. JFW | T@lk 22:26, 23 January 2012 (UTC)

Axl (talk · contribs) (on the FAC page) has raised a concern that the drain site is too far anteriorly, and that the omental tag is placed in such a way as to allow too little slack on the drain. JFW | T@lk 11:40, 8 January 2012 (UTC)

"as for peak incidence in ages 16-24 that is an age that most doctors would regard as "adult""

In regard to incidence, specifically since the context was in pediatric incidence, 16-24 would not be regarded as "adult incidence" without qualifying language. At least, from how I intended the addition to the article | pulmonological ^{talk • contribs} 22:16, 11 January 2012 (UTC)

You need to be clearer here. Why would I want to regard anyone over 18 as a child? JFW | T@lk 01:25, 12 January 2012 (UTC)

Point taken, out of context it doesn't make sense. | pulmonological ^{talk • contribs} 02:03, 27 January 2012 (UTC)

Waylah (talk · contribs) has now twice added a mention of pneumothorax secondary to acupuncture. This is based on doi:10.3233/JRS-2010-0503, a paper by Edzard Ernst and colleagues that collates complications of acupuncture. I don't think it should be cited here. None of the other sources even allude to it, while clearly mentioning other forms of iatrogenic pneumothorax. I suspect that while it is a recognised complication, it is sufficiently rare not to be suitable for mention here per WP:WEIGHT; the list of causes is not exhaustive. JFW | T@lk 09:55, 27 April 2012 (UTC)

While I can see your point, I'd always urge caution about rejecting a secondary source, just because the condition it describes is rare. This may be one of the issues where an encyclopedia diverges from a general medical textbook, as WP:WEIGHT specifically asks us to "consider a viewpoint's prevalence in reliable sources, not its prevalence among Wikipedia editors or the general public", which I would take in this case to imply that we consider the prevalence of 'pneumothorax secondary to acupuncture' in sources, rather than its incidence as a condition. Ernst is a well-published (if sometimes controversial) author, and if he is able to collate multiple reports to create a review, then it might be that there are sufficient sources for the condition to be significant (in the WEIGHT sense).

Anyway, you're the expert and you know the literature, so I'm always going to defer to your judgement on the prevalence of sources; but I did want you to give a little more thought to this issue as I wouldn't want the article be be accused of being less than comprehensive, if the sources are really there to justify mention of this condition. --RexxS (talk) 11:58, 27 April 2012 (UTC)

I'm having a bit of a déjà vu, after vertebral artery dissection went through exactly the same process involving a source by Ernst. I am in no doubt that the source is relevant on acupuncture, but on this article it would cause problems with WP:WEIGHT. JFW | T@lk 13:40, 27 April 2012 (UTC)

I also found this paper, again by Ernst. They report 201 cases of pneumothorax as an adverse event related to acupuncture, and four deaths, although it is impossible to know if the acupuncture was actually causal. In any case, sources about pneumothorax do not describe acupuncture as a cause. Therefore this material should not be in "Pneumothorax". It would be appropriate for "Acupuncture". Axl ¤ [Talk] 14:05, 27 April 2012 (UTC)

That's fine. Ernst is a professor of CAM, if I recall correctly, and he seems to focus on debunking inappropriate medical claims, so it's quite probable that topics such as acupuncture and chiropractic will have come under his scrutiny, producing a disproportionate degree of attention. At least we can now demonstrate to Waylah that his efforts have been taken seriously, even if consensus is that this article is not the place for them. --RexxS (talk) 15:17, 27 April 2012 (UTC)

Dr.saptarshi (talk · contribs) made a number of changes to the article. In the intro, there was a verbose addition on tension pneumothorax with a reference that relied heavily on the search function of Google Books. The additions to "mechanism", again on tension pneumothorax, were also quite long, supported by references not in keeping with WP:MEDRS, and creating attribution problems (e.g. text seemingly cited to Leigh-Smith but not actually in the source).

I am very happy discussing the changes here, but at the moment I don't think they were enhancing the article. JFW | T@lk 19:55, 21 May 2012 (UTC)

Thanks JFW. I had similar concerns about both verbosity and a few other concerns (probably similar to yours :). You might have noticed that I had already trimmed down the intro myself into something much smaller than an intermediate form - which of course was too verbose and I didnt keep it for more than 7 minutes. But I am glad you helped putting the article completely back. Else I was under major pressure to do a lot of cleaning/major revisions urgently myself . Sorry for the inconvenience so far. Now I am relieved that I can take my time without any further inconvenience to the readers or other editors- and can do my revisions off line/off the main article page.

I had a concern that current intro and mechanism both might give misleading info about tension pneumothorax. The below parts in the intro and mechanism might also need to be looked into, about its factual accuracy as a general statement, its appropriateness as a part of intro.. etc. My reading and edits was mainly to address(/bring your notice to) these. Hopefully my edits and references (and this discussion) will stay in the history log for future reference of others as well as myself.

