Risk Factors
Pneumocystis jirovecii, tuberculosis, chronic obstructive pulmonary disease, Marfans, familial, mechanical ventilation, smoking, cystic fibrosis

 

 

Condition Treatment Options
Small primary pneumothorax (<20% or 3 cm apex-cupula and asymptomatic)

Observation for >3 h on oxygen, repeat chest x-ray, discharge if no symptoms, and return for check if symptoms recur or in 24 h

Or

Small-size catheter aspiration with immediate catheter removal, then observe for >3 h, discharge if no symptoms, and return for check if symptoms recur or in 24 h

Or

Small-size catheter aspiration or small-size chest tube insertion, Heimlich valve, or water seal and admission
Small secondary pneumothorax Small-size catheter or small-size chest tube insertion, Heimlich valve, or water seal and admission
Large pneumothorax, either primary or secondary, or bilateral pneumothoraces Moderate-size chest tube and admission; large-size chest tube if fluid or hemothorax present; water seal and admission
Tension pneumothorax Immediate needle decompression followed by moderate or large-size chest tube insertion, water seal drainage, and admission; immediate chest tube placement ideal

The stability of the patient, the degree of symptoms, the size and relative change in size over time, the cause of the pneumothorax, the degree of underlying lung disease, the likelihood of recurrence and resolution, and the need for positive-pressure ventilation are factors to consider in deciding to intervene procedurally on a pneumothorax,

Oxygen administration (>28%) increases pleural air resorption three- to fourfold over the base 1.25% reabsorbed per day, by creating a nitrogen gas pressure gradient between the alveolus and trapped air.19,20,21 

Without supplemental oxygen, a 25% pneumothorax would take approximately 20 days to resolve. Recommended dosing ranges from 3 L/min nasal cannula to 10 L/min by mask and should be guided by the patient's status. Monitor for hypercapnia in patients with chronic obstructive pulmonary disease.

 

Observation is appropriate for small, stable pneumothoraces only. If this option is selected, observe the patient for at least 4 hours on supplemental oxygen, and then repeat the chest radiograph. If symptoms and chest radiograph improve, the patient should return in 24 hours for repeat examination. First-time spontaneous pneumothorax of <20% lung volume in a stable, healthy adult may be treated initially with oxygen therapy and observation.19,20,21,22,23,24

Aspiration or tube thoracostomy is selected based on likelihood of recurrence and likelihood of spontaneous resolution. Pneumothoraces in patients with underlying pulmonary disease are likely to recur. Large pneumothoraces and those with an air leak are unlikely to resolve without drainage. Inability to return for care or to tolerate any pneumothorax increase (i.e., those with poor cardiopulmonary reserve) should prompt drainage.

 

 Thoracostomy Devices*

 

Diagnosis   Characteristic Findings Diagnostic Testing
Pneumothorax   Decreased breath sounds, hyperresonant percussion, distended neck veins, tracheal deviation Chest radiography, computed tomography
Special considerations: Of all emergency diagnoses, the only one that is immediately reversible is a tension pneumothorax. Needle decompression involves placing a 14-gauge angiocath in the second or third intercostal space in the midclavicular line. In a study of trauma patients with computed tomography scans of the chest, the mean chest wall thickness studied averaged 4.24 cm at this location, and almost a quarter of patients had chest walls thicker than 5 cm.¶ Therefore, one should use the longest catheter possible. Alternatives include using a spinal needle or rapid tube thoracostomy.

 

 

 

Occurs most often in thin, young males and in those with underlying lung disease.

 

Most people with pyelonephritis do not have complications if appropriately treated with bacteria-fighting medications called antibiotics.

In rare cases, pyelonephritis may cause permanent kidney scars, which can lead to chronic kidney disease, high blood pressure, and kidney failure. These problems usually occur in people with a structural problem in the urinary tract, kidney disease from other causes, or repeated episodes of pyelonephritis.

Infection in the kidneys may spread to the bloodstream—a serious condition called sepsis—though this is also uncommon.

 

 

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