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The annual age-adjusted incidence rate (AAIR) of PSP is thought to be three to six times as high in males as in females. Fishman cites AAIR's of 7.4 and 1.2 cases per 100,000 person-years in males and females, respectively. Significantly above-average height is also associated with increased risk of PSP – in people who are at least 76 inches (1.93 meters) tall, the AAIR is about 200 cases per 100,000 person-years. Slim build also seems to increase the risk of PSP.
The risk of contracting a first spontaneous pneumothorax is elevated among male and female smokers by factors of approximately 22 and 9, respectively, compared to matched non-smokers of the same sex. Individuals who smoke at higher intensity are at higher risk, with a "greater-than-linear" effect; men who smoke 10 cigarettes per day have an approximate 20-fold increased risk over comparable non-smokers, while smokers consuming 20 cigarettes per day show an estimated 100-fold increase in risk.
In secondary spontaneous pneumothorax, the estimated annual AAIR is 6.3 and 2.0 cases per 100,000 person-years for males and females, respectively, with the risk of recurrence depending on the presence and severity of any underlying lung disease. Once a second episode has occurred, there is a high likelihood of subsequent further episodes. The incidence in children has not been well studied, but is estimated to be between 5 and 10 cases per 100,000 person-years.
Death from pneumothorax is very uncommon (except in tension pneumothoraces). British statistics show an annual mortality rate of 1.26 and 0.62 deaths per million person-years in men and women, respectively. A significantly increased risk of death is seen in older victims and in those with secondary pneumothoraces.
A preventative procedure (thoracotomy or thoracoscopy with pleurodesis) may be recommended after an episode of pneumothorax, with the intention to prevent recurrence. Evidence on the most effective treatment is still conflicting in some areas, and there is variation between treatments available in Europe and the US. Not all episodes of pneumothorax require such interventions; the decision depends largely on estimation of the risk of recurrence. These procedures are often recommended after the occurrence of a second pneumothorax. Surgery may need to be considered if someone has experienced pneumothorax on both sides ("bilateral"), sequential episodes that involve both sides, or if an episode was associated with pregnancy.
For individuals who survive the initial crush injury, survival rates are high for traumatic asphyxia.
Complications are not common but include infection, pulmonary abscess, and bronchopleural fistula (a fistula between the pleural space and the bronchial tree). A bronchopleural fistula results when there is a communication between the laceration, a bronchiole, and the pleura; it can cause air to leak into the pleural space despite the placement of a chest tube. The laceration can also enlarge, as may occur when the injury creates a valve that allows air to enter the laceration, progressively expanding it. One complication, air embolism, in which air enters the bloodstream, is potentially fatal, especially when it occurs on the left side of the heart. Air can enter the circulatory system through a damaged vein in the injured chest and can travel to any organ; it is especially deadly in the heart or brain. Positive pressure ventilation can cause pulmonary embolism by forcing air out of injured lungs and into blood vessels.
Pulmonary laceration is a common result of penetrating trauma but may also be caused by blunt trauma; broken ribs may perforate the lung, or the tissue may be torn due to shearing forces that result from different rates of acceleration or deceleration of different tissues of the lung. Violent compression of the chest can cause lacerations by rupturing or shearing the lung tissue. Pulmonary laceration may result from blunt and penetrating forces that occur in the same injury and may be associated with pulmonary contusion. Lacerations of the lung tissue can also occur by compression of the alveoli against the ribs or spine. As with contusions, pulmonary lacerations usually occur near solid structures in the chest such as ribs. Pulmonary laceration is suspected when rib fractures are present.
Its cause is usually traumatic, from a blunt or penetrating injury to the thorax, resulting in a rupture of the serous membrane either lining the thorax or covering the lungs. This rupture allows blood to spill into the pleural space, equalizing the pressures between it and the lungs. Blood loss may be massive in people with these conditions, as each side of the thorax can hold 30 to 40% of a person's blood volume or 1.5 to 2 L per side in the average adult. Even minor injury to the chest wall can lead to significant hemothorax.
Less frequently, hemothorax occurs spontaneously. A major vascular cause of hemothorax is aortic dissection or rupture of thoracic aortic aneurysms. It may also follow surgical intervention in the thoracic area. Infrequently, patients with pneumothorax may develop spontaneous hemothorax. Spontaneous hemothorax or hemopneumothorax may be occur with endometriosis, if endometrial tissue implants on the pleural surface, then bleeds in response to cyclical hormonal changes in menstruating women.