1. The intro talks about "tension" as if it is all about volume. But it has also a lot to do with pressure (the definition and our understanding in relation to pressure has been evolving over time and Leigh smith definition infobox last bullet summarizes it nicely).
2. One way valve is a idea we all talk about first thing when we talk about TPT.. but will a lay man understand it in the same way as we do by mentioning it right in the intro? Plus is it necessary to have a one way valve? what about a Positive presure ventilation with a Bronchopulmonary fistula? More over is it sufficient to have a one way valve to have a tension pneumothorax? Dont people with Asthma/COPD have one way valve mechanism that cause the retention of the residual volume. If they have a ruptured bulla will they necessarily always have a Tension unless the parallelly escalating compensatory increase in respiraory effort actually add the positive part of the pressure? One of the primary references I mentioned in the mechanism section cited a one way valve that lead to bilateral spontaneous pneumothorax that stayed non-tension for quite sometime despite its one-way-ness.
3. The current section on mechanism again gives a misleading info as if respiratory arrest is the major problem but actually reduced cardiac output is the major problem which has been shown well enough in animal studies mentioned in the google book references I cited.
4. I started to mention the positive pressure ventilation type TPT but realized that intro was not the right place and so had already removed that part.

I am also happy to discuss here without disturbing the main page. After doing the edits I myself realized that my own idea about "tension" evolved so rapidly after sarting to think and read about it, that had I foreseen such huge shift, I would not have touched the article, and would have liked to discuss them here first. Sorry for my verbose language and poor English in this discussion I just woke up in the middle of a catch up sleep post call after tandem night duty and then a day duty. Didnt have enough time/alertness to articulate my thoughts sufficiently at this instance. But hope the wisdom of others combined with mine will benefit the article. Feel free to be candid if you disagree (since it is discussion page.. and I assure you I will not take them personally. ;)

Sincere regards-- Dr.saptarshi (talk) 22:58, 21 May 2012 (UTC)

I think we need to be clear which bits of information we need to include to enhance the article. I agree that discussing the pathophysiology of tension pneumothorax in the intro may be a bit excessive. I too am not clear that all cases of tension pneumothorax result from a one-way valve the way it happens in trauma.

Leigh-Smith does appear to discuss the fact that respiratory arrest is not the main "endgame" of tension pneumothorax. We need to verify this before committing it to the article. JFW | T@lk 21:48, 22 May 2012 (UTC)

1. At present, the definition of tension pneumothorax in the lead is different to the definition used in "Signs and symptoms", subsection "Tension pneumothorax". This needs to be fixed.

2. The "one-way valve" concept is used in specialist respiratory texts, such as Fishman's Pulmonary Diseases & Disorders and Light's Pleural Disorders. While it may be interesting to speculate on the nature of (tension) pneumothorax in asthma, COPD or bronchopleural fistula, in Wikipedia articles we must use reliable sources, ideally secondary sources.

3. You're referring to "Mechanism", paragraph 3. That's a fair point. The reduction in cardiac output should be mentioned. (Whether "reduced cardiac output is the major problem" is somewhat academic, and I think beyond the scope of Wikipedia's article.)

4. "Signs and symptoms", subsection "Tension pneumothorax" has a short paragraph about mechanical ventilation. I think that is enough for Wikipedia's article.

Axl ¤ [Talk] 18:02, 23 May 2012 (UTC)

Dear Axl, as far as I could read (correct me if I am wrong), the definition of Tension is done by "pressure" and neither by one way valve nor by volume expansion in the "specialist respiratory textbook" Fishman and most other textboks. For the convenience of others let me give some excerpts:

Fishman 4th Edition Chapter 87 (page 1531) Opening lines about tension pneumothorax says:

"A tension pneumothorax is present when the intrapleural PRESSURE is greater than atmospheric throughout expiration and often during inspiration as well. The term expiratory tension pneumothorax has been proposed to highlight the fact that in a SPONTANEOUSLY BREATHING person, pleural pressure must be negative in relation to atmospheric pressure during part of the respiratory cycle for air to enter the pleural space. The mechanism responsible for tension pneumothorax is the disruption of the visceral or parietal pleura in such a manner that a one-way valve develops.....As a tension pneumothorax progresses, the pleural pressure remains positive during a greater portion of the inspiratory cycle. If the patient is on MECHANICAL VENTILATION, the ALVEOLAR pressure remains POSITIVE throughout inspiration and expiration.

A tension pneumothorax can occur after any type of pneumothorax; it is independent of the etiology. It can sometimes occur after a spontaneous pneumothorax but is more common after a traumatic pneumothorax, with mechanical ventilation, or during cardiopulmonary resuscitation.

....

A tension pneumothorax may develop because of improper connection of a one-way flutter valve to the chest tube. It can occur even if there is a chest tube in place, due to either mal-positioning of the tube or disconnection at the site of tube or the site of the pleural-vac container.

..

The decompensation of the cardiopulmonary status in patients with tension pneumothorax is usually attributed to diminished venous return and marked decrease in the cardiac output, which is THE most life-threatening. However, there is ALSO a significant decrease in the PaO2, which also needs to be addressed immediately as well.

