Spontaneous Primary Pneumothorax

Authors: V. Mundra, M.D., J. Zapatier, M.D., H. Feiz, M.D., Cleveland Clinic Florida
Reviewer: V. Dimov, M.D., University of Chicago

A 16-year-old male patient came to the emergency department with complaints of shortness of breath and chest pain which started one day ago. The shortness of breath was mild in severity, made worse by exertion and relieved with rest, associated with pleuritic chest pain, left sided, 5-6/10, sharp in nature. He denied any similar symptoms in the past.

Past medical, social, surgical and family history

He also denied any use of illicit drug like cocaine or and any history of trauma. He did not have any past medical history or past surgical history. He had no family history of premature CAD or asthma. He did not smoke or drink alcohol. He was on no prescription medications and he participated in sports without any difficulty.

Physical examination

Blood pressure was 112/70 mm/Hg, HR 90 bpm, temp. 98.7 F and RR was 23/min, SpO2 90 % on room air. His height was 5’10’’ with BMI of 19.9. He was in mild respiratory distress. HENT exam was unremarkable. No crepitus was felt. Trachea was in the midline. On auscultation, there were no breath sounds on the left side with hyperresonance on percussion. S1 and S2 were normal with no murmurs/rubs or gallops. The abdomen was unremarkable. No pedal edema was appreciated. No clinical stigmata of Marfan’s syndrome like high arched palate or increased arm span were observed.

What is the next step in the management of this patient?

A chest X-ray was done which showed a large left pneumothorax with tracheal deviation to the right (figure 1). An emergency chest tube was placed and the lung re-expanded (figure 2).


Figure 1. A large left pneumothorax with tracheal deviation to the right (click to enlarge the image).


Figure 2. An emergency chest tube was placed and the lung re-expanded (click to enlarge the image).

CBC and BMP were normal. Urine toxic screen was negative. A CT scan of the chest was done which did not show any blebs/bulla or lung parenchymal abnormalities.

What happened next?

The chest was clamped after 48 hours but the pneumothorax expanded. Subsequently, he was given two more trials of clamping which were unsuccessful. Finally, after a week he was taken to surgery for a possible bronchopleural fistula leak. During surgery, he was found to have a bulla at the apex of the lung which was ligated. He tolerated the procedure well and the pneumothorax did not recur.

Diagnosis

Spontaneous Primary Pneumothorax.

Summary

Types of pneumothorax

Pneumothorax is the collection of air in pleural space.

1. Primary pneumothorax occurs in the absence of any lung disorder. It occurs mostly in tall thin young men. A subset of the patients may be predisposed by a genetic disorder, Marfan’s syndrome.

2. Secondary pneumothorax results from an underlying lung disorder. It may result from trauma, asthma, COPD, cystic fibrosis, or whooping cough. Smoking has been shown to increase the risk of pneumothorax.

3. Tension pneumothorax results from continuous/large air leak resulting in compression of great vessels of thorax and other structures.

Clinical symptoms of pneumothorax

Chest pain, dyspnea, chest tightness or hypotension.

Physical examination findings in pneumothorax

Decreased or absent breath sounds and hyperresonance on percussion on the affected side. Tracheal deviation may be evident.

Investigations in pneumothorax

A chest x-ray should be done to make the diagnosis. ABG may be needed.

Management of pneumothorax

The management of the patient depends on the extent and type of the pneumothorax.

A small-size primary spontaneous pneumothorax may be observed in ED with a follow-up chest x ray in 3-6 hours. The patient may be discharged home with a follow-up in 12-24 hours and a repeat chest x-ray to document the resolution of pneumothorax. Patients with a primary spontaneous pneumothorax with a large pneumothorax who are clinically stable should receive a chest tube with or without suction. They need a follow-up chest x-ray in 48 hours. Patients with primary spontaneous pneumothorax who are not stable should undergo urgent large bore 22-24F chest tube placement with suction.

In contrast, patients with a secondary pneumothorax with a small pneumothorax who are clinically stable, should be hospitalized and have a chest tube inserted because of the higher risk associated with it. Patients with a secondary penumothorax with a large pneumothorax who are clinically stable/unstable should undergo an urgent chest tube placement with suction.

The chest tube may be removed after 48 hours. The suction should be discontinued, if applied, at least 6 hours before the chest tube removal. A check x-ray should be done after the chest tube removal to check for an air leak.

Persistent air leaks

Patients with prolonged air leaks should be observed for 4-7 days before advancing to a surgical procedure. However, more prolonged delays may decrease the effectiveness of thoracoscopy and increase the cost of care.

References

1. M H Baumann, C Strange, J E Heffner et al. Management of Spontaneous Pneumothorax-An American College of Chest Physicians Delphi Consensus Statement: CHEST February 2001 vol. 119 no. 2 590-602.
2. Waller, DA, McConnell, SA, Rajesh, PB Delayed referral reduces the success of video-assisted thoracoscopic surgery for spontaneous pneumothorax. Respir Med 1998; 92,246-249.
3. Schramel, FM, Sutedja, TG, Braber, JC, et al Cost-effectiveness of video-assisted thoracoscopic surgery versus conservative treatment for first time or recurrent spontaneous pneumothorax.

Cite this article as:

Mundra V, Zapatier J, Feiz H. Spontaneous Primary Pneumothorax. Clinical Cases and Images. Retrieved on August 24, 2009, from http://clinicalcases.org/2009/08/spontaneous-primary-pneumothorax.html.

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Published: 08/24/2009
Updated: 01/24/2011

1 comment:

  1. Excellent case for discussion and learning. However i would like to comment on a few aspects. Firstly, the 1st chest radiograph is slightly rotated towards the patient's left side, thus enhancing the tracheal deviation (if any) or misleading about tracheal deviation (if there is none). If the clinical examination was technically correct (about no tracheal deviation) then i would concur that it is due to leftward rotation of the chest wall/thorax.

    Secondly, regarding your statement that "A chest x-ray should be done to make the diagnosis. ABG may be needed." --> I agree that CXR may be needed for small pneumothorax or stable patient however i would like to reiterate that tension pneumothorax is a clinical diagnosis. The fact that the pneumothorax was HUGE then i would say that it should have been diagnosed clinically. And if tension pneumothorax was the diagnosis, don't delay treatment in order to obtain CXR. Treatment should begin immediately as it is rapidly life threatening. And i agree that ABG may be needed in other cases.

    Thank you.
    Dr. Faizal Amri Hamzah
    Emergency Physician & Senior Lecturer
    Department of Emergency Medicine,
    University Kebangsaan Malaysia Medical Centre (UKMMC)
    vit_ron@yahoo.com

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