Pneumothorax
- Fysiobasen
- Sep 8
- 6 min read
Pneumothorax is a condition in which air accumulates in the pleural cavity (the space between the lung and the chest wall), leading to collapse of the lung. This occurs due to disruption of the normal pressure gradient in the thoracic cavity¹. Pneumothorax is a potentially life-threatening condition that may cause severe respiratory failure and affect cardiac function, making rapid diagnosis and treatment essential for prognosis².
Causes and Types
Pneumothorax can be classified according to cause and underlying pathology:
Primary spontaneous pneumothorax:
Occurs without known underlying lung disease. Most common in young adults, especially tall, thin men. The exact trigger is often unknown, but risk factors include smoking (tobacco or cannabis), heredity, and rupture of small air-filled blebs (bullae) in the lung tissue³.
Secondary spontaneous pneumothorax:
Caused by underlying lung disease, such as COPD, asthma, cystic fibrosis, lung cancer, or tuberculosis. In these patients, pneumothorax is often more severe⁴.
Traumatic pneumothorax:
Caused by injury to the chest, such as stab or gunshot wounds, rib fractures, or injury during medical procedures (iatrogenic pneumothorax). Air can also enter the pleural cavity under certain pressure changes, such as diving or flying⁵.
Tension pneumothorax:
A particularly severe variant in which a one-way valve mechanism allows air to enter the pleural cavity but not escape. Pressure rises rapidly and may compress the lung, heart, and major blood vessels. Without emergency treatment, this can cause circulatory collapse and death⁵.
Risk Factors
The most important risk factors for pneumothorax include:
Male sex
Smoking (including cannabis)
Family history
Underlying lung disease (COPD, asthma, cystic fibrosis, lung cancer, tuberculosis)
Previous pneumothorax
Chest trauma
Medical procedures in the thoracic region
Sudden pressure changes (e.g., diving or flying)³
Epidemiology
Primary spontaneous pneumothorax most often affects individuals between the ages of 18 and 40, while secondary spontaneous pneumothorax is more common in older adults with chronic lung disease. The condition is rare in children but can be severe in newborns³. The incidence is higher in men than in women.
Symptoms and Clinical Presentation
Pneumothorax most often presents with:
Sudden, sharp chest pain (typically worsens with inspiration)
Sudden onset of shortness of breath (dyspnea)
Rapid breathing and heart rate (tachypnea, tachycardia)
Dry cough
Fatigue, restlessness, and anxiety
Signs of respiratory failure: use of accessory muscles, nasal flaring
In large or tension pneumothorax: hypotension, cyanosis, decreased consciousness, jugular venous distension, subcutaneous emphysema, and circulatory collapse⁷
On examination, decreased breath sounds, hyperresonance on percussion, and occasionally tracheal deviation (in tension pneumothorax) may be observed.
Pathophysiology
Normally, intrapleural pressure is lower than atmospheric pressure, which keeps the lung expanded against the chest wall. When air enters the pleural space—from the lung or externally—this pressure difference is lost, and the lung collapses. In tension pneumothorax, pressure can rise so high that it shifts the heart and great vessels, rapidly leading to circulatory collapse and death without immediate treatment⁷.
Diagnosis
Diagnosis is often based on history and clinical examination. In cases of uncertainty, or to assess extent, chest X-ray is used. In acute respiratory failure or suspected tension pneumothorax, treatment must be initiated immediately without waiting for imaging.
Treatment
Management depends on type and severity:
Primary spontaneous pneumothorax: Small, asymptomatic cases may resolve spontaneously under observation. Larger or symptomatic cases require drainage with needle aspiration or chest tube.
Secondary spontaneous pneumothorax: Often requires more urgent drainage and closer monitoring due to reduced lung reserve.
Tension pneumothorax: Emergency treatment with needle decompression (large-bore cannula inserted into the chest wall to release air), followed by chest tube insertion.
Traumatic/iatrogenic pneumothorax: Treated similarly with drainage and monitoring.
All patients must be closely monitored for respiratory and circulatory status as well as complications. Smoking cessation is strongly recommended, and future risk exposures (e.g., diving) should be carefully evaluated with a physician.
Complications
Severe complications of pneumothorax include:
Respiratory and circulatory collapse (in tension pneumothorax)
Recurrent episodes (recurrence)
Infection or empyema
Scarring or reduced lung function, especially after multiple episodes or in patients with underlying lung disease³
Physiotherapy
Physiotherapy plays an important role in rehabilitation and follow-up after pneumothorax, especially following treatment and in cases with risk of complications. The main goals are to improve ventilation, facilitate secretion clearance, reduce breathing effort, and restore physical capacity. All interventions must be tailored to the patient’s condition, and physiotherapists should always collaborate closely with physicians in cases of uncertainty.
Indications for Physiotherapy
Physiotherapy is considered in the following situations:
Lung collapse with reduced ventilation¹⁸
Retention of secretions in the airways¹⁹
Ventilation/perfusion mismatch (V/Q disturbance)²⁰
Increased work of breathing and reduced oxygenation
Abnormal blood gas values (hypoxemia, hypercapnia)
Need for postoperative intensive follow-up
Goals of Physiotherapy
Improve ventilation and increase oxygen levels (PaO₂):
Physical activity: Stair climbing, walking, gradual increase in activity as tolerated.