If left untreated, the condition can progress to a point where the blood accumulation begins to put pressure on the mediastinum and the trachea, effectively limiting the amount that the heart's ventricles are able to fill. The condition can cause the trachea to deviate, or move, toward the unaffected side.
Rupture of the trachea or bronchus is the most common type of blunt injury to the airway. It is difficult to determine the incidence of TBI: in as many as 30–80% of cases, death occurs before the person reaches a hospital, and these people may not be included in studies. On the other hand, some TBI are so small that they do not cause significant symptoms and are therefore never noticed. In addition, the injury sometimes is not associated with symptoms until complications develop later, further hindering estimation of the true incidence. However, autopsy studies have revealed TBI in 2.5–3.2% of people who died after trauma. Of all neck and chest traumas, including people that died immediately, TBI is estimated to occur in 0.5–2%. An estimated 0.5% of polytrauma patients treated in trauma centers have TBI. The incidence is estimated at 2% in blunt chest and neck trauma and 1–2% in penetrating chest trauma. Laryngotracheal injuries occur in 8% of patients with penetrating injury to the neck, and TBI occurs in 2.8% of blunt chest trauma deaths. In people with blunt trauma who do reach a hospital alive, reports have found incidences of 2.1% and 5.3%. Another study of blunt chest trauma revealed an incidence of only 0.3%, but a mortality rate of 67% (possibly due in part to associated injuries). The incidence of iatrogenic TBI (that caused by medical procedures) is rising, and the risk may be higher for women and the elderly. TBI results about once every 20,000 times someone is intubated through the mouth, but when intubation is performed emergently, the incidence may be as high as 15%.
The mortality rate for people who reach a hospital alive was estimated at 30% in 1966; more recent estimates place this number at 9%. The number of people reaching a hospital alive has increased, perhaps due to improved prehospital care or specialized treatment centers. Of those who reach the hospital alive but then die, most do so within the first two hours of arrival. The sooner a TBI is diagnosed, the higher the mortality rate; this is likely due to other accompanying injuries that prove fatal.
Accompanying injuries often play a key role in the outcome. Injuries that may accompany TBI include pulmonary contusion and laceration; and fractures of the sternum, ribs and clavicles. Spinal cord injury, facial trauma, traumatic aortic rupture, injuries to the abdomen, lung, and head are present in 40–100%. The most common accompanying injury is esophageal perforation or rupture (known as Boerhaave syndrome), which occurs in as many as 43% of the penetrating injuries to the neck that cause tracheal injury.
The sudden impact on the thorax causes an increase in intrathoracic pressure. In order for traumatic asphyxia to occur, a Valsalva maneuver is required when the traumatic force is applied. Exhalation against the closed glottis along with the traumatic event causes air that cannot escape from the thoracic cavity. Instead, the air causes increased venous back-pressure, which is transferred back to through the right atrium, to the superior vena cava and to the head and neck veins and capillaries.
Treatment for this condition is the same as for hemothorax and pneumothorax independently: by tube thoracostomy, the insertion of a chest drain through an incision made between the ribs, into the intercostal space. A chest tube must be inserted to drain blood and air from the pleural space so it can return to a state of negative pressure and function normally.
Commonly, surgery is needed to close off whatever injuries caused the blood and air to enter the cavity (e.g. stabbing, broken ribs).
Hemopneumothorax, or haemopneumothorax, is a medical term describing the combination of two conditions: pneumothorax, or air in the chest cavity, and hemothorax (also called hæmothorax), or blood in the chest cavity.
A hemothorax, pneumothorax or both can occur if the chest wall is punctured. To understand the ramifications of this it is important to have an understanding of the role of the pleural space. The pleural space is located anatomically between the visceral membrane, which is firmly attached to the lungs, and the parietal membrane which is firmly attached to the chest wall (a.k.a. ribcage and intercostal muscles, muscles between the ribs). The pleural space contains pleural fluid. This fluid holds the two membranes together by surface tension, as much as a drop of water between two sheets of glass prevents them from separating. Because of this, when the intercostal muscles move the ribcage outward, the lungs are pulled out as well, dropping the pressure in the lungs and pulling air into the bronchi, when we 'breathe in'. The pleural space is maintained in a constant state of negative pressure (in comparison to atmospheric pressure).