Animal studies demonstrate that cardiac output is maintained by the tachycardia and the increase in negative intrathoracic pressure during inspiration. Deterioration has been shown to be related to severe hypoxemia, probably because of increased shunting and V-Q mismatch in the compressed lung. Preterminally, animals develop CO2 retention and respiratory acidosis. The importance of negative intrathoracic pressure swings in maintaining cardiac output was demonstrated by the precipitous fall in cardiac output when mechanical ventilation was initiated."

Rosen's emergency medicine, Chapter 75, Pleural Disease by Joshua M. Kosowsky, Says:

"With tension pneumothorax, signs of asphyxia and decreased cardiac output develop. Tachycardia (often >120 beats/min) and hypoxia are common. Hypotension is a late and ominous finding. Distention of the jugular veins is common but may be difficult to detect. Displacement of the trachea to the contralateral side is classically described but is an uncommon finding, usually occurring only in the immediately preterminal phase of the pneumothorax, if at all. Its absence should not be considered evidence that a tension phenomenon is not present."

Harrison's Principles of Internal Medidine introduction about TPT says:

"This condition usually occurs during mechanical ventilation or resuscitative efforts. The positive pleural pressure is lifethreatening both because ventilation is severely compromised and because the positive pressure is transmitted to the mediastinum, which results in decreased venous return to the heart and reduced cardiac output."

I could not so far find any of these textbooks mention the "respiratory arrest". If we prefer to use secondary sources like textbooks probably we might have to replace "respiratory arrest" and replace it with hypoxemia or asphyxia. But interestingly there is primary literature highlighting this. For example this paper Accidentally created tension pneumothorax in patient with primary spontaneous pneumothorax – confirmation of the experimental studies, putting into question the classical explanation says: "The widespread explanation of patophysiology of tension pneumothorax is that compression to the mediastinum by the progressively accumulating intrapleural air causes torsion at the atrio-caval junction, impaired filling of the right heart and circulatory arrest as potentially life-threatening complication. Some experimental studies on animals put into question such an explanation, suggesting that respiratory arrest due to hypoxia of the respiratory center, not a circulatory arrest, represents dominant life threatening feature."

Sincere regards --Dr.saptarshi (talk) 23:49, 23 May 2012 (UTC)

I am certainly not disputing the importance of pressure in the development of tension pneumothorax. Of course I agree that Fishman defines tension pneumothorax in terms of pressure. However the one-way valve is also an important concept. To repeat your quote of Fishman: "The mechanism responsible [in a spontaneously breathing person] for tension pneumothorax is the disruption of the visceral or parietal pleura in such a manner that a one-way valve develops." Indeed if there was no one-way valve, the intrapleural pressure would equilibrate with atmospheric during expiration, thus the pneumothorax would not be tension by definition.

Wikipedia's article currently states "Although multiple definitions exist, a tension pneumothorax is generally considered to be present when a pneumothorax leads to significant impairment of respiration or blood circulation." This is referenced to Leigh-Smith. Leigh-Smith's article has a section entitled "Tension Pneumothorax – Definition". Leigh-Smith mentions various definitions used in the literature. Ironically, Leigh-Smith fails to state their chosen definition, and then goes on to say "Definitions using intrapleural pressure (IPP) are more accurate than clinical definitions".

I do not believe that Leigh-Smith should be used as a reference to define tension pneumothorax. At best, it can be used to say that more than one definition is described in the literature.

Thank you for pointing out the paragraph in Fishman that describes the importance of reduced cardiac output. You are quite right to emphasize this. However Leigh-Smith's description of animal studies states: "Despite falling stroke volumes cardiac output was almost universally preserved throughout with one study noting a 19% increase in BP. In all these studies just two animals (both immature monkeys with mobile mediastinums) developed hypotension immediately before death from respiratory arrest, but cardiac output was still 70% normal at this stage.... There was minimal evidence of right sided venous obstruction with only bilateral TPTs causing a linear rise in central venous pressure (CVP). Only one of the three unilateral TPT studies found increased superior and inferior vena caval pressures and these occurred in the agonal stages of respiration."

Axl ¤ [Talk] 09:57, 24 May 2012 (UTC)

Dbann (talk · contribs) added the following content:

This is based on doi:10.1016/j.athoracsur.2012.05.073, which is a primary research study. Dbann reverted my removal of the study because "it summarises the previous research". This is a common argument for using primary research studies as sources for encyclopedia content. There is however a longstanding concern (discussed repeatedly on WT:MEDRS) that such summaries are often one-sided because of space or because the researchers wish to place their findings in a particular context. Of course any appropriate new secondary sources citing this study are suitable. JFW | T@lk 19:57, 24 June 2013 (UTC)

No worries. Both narrative reviews (which are currently cited) and original researcher articles doi:10.1016/j.athoracsur.2012.05.073 may suffer from this bias in the studies they do or not include. The only robust source would be a systematic review, which I have not found. Would this sentence not require a citation? "...blebs occur in 15% of healthy people". Dbann (talk) 23:04, 24 June 2013 (UTC)

Narrative reviews are meant to be comprehensive (or at least declare when they are not comprehensive), while again most research papers are more selective out of necessity. I agree that systematic reviews are "the bees' knees" in this regard (on our hierarchy of needs) but often not available. I would not be surprised if the Casali paper was soon included in reviews.

