Can Healthy Lungs "Collapse"?

My last blog entry talked about costochondritis, a common frustrating but benign cause of chest pain in young people. Today I would like to talk about a much less common but potentially far more serious cause of chest pain in young adults- pneumothorax, more commonly known as a "collapsed lung".  If images of television's Dr. McDreamy dramatically inserting a chest tube into an ER patient pop up in your head, please keep in mind that this medical issue only occurs in just over 1 in 100,000 people in the United States per year. In my private clinical practice, I saw less than an average of one per year, despite seeing innumerable patients with chest pain. Now working in an urgent care setting, I definitely see this more often but it is still relatively infrequent (I diagnosed three in the last six months, only one of which required surgical intervention.)

Wouldn't you know if you had a collapsed lung? Shouldn't you be gasping for breath? Well, not necessarily. Most of what we see outside of hospitals is much more subtle, and typically involves a very small portion of the lung. (I should clarify that I am talking about primary spontaneous pneumothorax here, where the person has no known underlying lung diseases such as pneumonias, tuberculosis or cystic fibrosis.)

Who gets this? The classic body type we think of as a risk factor is a very tall, thin, frequently athletic person. Smoking is also a risk factor, but is not necessary. 

What does it feel like? The pain is typically very sudden, sharp, and one sided, often near the shoulders or neck (not towards the heart or breast bone). Pain is worse with a deep breath or cough. Often patients think they "pulled something" in their back/chest/neck. 

How can the doctor know if the lung is collapsed? When the doctor listens to your heart and lungs with her stethoscope, she may be able to hear a discrepancy in your breath sounds- the side with a partially collapsed lung may have softer (or absent) breath movement than the other side. However, when the portion collapsed is very small, there may be no obvious findings on the physical exam.  In the schematic above, my balloons are demonstrating a fully inflated lung on the image right hand side, with a partially deflated "lung" on the left. On regular chest x-rays, the outline of the shrunken lung can be identified as an opaque shadow, leaving the remaining "empty" part of the chest cavity that an inflated lung would normally fill looking darker black than the other side. Chest X-rays are typically the only imaging necessary, though occasionally a CT scan is needed to identify additional lung pathology.

What is the treatment?  The treatment for pneumothorax is highly dependent upon the size of the collapse as well as physical symptoms. Larger or recurrent collapses may require chest tube placement to re-inflate the lung, and/or surgical intervention to prevent additional lung collapses.

BOTTOM LINE: Most sharp chest pains in otherwise healthy young adults are NOT from the lungs, but partially collapsed lungs do occur and are not always dramatic. See your doctor if you have any concerns about your chest pains, even if you are not short of breath (and even if you are otherwise young and healthy.)