Air in subcutaneous tissue does not usually pose a lethal threat; small amounts of air are reabsorbed by the body. Once the pneumothorax or pneumomediastinum that causes the subcutaneous emphysema is resolved, with or without medical intervention, the subcutaneous emphysema will usually clear. However, spontaneous subcutaneous emphysema can, in rare cases, progress to a life-threatening condition, and subcutaneous emphysema due to mechanical ventilation may induce ventilatory failure.
Most people with TBI who die do so within minutes of the injury, due to complications such as pneumothorax and insufficient airway and to other injuries that occurred at the same time. Most late deaths that occur in TBI are attributed to sepsis or multiple organ dysfunction syndrome (MODS). If the condition is not recognized and treated early, serious complications are more likely to occur; for example, pneumonia and bronchiectasis may occur as late complications. Years can pass before the condition is recognized. Some TBI are so small that they do not have significant clinical manifestations; they may never be noticed or diagnosed and may heal without intervention.
If granulation tissue grows over the injured site, it can cause stenosis of the airway, after a week to a month. The granulation tissue must be surgically excised. Delayed diagnosis of a bronchial rupture increases risk of infection and lengthens hospital stay. People with a narrowed airway may suffer dyspnea, coughing, wheezing, respiratory tract infection, and difficulty with clearing secretions. If the bronchiole is completely obstructed, atelectasis occurs: the alveoli of the lung collapse. Lung tissue distal to a completely obstructed bronchiole often does not become infected. Because it is filled with mucus, this tissue remains functional. When the secretions are removed, the affected portion of the lung is commonly able to function almost normally. However, infection is common in lungs distal to a partially obstructed bronchiole. Infected lung tissue distal to a stricture can be damaged, and wheezing and coughing may develop due to the narrowing. In addition to pneumonia, the stenosis may cause bronchiectasis, in which bronchi are dilated, to develop. Even after an airway with a stricture is restored to normal, the resulting loss of lung function may be permanent.
Complications may also occur with treatment; for example a granuloma can form at the suture site. Also, the sutured wound can tear again, as occurs when there is excessive pressure in the airways from ventilation. However, for people who do receive surgery soon after the injury to repair the lesion, outcome is usually good; the long-term outcome is good for over 90% of people who have TBI surgically repaired early in treatment. Even when surgery is performed years after the injury, the outlook is good, with low rates of death and disability and good chances of preserving lung function.
Conditions that cause subcutaneous emphysema may result from both blunt and penetrating trauma; SCE is often the result of a stabbing or gunshot wound.
Subcutaneous emphysema is often found in car accident victims because of the force of the crash.
Chest trauma, a major cause of subcutaneous emphysema, can cause air to enter the skin of the chest wall from the neck or lung. When the pleural membranes are punctured, as occurs in penetrating trauma of the chest, air may travel from the lung to the muscles and subcutaneous tissue of the chest wall. When the alveoli of the lung are ruptured, as occurs in pulmonary laceration, air may travel beneath the visceral pleura (the membrane lining the lung), to the hilum of the lung, up to the trachea, to the neck and then to the chest wall. The condition may also occur when a fractured rib punctures a lung; in fact, 27% of patients who have rib fractures also have subcutaneous emphysema. Rib fractures may tear the parietal pleura, the membrane lining the inside of chest wall, allowing air to escape into the subcutaneous tissues.
Subcutaneous emphysema is frequently found in pneumothorax (air outside of the lung in the chest cavity) and may also result from air in the mediastinum, pneumopericardium (air in the pericardial cavity around the heart). A tension pneumothorax, in which air builds up in the pleural cavity and exerts pressure on the organs within the chest, makes it more likely that air will enter the subcutaneous tissues through pleura torn by a broken rib. When subcutaneous emphysema results from pneumothorax, air may enter tissues including those of the face, neck, chest, armpits, or abdomen.
Pneumomediastinum can result from a number of events. For example, foreign body aspiration, in which someone inhales an object, can cause pneumomediastinum (and lead to subcutaneous emphysema) by puncturing the airways or by increasing the pressure in the affected lung(s) enough to cause them to burst.