You are correct that the "blebs in 15%" claim needs a specific citation, because it is does not appear in Tschopp's review (it's only in Noppen). Grundy gives a figure of 6% based on data acquired in a non-affected population. I have adjusted the content to reflect this. Hope you agree. JFW | T@lk 14:03, 26 June 2013 (UTC)

Seems sensible to me Dbann (talk) 21:14, 28 June 2013 (UTC)

J Hosp Med review on management doi:10.1002/jhm.2053 JFW | T@lk 15:55, 18 August 2013 (UTC)

I have reverted this edit. The source describes two case reports of people who used cannabis and developed emphysema (with bullae) and aspergillomas, with subsequent pneumothoraces. The reference is a primary source, and in any case concentrates more on the connection between cannabis and aspergillus. The presence of pneumothoraces is incidental. Perhaps more importantly, my main secondary sources do not describe cannabis use as a cause for pneumothorax, I am inviting the anonymous IP editor to comment. Axl ¤ [Talk] 19:24, 25 August 2013 (UTC)

More refs can be found including:

http://books.google.com/books?id=qGDD--GXcG8C&pg=PA61&dq=cannabis+spontaneous+pneumothorax&hl=en&sa=X&ei=3RMdUtHlCsbmyQHEuoGACA&ved=0CEIQ6AEwAg#v=onepage&q=cannabis%20spontaneous%20pneumothorax&f=false

http://books.google.com/books?id=ATDRt1HM9MwC&pg=PA166&dq=cannabis+spontaneous+pneumothorax&hl=en&sa=X&ei=3RMdUtHlCsbmyQHEuoGACA&ved=0CFIQ6AEwBQ#v=onepage&q=cannabis%20spontaneous%20pneumothorax&f=false

http://books.google.com/books?id=fwutfifAS-4C&pg=PT3748&dq=cannabis+spontaneous+pneumothorax&hl=en&sa=X&ei=3RMdUtHlCsbmyQHEuoGACA&ved=0CGYQ6AEwCQ#v=onepage&q=cannabis%20spontaneous%20pneumothorax&f=false 66.188.191.126 (talk) 21:08, 27 August 2013 (UTC)

Others: http://books.google.com/books?id=KDOeIldGWxQC&pg=PT203&dq=cannabis+pneumothorax&hl=en&sa=X&ei=DRcdUtXrI8qCygGl8oG4CA&ved=0CDUQ6AEwAjgK#v=onepage&q=cannabis%20pneumothorax&f=false

http://books.google.com/books?id=Sossht2t5XwC&pg=PA533&dq=marijuana+pneumothorax&hl=en&sa=X&ei=gRcdUuXLLIbwyAHGl4DYCQ&ved=0CC0Q6AEwAA#v=onepage&q=marijuana%20pneumothorax&f=false

http://books.google.com/books?id=KuVJXCJldOQC&pg=PA720&dq=marijuana+pneumothorax&hl=en&sa=X&ei=gRcdUuXLLIbwyAHGl4DYCQ&ved=0CEYQ6AEwBA#v=onepage&q=marijuana%20pneumothorax&f=false — Preceding unsigned comment added by 66.188.191.126 (talk) 21:22, 27 August 2013 (UTC)

Source 1 is a book about addiction and drug abuse. It mentions pneumothorax only in passing.

Similarly, source 2 is a book about cannabinoids. It mentions pneumothorax is passing.

With source 3, you seem to be directing me towards a letter in a medical journal. This is not a suitable reference.

Source 4 is a toxicology handbook that mentions pneumothorax as a rare complication. This is another unsuitable source.

Source 5 is actually a reasonable source. It is a radiology textbook. It mentions marijuana in the text, although it does not include marijuana in its table of causes.

Source 6 is a manual of emergency pediatrics. Even with its focus on pediatrics, I question whether cannabis-induced pneumothorax is really more common than connective tissue disease peumothorax. In any case, it certainly isn't approaching a comprehensive list.

WP:MEDRS has guidance on the selection of sources. In particular, secondary sources should be used—reference 3 is an unsuitable source.