Breathing exercises: Active Cycle of Breathing Technique (ACBT), deep diaphragmatic breathing, use of PEP devices or other resistance tools.
Incentive spirometry: Stimulates deep inspiration and increases lung expansion.
Non-invasive ventilation (NIV): May be considered when additional ventilatory support is required.
Assist in secretion mobilization and clearance:
Postural drainage: Positioning techniques to use gravity, if approved by the medical team.
Manual techniques: Percussion, vibration, and shaking performed gently to loosen secretions. Contraindications must always be assessed.
Coughing and huffing techniques: Guidance in effective coughing and huff maneuvers to mobilize and clear mucus.
Physical activity and movement: Early mobilization promotes better lung function and secretion clearance.
Suctioning: Performed when necessary and according to clinical guidelines.
Reduce the work of breathing:
Optimal positioning: Upright or slight forward-leaning positions can ease breathing.
Breathing control: Calm, deep breathing and relaxation techniques to reduce accessory muscle use and avoid unnecessary effort.
Relaxation: Training in relaxation and energy-conserving strategies.
Increase physical capacity and tolerance:
Early mobilization: Start activity as soon as possible, tailored to the patient’s capacity.
Graded exercise programs: Gentle, progressive increase in endurance and strength.
Integration of breathing exercises into activity.
Evaluation of Effect
The effectiveness of physiotherapy is assessed continuously through:
Changes in respiratory rate and oxygen saturation
Improvement in blood gas values
Altered need for supplemental oxygen
Lung auscultation (breath sounds)
Chest X-ray (evaluation of lung expansion)
Functional level and mobility
Important Considerations
All interventions must be weighed against the risk of recurrent pneumothorax or deterioration. In cases of ongoing air leakage, unstable condition, or unclear lung status, the physiotherapist must always consult the treating physician before initiating manual techniques or intensive breathing exercises. Too early or too aggressive secretion mobilization may be harmful.
Summary
Physiotherapy after pneumothorax focuses on supporting lung function, promoting secretion clearance, encouraging early mobilization, and gradually returning to daily activity. The goal is to prevent complications and recurrence while improving the patient’s quality of life.
Sources:
Medicinenet.com. Pneumothorax. Available from: http://medicinenet.com/pneumothorax/page2.htm [last accessed: 05.07.2025]
Oxford Concise Medical Dictionary. Pneumothorax. 6th ed. Oxford: Oxford University Press; 2002. p. 544
Sahota RJ, Sayad E. Tension Pneumothorax. [Updated Jan 30, 2024]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025. Available from: https://www.ncbi.nlm.nih.gov/books/NBK559090/ [last accessed: 05.07.2025]
Gupta D, Hansell A, Nichols T, et al. Epidemiology of pneumothorax in England. Thorax. 2000;55:666–71
Bascom R. Pneumothorax. eMedicine. Available from: http://emedicine.medscape.com/article/424547-overview [last accessed: 05.07.2025]
Baumann MH, Noppen M. Pneumothorax. Respirology. 2004;9:157–64
Bintcliffe O, Maskell N. Spontaneous pneumothorax. BMJ. 2014;348:g2928
Roberts DJ, et al. Clinical Presentation of Patients With Tension Pneumothorax. Ann Surg. 2015;261(6):1068–78
Medicosis Perfectionalis. Pneumothorax | Lung Physiology | Pulmonary Medicine. Available from: https://www.youtube.com/watch?v=ZYMcyyNMYrQ [last accessed: 05.07.2025]
Rankine JJ, Thomas AN, Fluechter D. Diagnosis of pneumothorax in critically ill adults. Postgrad Med J. 2000;76:399–404
Wu D, Shen Y, Yang J, et al. Diagnosis of Pneumothorax by Radiography and Ultrasonography: A Meta-analysis. Chest. 2011;140(4):859–66
Zarogoulidis P, Kioumis I, Pitsiou G, et al. Pneumothorax: from definition to diagnosis and treatment. J Thorac Dis. 2014;6(Suppl 4):S372–6
Simon GA, et al. Conservative versus Interventional Treatment for Spontaneous Pneumothorax. N Engl J Med. 2020;382:405–15
Brims FJH, Maskell NA. Ambulatory treatment in the management of pneumothorax: a systematic review. Thorax. 2013;68:664–9
Tschopp JM, Rami-Porta R, Noppen M, Astoul P. Management of spontaneous pneumothorax: state of the art. Eur Respir J. 2006;28(3):637–50
Almoosa KF, et al. Management of Pneumothorax in Lymphangioleiomyomatosis. Chest. 2006;129(5):1274–81
FlippedEM. Treating a tension pneumothorax. Available from: https://www.youtube.com/watch?v=ubBYHfVGzJg [last accessed: 05.07.2025]
Weill D, Benden C, Corris PA, et al. A consensus document for the selection of lung transplant candidates. J Heart Lung Transplant. 2015;34(1):1–15
Pryor JA, Prasad SA. Physiotherapy for Respiratory and Cardiac Problems. 3rd ed. New York: Churchill Livingstone; 2006. p. 389
Selsby DS. Chest physiotherapy. BMJ. 1989;298(6673):541–2
Torre C, Silva A. Physiotherapy Intervention after Surgical Treatment of Pneumothorax – Case Study. Eur J Public Health. 2019;29(Suppl_1)