Subcutaneous emphysema of the chest wall is commonly among the first signs to appear that barotrauma, damage caused by excessive pressure, has occurred, and it is an indication that the lung was subjected to significant barotrauma. Thus the phenomenon may occur in diving injuries.
Trauma to parts of the respiratory system other than the lungs, such as rupture of a bronchial tube, may also cause subcutaneous emphysema. Air may travel upward to the neck from a pneumomediastinum that results from a bronchial rupture, or downward from a torn trachea or larynx into the soft tissues of the chest. It may also occur with fractures of the facial bones, neoplasms, during asthma attacks, when the Heimlich maneuver is used, and during childbirth.
Injury with pneumatic tools, those that are driven by air, is also known to cause subcutaneous emphysema, even in extremities (the arms and legs). It can also occur as a result of rupture of the esophagus; when it does, it is usually as a late sign.
Isolated mechanical forces may not adequately explain ventilator induced lung injury (VILI). The damage is affected by the interaction of these forces and the pre-existing state of the lung tissues, and dynamic changes in alveolar structure may be involved. Factors such as plateau pressure and positive end-expiratory pressure (PEEP) alone do not adequately predict injury. Cyclic deformation of lung tissue may play a large part in the cause of VILI, and contributory factors probably include tidal volume, positive end-expiratory pressure and respiratory rate. There is no protocol guaranteed to avoid all risk in all applications.
Professional divers are screened for risk factors during initial and periodical medical examination for fitness to dive. In most cases recreational divers are not medically screened, but are required to provide a medical statement before acceptance for training in which the most common and easy to identify risk factors must be declared. If these factors are declared, the diver may be required to be examined by a medical practitioner, and may be disqualified from diving if the conditions indicate.
Asthma, Marfan syndrome, and COPD pose a very high risk of pneumothorax. In some countries these may be considered absolute contraindications, while in others the severity may be taken into consideration. Asthmatics with a mild and well controlled condition may be permitted to dive under restricted circumstances.
Onset of lung collapse is less than 72 hours after menstruation. Typically, it occurs in women aged 30–40 years, but has been diagnosed in young girls as early as 10 years of age and post menopausal women (exclusively in women of menstrual age) most with a history of pelvic endometriosis.
The most common cause is post-surgical atelectasis, characterized by splinting, i.e. restricted breathing after abdominal surgery.
Another common cause is pulmonary tuberculosis. Smokers and the elderly are also at an increased risk. Outside of this context, atelectasis implies some blockage of a bronchiole or bronchus, which can be within the airway (foreign body, mucus plug), from the wall (tumor, usually squamous cell carcinoma) or compressing from the outside (tumor, lymph node, tubercle). Another cause is poor surfactant spreading during inspiration, causing the surface tension to be at its highest which tends to collapse smaller alveoli. Atelectasis may also occur during suction, as along with sputum, air is withdrawn from the lungs. There are several types of atelectasis according to their underlying mechanisms or the distribution of alveolar collapse; resorption, compression, microatelectasis and contraction atelectasis.
A bronchopleural fistula (BPF) is a fistula between the pleural space and the lung. It can develop following Pneumonectomy, post traumatically, or with certain types of infection. It may also develop when large airways are in communication with the pleural space following a large pneumothorax or other loss of pleural negative pressure, especially during positive pressure mechanical ventilation. On imaging, the diagnosis is suspected indirectly on radiograph. Increased gas in the pneumonectomy operative bed, or new gas within a loculated effusion are highly suggestive of the diagnosis. Infectious causes include tuberculosis, "Actinomyces israelii", "Nocardia", and "Blastomyces dermatitidis". Malignancy and trauma can also result in the abnormal communication.
Pneumothorax can be a medical emergency, as it can become associated with decreased lung function, and if progressed to tension pneumothorax, potentially fatal. A chest tube should be inserted after clinical assessment. This releases the air and menstrual blood, and the lung can re-expand.
Surgery, hormonal treatments and combined approaches have all been proposed, with variable results in terms of short and long term outcome. Surgical removal of the endometrial tissue should be endeavoured during menstruation for optimal visualisation of the cyst. Pleurodesis may also be helpful. Menstruation and accompanying lung collapse can be suppressed with hormone therapy, like with Lupron Depot, danazol or extended cycle combined oral contraceptive pills.
