Sudden fall in oxygen saturation followed by hypotension are often observed clinically in these patients. Prompt recognition and treatment of pneumothorax is important to minimize morbidity and mortality because if pneumothorax is not diagnosed quickly, once tension pneumothorax ensues, it usually has a malignant course leading to death if untreated. In critical illness, pneumothoraces may be difficult to diagnose when they have different clinical presentations and their locations are atypical and complicated by other disease processes in unconscious patients. Pneumothorax is rare in intubated patients with normal lungs and most patients with pneumothorax related to mechanical ventilation (PRMV) have underlying lung diseases that range from primary obstructive lung disease to secondary pneumonia and acute respiratory distress syndrome (ARDS). Mechanical ventilation was found to be the common cause of iatrogenic pneumothorax in an intensive care unit (ICU). Pneumothorax can be categorized as primary, secondary, iatrogenic or traumatic according to etiology. Pneumothorax, defined as the presence of air in the pleural space, is a serious complication of mechanical ventilation and is associated with increased morbidity and mortality. Patients with pneumothorax related to mechanical ventilation who have tension pneumothorax, a higher acute physiology and chronic health evaluation II score or PaO 2/FiO 2 < 200 mmHg were found to have higher mortality. Furthermore, if there are clinical signs of a tension pneumothorax, emergency needle decompression followed by tube thoracostomy is widely advocated. Small-bore catheters are now preferred in the majority of ventilated patients. Mechanically ventilated patients with a pneumothorax require tube thoracostomy placement because of the high risk of tension pneumothorax. Respiration-dependent movement of the visceral pleura and lung surface with respect to the parietal pleura and chest wall can be easily visualized with transthoracic sonography given that the presence of air in the pleural space prevents sonographic visualization of visceral pleura movements. For this reason, ultrasonography is beneficial for excluding the diagnosis of pneumothorax. The diagnosis of pneumothorax in critical illness is established from the patients’ history, physical examination and radiological investigation, although the appearances of a pneumothorax on a supine radiograph may be different from the classic appearance on an erect radiograph. Underlying lung diseases are associated with ventilator-related pneumothorax with pneumothoraces occurring most commonly during the early phase of mechanical ventilation. Tension pneumothorax is more common in ventilated patients with prompt recognition and treatment of pneumothorax being important to minimize morbidity and mortality. Most of the patients with pneumothorax from mechanical ventilation have underlying lung diseases pneumothorax is rare in intubated patients with normal lungs. Pneumothorax is a potentially lethal complication associated with mechanical ventilation.
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