In my opinion, when listing causes of a particular disease, it is better to use a secondary source about the disease that includes a comprehensive list of the major causes. This helps to prevent inappropriate weighting of rare causes. The article is not intended to include an exhaustive list of every cause ever reported. This approach has already been used with this article, using this reference. Axl ¤ [Talk] 17:07, 28 August 2013 (UTC)

You may want to look at these sources also:

Source 7

Source 8

Source 9

Source 10

Source 11

Source 12

Thank you for taking the time explain your reasoning, but it seems clear that cannabis use has a better than good association with secondary and tertiary sources on the topic of Pneumothorax. 66.188.191.126 (talk) 20:14, 28 August 2013 (UTC)

Those references are reasonable suggestions. I am inviting WikiProject Medicine editors to comment here. Axl ¤ [Talk] 09:39, 4 September 2013 (UTC)

It would not really be surprising that all types of smoking increases the risk. We could summarize it as "smoking (either tobacco or cannabis)"Doc James (talk · contribs · email) (if I write on your page reply on mine) 10:09, 4 September 2013 (UTC)

Should I wish to update the article, the following sources might be useful (using "Pneumothorax"[MAJR] with "Review" on PubMed):

• doi:10.1136/thoraxjnl-2012-202875 Thorax systematic review of ambulatory management
• doi:10.1016/j.jtcvs.2012.12.003 JTCS use of endobronchial valves for persistent air leaks
• doi:10.1016/j.jemermed.2012.02.049 J Emerg Med alternative treatments
• doi: 10.1016/j.thorsurg.2012.10.006 Thorac Surg Clinics types of chest tubes
• doi:10.1097/MCP.0b013e32835358ca Curr Opin Pulm Med use of blood patch for persistent air leaks
• doi:10.1007/s11748-012-0080-9 Gen Thorac Cardiovasc Surg meta-analysis of surgical approaches
• doi:10.1378/chest.11-1691 Chest pneumothorax in the critically ill patient
• doi:10.1378/chest.11-0131 Chest ultrasound characteristics
• doi:10.1159/000335993 Respiration Noppen again suggesting pleural porosity as the main cause of PSP

The ultimate aim of updating this article would be FA candicacy, again. JFW | T@lk 18:32, 26 January 2014 (UTC)

http://articles.chicagotribune.com/1996-06-30/news/9606300409_1_kit-emergency-medicine-lung

This is a pretty interesting case of pneumothorax. Is this notable enough to include in the article? — Preceding unsigned comment added by 108.7.145.90 (talk) 04:29, 10 September 2014 (UTC)

It is a case report in a newspaper. This sort of case crops up from time to time. As well as being non-notable, it does not meet WP:MEDRS. It should not be added to the article. Axl ¤ [Talk] 10:43, 10 September 2014 (UTC)

In behalf of Drs. Frank McCormack and Nishant Gupta at the University of Cincinnati College of Medicine, Division of Pulmonary Medicine, I have tried to add the following information twice. They believe this information is very critical to add as a spontaneous pneumothorax can be the first indication of a rare lung disease. We believe both physicians and patients would be helped as they search for the cause of their pneumothorax.

If you would like for Dr. Gupta to shorten or modify please let me know and I will work with him to do this. Again we believe this information is important to add to one of the pages on Wiki new rare ling disease patients may look.

LAM Pneumothorax Wiki write-up

One of the most common etiologies for a secondary spontaneous pneumothorax is the disease lymphangioleiomyomatosis (LAM). LAM is a rare, progressive, neoplastic disease characterized by infiltration of the lung parenchyma with smooth muscle cells ultimately leading to the formation of multiple lung cysts. LAM is seen almost exclusively in females, with the majority of females diagnosed in their reproductive years. LAM can be seen as a part of the neurocutaneous syndrome Tuberous Sclerosis Complex (TSC-LAM) or can exist separately, in patients who do not have heritable mutations (Sporadic LAM). LAM, both sporadic as well as TSC-LAM, is caused by mutations in one the two tumor suppressor genes: TSC1 or TSC2 (1).

LAM is characterized by an increased risk of development of recurrent spontaneous pneumothoraces. In fact, pneumothorax is the presenting manifestation in greater than 50% of patients with LAM (2). The lifetime incidence of pneumothorax in patients with LAM varies from 39-81% (2). In the largest study analyzing the incidence and prevalence of pneumothoraces in LAM, the authors found an initial pneumothorax rate of 66% (260 out of 395 patients) (2). In addition, patients with LAM have a very high rate of having repeated episodes of pneumothoraces. In the study by Almoosa et al more than three-quarters of the patients (77%, 200 out of 260 patients) experienced a recurrent pneumothorax. On average a patient with LAM experiences more than three episodes of pneumothoraces in their lifetime (2).

Pleurodesis is a procedure commonly employed in an effort to reduce the chance of having a recurrent episode of pneumothorax (see section below on pleurodesis). In patients with LAM, conservative management (No pleurodesis) of the first episode of pneumothorax was associated with a 66% recurrence rate, while management with pleurodesis reduced the recurrence rate considerably, resulting in a 27-32% recurrence rate following pleurodesis (2). Based on this data, most experts recommend patients with LAM undergo pleurodesis after their first episode of pneumothorax (1, 2).