The atmosphere is composed of 78% nitrogen and 21% oxygen. Since oxygen is exchanged at the alveoli-capillary membrane, nitrogen is a major component for the alveoli's state of inflation. If a large volume of nitrogen in the lungs is replaced with oxygen, the oxygen may subsequently be absorbed into the blood, reducing the volume of the alveoli, resulting in a form of alveolar collapse known as absorption atelectasis.
Pregnancy has been reported to exacerbate LAM in some cases. However, the risk has not been rigorously studied. In a survey of 318 patients who indicated that they had had at least one pregnancy, 163 responded to a second survey focusing on lung collapse. A total of 38 patients reported a pneumothorax with pregnancy, consistent with an incidence of pneumothorax in pregnancy of at least 10% (38 of 318). In one third of patients, the pneumothorax during pregnancy led to the LAM diagnosis. Pneumothoraces were almost twice as frequent on the right as on the left, and four women presented with bilateral spontaneous pneumothorax. Most pneumothoraces took place during the second and third trimesters. This study and others suggest that pregnancy is associated with pleural complications in LAM patients. Few women with a known LAM diagnosis choose to become pregnant and patients in whom LAM is diagnosed during pregnancy rarely have baseline pulmonary function tests available, complicating resolution of this question.
Respiratory disease is a common and significant cause of illness and death around the world. In the US, approximately 1 billion "common colds" occur each year. A study found that in 2010, there were approximately 6.8 million emergency department visits for respiratory disorders in the U.S. for patients under the age of 18. In 2012, respiratory conditions were the most frequent reasons for hospital stays among children.
In the UK, approximately 1 in 7 individuals are affected by some form of chronic lung disease, most commonly chronic obstructive pulmonary disease, which includes asthma, chronic bronchitis and emphysema.
Respiratory diseases (including lung cancer) are responsible for over 10% of hospitalizations and over 16% of deaths in Canada.
In 2011, respiratory disease with ventilator support accounted for 93.3% of ICU utilization in the United States.
Thoracic endometriosis affects women aged 15–54, who are between menarche and menopause. It can affect their qualify of life, with catamenial pneumothorax being the most common presentation.
LAM is almost completely restricted to women. While lung cysts consistent with LAM are reported in some men with tuberous sclerosis, very few of these men develop symptoms. The prevalence of LAM is estimated using data from registries and patient groups and is between 3.4-7.8/million women. The number of new cases each year is between 0.23-0.31/million women/year in the US, UK and Switzerland. The variation between countries and between adjacent states in the US, suggest that a significant number of women with LAM remain either undiagnosed or their symptoms are attributed to other diseases. Adult women with tuberous sclerosis are more likely to develop LAM than women without tuberous sclerosis. Cohorts of patients with tuberous sclerosis have been screened for LAM using CT scanning. In a retrospective study of adults with tuberous sclerosis, CT demonstrated lung cysts in 42% of 95 women and 13% of 91 men. In general, lung cysts were larger and more numerous in women than in men. In a further retrospective study of women with TSC who underwent CT scanning to detect LAM, 25% of those in their 20s had lung cysts whereas 80% of women in their 40s were affected, suggesting that the development of LAM is age dependent at least in tuberous sclerosis-related LAM. Although the prevalence of tuberous sclerosis at 1 in 6000 births is much greater than that of LAM, most pulmonary clinics see more cases of sporadic than tuberous sclerosis-LAM: probably due to a combination of low levels of screening for LAM in tuberous sclerosis and in many, the absence of symptoms.
Female sex and tuberous sclerosis are the only known risk factors. Although use of supplemental estrogen is not associated with development of LAM, one study suggested that use of estrogen-containing contraceptive pills was associated with earlier onset.
It occurs in more than 30% of women with tuberous sclerosis complex (TSC-LAM), a heritable syndrome that is associated with seizures, cognitive impairment and benign tumors in multiple tissues. Most LAM patients who present for medical evaluation have the sporadic form of the disease (S-LAM), however, which is not associated with other manifestations of tuberous sclerosis complex.
Mild cystic changes consistent with LAM have been described in 10–15% of men with TSC, but symptomatic LAM in males is rare. Sporadic LAM occurs exclusively in women, with one published exception to date. Both TSC-LAM and S-LAM are associated with mutations in tuberous sclerosis genes.