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If the patient is a young, tall, thin, cigarette-smoking man, the diagnosis of primary spontaneous pneumothorax is usually obvious and can be confirmed by chest radiograph In secondary pneumothorax, it is sometimes difficult to distinguish loculated pneumothorax from an emphysematous bleb Occasionally, pneumothorax may mimic myocardial infarction, pulmonary embolization, or pneumonia
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Tension pneumothorax may be life-threatening Pneumomediastinum and subcutaneous emphysema may occur as
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Sahn SA et al Spontaneous pneumothorax N Engl J Med 2000 Mar 23;342(12):868 74 [PMID: 10727592]
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complications of spontaneous pneumothorax If pneumomediastinum is detected, rupture of the esophagus or a bronchus should be considered
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Treatment depends on the severity of pneumothorax and the nature of the underlying disease In a reliable patient with a small (< 15% of a hemithorax), stable spontaneous primary pneumothorax, observation alone may be appropriate Many small pneumothoraces resolve spontaneously as air is absorbed from the pleural space; supplemental oxygen therapy may increase the rate of reabsorption Simple aspiration drainage of pleural air with a small-bore catheter (eg, 16 gauge angiocatheter or larger drainage catheter) can be performed for spontaneous primary pneumothoraces that are large or progressive Placement of a small-bore chest tube (7F to 14F) attached to a one-way Heimlich valve provides protection against development of tension pneumothorax and may permit observation from home The patient should be treated symptomatically for cough and chest pain, and followed with serial chest radiographs every 24 hours Patients with secondary pneumothorax, large pneumothorax, tension pneumothorax, or severe symptoms or those who have a pneumothorax on mechanical ventilation should undergo chest tube placement (tube thoracostomy) The chest tube is placed under water-seal drainage, and suction is applied until the lung expands The chest tube can be removed after the air leak subsides All patients who smoke should be advised to discontinue smoking and warned that the risk of recurrence is 50% Future exposure to high altitudes, flying in unpressurized aircraft, and scuba diving should be avoided Indications for thoracoscopy or open thoracotomy include recurrences of spontaneous pneumothorax, any occurrence of bilateral pneumothorax, and failure of tube thoracostomy for the first episode (failure of lung to reexpand or persistent air leak) Surgery permits resection of blebs responsible for the pneumothorax and pleurodesis by mechanical abrasion and insufflation of talc Management of pneumothorax in patients with Pneumocystis pneumonia is challenging because of a tendency toward recurrence, and there is no consensus on the best approach Use of a small chest tube attached to a Heimlich valve has been proposed to allow the patient to leave the hospital Some clinicians favor its insertion early in the course
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The principal influences on ventilatory control are arterial PCO2, pH, PO2, and brainstem tissue pH These variables are monitored by peripheral and central chemoreceptors Under normal conditions, the ventilatory control system maintains arterial pH and PCO2 within narrow limits; arterial PO2 is more loosely controlled Abnormal control of ventilation can be seen with a variety of conditions ranging from rare disorders such as Ondine s curse, neuromuscular disorders, myxedema, starvation, and carotid body resection to more common disorders such as asthma, COPD, obesity, congestive heart failure, and sleep-related breathing disorders A few of these disorders will be discussed in this section
Caruana-Montaldo B et al The control of breathing in clinical practice Chest 2000 Jan;117(1):205 25 [PMID: 10631221] Perrin C et al Pulmonary complications of chronic neuromuscular diseases and their management Muscle Nerve 2004 Jan;29(1):5 27 [PMID: 14694494] Prabhakar NR et al Peripheral chemoreceptors in health and disease J Appl Physiol 2004 Jan;96(1):359 66 [PMID: 14660497]
PRIMARY ALVEOLAR HYPOVENTILATION
Primary alveolar hypoventilation ( Ondine s curse ) is a rare syndrome of unknown cause characterized by inadequate alveolar ventilation despite normal neurologic function and normal airways, lungs, chest wall, and ventilatory muscles Hypoventilation is even more marked during sleep Individuals with this disorder are usually nonobese males in their third or fourth decades who have lethargy, headache, and somnolence Dyspnea is absent Physical examination may reveal cyanosis and evidence of pulmonary hypertension and cor pulmonale Hypoxemia and hypercapnia are present and improve with voluntary hyperventilation Erythrocytosis is common Treatment with ventilatory stimulants is usually unrewarding Augmentation of ventilation by mechanical methods (phrenic nerve stimulation, rocking bed, mechanical ventilators) has been helpful to some patients Adequate oxygenation should be maintained with supplemental oxygen, but nocturnal oxygen therapy should be prescribed only if diagnostic nocturnal polysomnography has demonstrated its efficacy and safety Primary alveolar hypoventilation resembles but should be distinguished from central alveolar hypoventilation, in which impaired ventilatory drive with chronic respiratory acidemia and hypoxemia follows an insult to the brainstem (eg, bulbar poliomyelitis, infarction, meningitis, encephalitis, trauma)
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