Another concern of patients, and their caregivers, in LAM is related to the impact of pleurodesis on the future chances of having a lung transplant, if needed. Prior pleural interventions, such as pleurodesis, can increase the risk of bleeding complications at the time of lung transplantation, and some centers consider bilateral pleurodesis to be a relative or absolute contraindication to lung transplantation (3). However, multiple studies have shown that while prior pleurodesis can produce a higher risk of bleeding during the transplant, it doesn't affect the mortality or other outcomes following lung transplant (2, 4-6). Based on these data, a history of pleurodesis is not considered a contraindication to lung transplantation in patients with LAM (7), and patients with LAM should be offered the option to undergo pleurodesis following their initial episode of pneumothorax.

The diagnosis of LAM is frequently delayed by 3–5 years from the onset of symptoms (7, 8). Performing a high-resolution computed tomography (HRCT) of the chest, in women presenting with a pneumothorax can lead to earlier diagnosis of LAM thus facilitating timely interventions to prevent recurrent episodes of pneumothoraces. In fact, in a cost-effectiveness study, Hagaman et al (9) have shown that performing a HRCT chest in non-smoking women presenting with a pneumothorax in their reproductive years is cost-effective in diagnosing LAM.

Birt-Hogg-Dubé syndrome (BHD) is another diffuse cystic lung disease that accounts for a significant proportion of secondary spontaneous pneumothoraces. BHD is a rare, autosomal-dominant disorder resulting from mutations in the folliculin (FLCN) gene on chromosome 17, and is characterized by the development of hair follicle tumors, renal neoplasms, and pulmonary cysts (10). More than 80% of patients with BHD have lung cysts. These cystic air spaces predispose patients with BHD to develop recurrent pneumothoraces (10). The incidence of pneumothorax in patients with BHD is 32-fold higher than the general population, extending up to 50-fold higher after adjusting for age (11). Approximately 25% of the patients with BHD will develop a pneumothorax in their lifetime; however, there is a 75% chance of a recurrent event after the initial episode of pneumothorax (12). Based on the high recurrence rate following a sentinel event, pleurodesis should be considered following the first episode of a pneumothorax in patients with BHD (10, 13). Two recent studies have demonstrated that BHD can be the underlying etiology for a pneumothorax in 5-10% of the patients presenting to the emergency room with an apparent primary spontaneous pneumothorax (14, 15). Similar to LAM, a recent analysis shows that performing a HRCT to screen for BHD in patients presenting with a pneumothorax is cost-effective. Pulmonary Langerhans cell histiocytosis (PLCH) is a rare, cystic lung disease most commonly encountered in young to middle aged patients (1). Approximately 90% of adult PLCH are active or former smokers, or have a history of exposure to second-hand cigarette or marijuana smoke (1, 16). Pneumothorax occurs in approximately 15% of patients with PLCH (17). The recurrence rate of pneumothorax following a sentinel event is quite high in PLCH. In the study by Mendez et al. 58% of patients had a recurrent pneumothorax if managed with observation or chest tube alone. In contrast, performing a pleurodesis reduced the recurrence rate to zero (17). This forms the basis for the recommendation to consider pleurodesis following the initial episode of pneumothorax in patients with PLCH (1).

Catamenial pneumothorax (CP) is defined as a spontaneous pneumothorax that occurs within the window of 24 hours before and 72 hours after the onset of menstrual cycle (18). Previously considered a rare cause of spontaneous pneumothorax, CP is now increasingly been recognized as a common cause for recurrent pneumothoraces in females. In fact, CP is now considered to account for 20–25% of the cases of primary spontaneous pneumothorax in females of reproductive age (19, 20). CP develops as a result of thoracic endometriosis. While diaphragmatic endometriosis is seen in almost all patients with CP, endometrial implants on the visceral pleura have also been known to cause CP (20). The exact mechanism of thoracic implantation of the endometrial tissue remains unclear (18). It is important to recognize that not all patients with thoracic endometriosis related pneumothorax have the temporal association with onset of menses characteristic of CP. In a recent analysis, CP represented only approximately one-third of all thoracic endometriosis related pneumothoraces (20). CP is almost always seen on the right side, with very rare left sided or bilateral episodes reported in the literature (21). On average, patients experience 3-5 pneumothoraces before getting a definitive diagnosis and treatment for CP (22). Thus, it is important for clinicians to maintain a high index of suspicion for thoracic endometriosis related pneumothorax/CP when evaluating females in their reproductive age group presenting with a spontaneous pneumothorax. Lack of a temporal relationship with menstrual cycle should not preclude the diagnosis of thoracic endometriosis related pneumothorax. Timely referral for video-assisted thoracoscopic surgery (VATS) can not only establish the definitive diagnosis but also help in reducing future recurrences. Medical treatment aimed to achieve hormonal blockade via oral contraceptive agents, progestins, or gonadotropin-releasing hormone (GnRH) agonists may be needed in addition to pleurodesis in order to achieve complete pleural symphysis, as well as help in symptomatic management of cyclical chest pain (18).

