In this X-ray, both lungs are collapsed. The arrows point to the outside linings of the lungs. The black areas are air.

by James Hubbard, MD, MPH

I remember one patient in particular, a nurse. I was less than a year out of training. She was working on the floor when I was in the emergency room. She came up to me and said, “I think I have a collapsed lung.” She was holding the side of her chest and obviously in pain but didn’t appear short of breath.

This was a first for me—someone just coming up and self diagnosing such a thing. I asked her how she knew. She said she’d had a couple before. Ohhh. I’d read about this. If someone’s had one spontaneous collapsed lung they’re at increased risk to have another—especially among smokers, and I knew she was one of those. Their small airway walls thin out, and sometimes one can spring a leak of air into the space between the lungs and the chest wall. Voilà—collapsed lung.

Anyway, when I listened to her chest with a stethoscope, she had decreased breath sounds on the side of the chest with the pain. Her oxygen level was good, but a chest X-ray showed a small pneumothorax (partially collapsed lung). She took some anti-inflammatories and stayed off work a few days; the leak sealed over, and soon the chest X-ray (and she) was back to normal.

What Causes a Collapsed Lung

Books adA pneumothorax means air (pneumo) in the chest (thorax). This happens when air leaks into the space between your lungs and your inner chest wall.

Normally this area is what we call a “potential space” because the lungs touch the chest wall. (There’s really no space, but there could be.) When you expand your chest, your lungs keep touching the chest wall and expand also. That brings in the air we all need to breathe. If something like air or fluid gets into that potential space, it takes the place of where the lung should be. All the lung can do is reduce in size or collapse.

Reasons for a collapsed lung:

  1. A puncture from a broken rib. That’s the kind I was familiar with before the nurse.
  2. A puncture wound through the chest wall. If a knife or stick or the like punctures the chest wall, air comes pouring in from the outside.
  3. A weak spot in the lung that starts leaking. Emphysema or other smoking damage to the lungs can do this, as can asthma, pneumonia, or lung cancer. Some people are born with a little bleb, or weak spot.

These are the ones you’re going to see in the field. In a hospital setting a lung can be damaged by surgery or a procedure like a bronchoscopy (looking down into the lungs with a long, lighted tube). The added lung air-pressure of being on a ventilator can do it too.

Signs and Symptoms

Symptoms: Usually you’ll have sudden pain on the affected side of the chest, and shortness of breath.

Signs: With a stethoscope or an ear to the back of the chest, you may hear that the breath sounds are notably decreased or absent on the side of the pneumothorax.

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The definitive treatment for a large pneumothorax (collapsed lung) is a chest tube hooked up to a device that provides constant suction so the hole has time to heal. This man has a chest tube in his right lung. It’s the tube coming from under the bandage. (Most of the other tubes are monitor wires.)

Treatment

If there’s a puncture wound through the chest wall, you’ll need to seal it with something like petroleum jelly and a bandage.

Until you can get to a medical facility you’re just going to have to decrease your activities (thereby decreasing your need for extra oxygen) and take whatever you have for pain. Many leaks heal on their own.

If there is severe shortness of breath and you’re not going to be able to get expert help, as a last resort, you can stick a hollow 18- or 20-gauge needle (with a syringe on it) over the top of one of the ribs in the area where there are no breath sounds (in the back or side of the chest). The reason it should be just over the top is a nerve, artery, and vein run underneath each rib, and you don’t want to hit those.

The needle is going to need to be one-and-a-half inches, or longer, to get into the chest cavity. As you go in, pull back on the syringe. You’ll know you’re in the right place if you start pulling back air. Don’t go further or you could stick the lung and make it worse. Also there’s always the risk for infection. In other words, like most medical procedures, this can be dangerous. Only do it as a last resort in someone who looks like they’re not going to last long enough to get expert medical care.

But, if there’s a large pneumothorax (and that’s usually the case if there’s severe shortness of breath), the definitive treatment is inserting a chest tube hooked up to a device applying constant suction for several hours to a few days, to give the leak time to heal. Unless you have this in your medical kit (and some people do) you’re going to have to suck as much air out as you can with the needle and syringe until the person is breathing better or you can get help. Use a 10cc or even 50cc syringe if you have it so you’ll only need to stick it in once or twice. Of course some holes never heal without surgery.

Caution

One other thing. You can get something called a tension pneumonthorax. Instead of the air pressure equalizing, the leak becomes a one-way valve. It pushes air in, but the air cannot escape. This puts enough pressure on the heart and other lung that it becomes a true emergency. The blood pressure drops and the pulse increases. Often the person becomes less alert and may lose consciousness. The heart may even stop. The treatment is relieving the pressure immediately. More on that in another post.

 

Have any of you ever had a collapsed lung? How did it happen? What were your symptoms? How was it treated?

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X-ray courtesy Morgan Le Guen, Catherine Beigelman, Belaid Bouhemad, Yang Wenjïe, Frederic Marmion [CC-BY-2.0], via Wikimedia Commons. Collapsed-lung patient photo by Kairuuinzuro on Flickr.