References:

1. Gupta N, Vassallo R, Wikenheiser-Brokamp KA, McCormack FX. Diffuse Cystic Lung Disease. Part I. Am J Respir Crit Care Med. 2015;191(12):1354-66.
2. Almoosa KF, Ryu JH, Mendez J, Huggins JT, Young LR, Sullivan EJ, et al. Management of pneumothorax in lymphangioleiomyomatosis: effects on recurrence and lung transplantation complications. Chest. 2006;129(5):1274-81.
3. Young LR, Almoosa KF, Pollock-Barziv S, Coutinho M, McCormack FX, Sahn SA. Patient perspectives on management of pneumothorax in lymphangioleiomyomatosis. Chest. 2006;129(5):1267-73.
4. Pechet TT, Meyers BF, Guthrie TJ, Battafarano RJ, Trulock EP, Cooper JD, et al. Lung transplantation for lymphangioleiomyomatosis. J Heart Lung Transplant. 2004;23(3):301-8.
5. Reynaud-Gaubert M, Mornex JF, Mal H, Treilhaud M, Dromer C, Quetant S, et al. Lung transplantation for lymphangioleiomyomatosis: the French experience. Transplantation. 2008;86(4):515-20.
6. Benden C, Rea F, Behr J, Corris PA, Reynaud-Gaubert M, Stern M, et al. Lung transplantation for lymphangioleiomyomatosis: the European experience. J Heart Lung Transplant. 2009;28(1):1-7.
7. Johnson SR, Cordier JF, Lazor R, Cottin V, Costabel U, Harari S, et al. European Respiratory Society guidelines for the diagnosis and management of lymphangioleiomyomatosis. Eur Respir J. 2010;35(1):14-26.
8. Ryu JH, Moss J, Beck GJ, Lee JC, Brown KK, Chapman JT, et al. The NHLBI lymphangioleiomyomatosis registry: characteristics of 230 patients at enrollment. Am J Respir Crit Care Med. 2006;173(1):105-11.
9. Hagaman JT, Schauer DP, McCormack FX, Kinder BW. Screening for lymphangioleiomyomatosis by high-resolution computed tomography in young, nonsmoking women presenting with spontaneous pneumothorax is cost-effective. Am J Respir Crit Care Med. 2010;181(12):1376-82.
10. Gupta N, Vassallo R, Wikenheiser-Brokamp KA, McCormack FX. Diffuse Cystic Lung Disease. Part II. Am J Respir Crit Care Med. 2015;192(1):17-29.
11. Zbar B, Alvord WG, Glenn G, Turner M, Pavlovich CP, Schmidt L, et al. Risk of renal and colonic neoplasms and spontaneous pneumothorax in the Birt-Hogg-Dube syndrome. Cancer Epidemiol Biomarkers Prev. 2002;11(4):393-400.
12. Toro JR, Pautler SE, Stewart L, Glenn GM, Weinreich M, Toure O, et al. Lung cysts, spontaneous pneumothorax, and genetic associations in 89 families with Birt-Hogg-Dube syndrome. Am J Respir Crit Care Med. 2007;175(10):1044-53.
13. Gupta N, Seyama K, McCormack FX. Pulmonary manifestations of Birt-Hogg-Dube syndrome. Fam Cancer. 2013;12(3):387-96.
14. Ren HZ, Zhu CC, Yang C, Chen SL, Xie J, Hou YY, et al. Mutation analysis of the FLCN gene in Chinese patients with sporadic and familial isolated primary spontaneous pneumothorax. Clin Genet. 2008;74(2):178-83.
15. Johannesma PC, Reinhard R, Kon Y, Sriram JD, Smit HJ, van Moorselaar RJ, et al. Prevalence of Birt-Hogg-Dube syndrome in patients with apparently primary spontaneous pneumothorax. Eur Respir J. 2015;45(4):1191-4.
16. Vassallo R, Ryu JH, Colby TV, Hartman T, Limper AH. Pulmonary Langerhans'-cell histiocytosis. N Engl J Med. 2000;342(26):1969-78.
17. Mendez JL, Nadrous HF, Vassallo R, Decker PA, Ryu JH. Pneumothorax in pulmonary Langerhans cell histiocytosis. Chest. 2004;125(3):1028-32.
18. Alifano M. Catamenial pneumothorax. Curr Opin Pulm Med. 2010;16(4):381-6.
19. Alifano M, Roth T, Broet SC, Schussler O, Magdeleinat P, Regnard JF. Catamenial pneumothorax: a prospective study. Chest. 2003;124(3):1004-8.
20. Fukuoka M, Kurihara M, Haga T, Ebana H, Kataoka H, Mizobuchi T, et al. Clinical characteristics of catamenial and non-catamenial thoracic endometriosis-related pneumothorax. Respirology. 2015;20(8):1272-6.
21. Alifano M, Jablonski C, Kadiri H, Falcoz P, Gompel A, Camilleri-Broet S, et al. Catamenial and noncatamenial, endometriosis-related or nonendometriosis-related pneumothorax referred for surgery. Am J Respir Crit Care Med. 2007;176(10):1048-53.
22. Johnson MM. Catamenial pneumothorax and other thoracic manifestations of endometriosis. Clin Chest Med. 2004;25(2):311-9. — Preceding unsigned comment added by KimHasselfeld (talk • contribs) 19:15, 16 January 2016 (UTC)

Please add PubMed IDs to sources that you propose using (I've done the first one for you) as a courtesy to other editors.

There is an article on Lymphangioleiomyomatosis as you are well aware. There could be a parent article on Diffuse Cystic Lung Disease or, more likely, on Cystic Lung Disease if sources were marshalled. In any of those articles it would be appropriate to discuss the etiology, classification, symptoms and management of LAM. It is wholly inappropriate to attempt to do so in this article on pneumothorax. Please review the section Pneumothorax #Cause and explain why the link to lymphangioleiomyomatosis is insufficient.

Similarly, we have an article on Birt–Hogg–Dubé syndrome and it doesn't need to be repeated here. Again, the section here on causes deals with Birt–Hogg–Dubé syndrome, and states "Generally, these conditions cause other signs and symptoms as well, and pneumothorax is not usually the primary finding." Why would we need to go into such great detail as you propose?

Our article on catamenial pneumothorax is relatively short, and expanding that with good MEDRS sources would be welcome, but I still can't see how it would improve this article to discuss the details of catamenial pneumothorax when it is clearly linked already from the same section that I referred you to. --RexxS (talk) 01:36, 17 January 2016 (UTC)

Kim, thank you for bringing this matter to the talk page.

My main concern about this text is that it brings undue weight to specific diseases (lymphangioleiomyomatosis & Birt–Hogg–Dubé syndrome) into a generic article about pneumothorax. You will see that many of the references provided in the article are about pneumothorax, or even more generically about respiratory disease. On the other hand, many of the references that you provide are specific to LAM or BHD. Much of the information that you suggest would be more appropriate in those disease-specific articles.

Our article states that 70% of spontaneous secondary pneumothoraces are associated with COPD. What proportion are associated with LAM & BHD? My own ("original") anecdotal evidence: In 18 years of clinical medicine, I have never seen a case of BHD, and only a handful of cases of LAM. Yet I have seen thousands of cases of COPD.

It is commendable that you and your colleagues want to draw attention to these rare causes of secondary pneumothorax, but Wikipedia's article on pneumothorax is not the place to do so.

How would you feel about adding this information to the disease-specific articles? Axl ¤ [Talk] 15:13, 18 January 2016 (UTC)

I will share with Dr. Gupta and get back with you. Just FYI - for the text I tried to post I did have PMID IDs in the references and will definitely include them. — Preceding unsigned comment added by 72.49.246.127 (talk) 21:11, 18 January 2016 (UTC)

The NICE guidelines for major trauma make recommendations about traumatic pneumothorax: http://www.nice.org.uk/guidance/ng39 JFW | T@lk 13:27, 17 February 2016 (UTC)

This was placed under "Cause" however it is (1) no longer a current cause of pneumonia as is no longer done (2) the sources are old and unformated. (3) the topic was already covered in the history section. Doc James (talk · contribs · email) 17:54, 29 November 2016 (UTC)

"In the 18th century, French physicians noticed that the prognosis of patients with tuberculosis improved if the patients developed spontaneous pneumothorax.^[1][2] In the late 19th century, the Italian physician Carlo Forlanini developed a technique to induce pneumothorax for therapeutic purposes, forcing the collapse of one lung in an attempt to close tuberculosis cavities.^[3] This inhibited progression of the disease, because it inhibited growth of the bacilli. Patients would survive on one lung while the damaged one healed, and the damaged lung would then be reinflated. Artificial pneumothorax was independently developed in the United States, but did not gain widespread popularity there until some years later.^[4][1][2] This procedure was an important part of treatment for tuberculosis until the introduction of the BCG vaccine and effective antibiotics in the 1950s. In this way, the treatment of tuberculosis laid the foundations for modern thoracic surgery.^[1][2][4]"

Pneumothorax#History here is the section in which it is already discussed.

Which source supports the effectiveness of the practice? Doc James (talk · contribs · email) 17:57, 29 November 2016 (UTC)

I made the following addition regarding pneumos of the Open/Closed/Sucking chest wound varieties . I tried to remain faithful to the source which describes sucking chest wounds as a type of open pneumothorax, but is it not more accurate to say that sucking chest wounds are a type of injury which leads to an open pneumothorax? AdventurousSquirrel (talk) 23:52, 28 September 2017 (UTC)

It is not described how to do the X-Ray. Can someone please help? I would suggest to do it in a lying position since it releaves the the pressure on the affected lung a bit. 91.38.167.199 (talk) 08:32, 26 March 2020 (UTC)

I read this article here:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4203989/. Published in 2014. Quite similar in structure and wordings when compared to this Wikipedia article. Any of you can confirm whether this is plagiarism of Wikipedia article by an external article?