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49. Pneumothorax: “Hmmm, I Guess Dr. Heimlich Had More Than One Maneuver!”
Keywords
Tension pneumothoraxHemodynamic instabilityJugular venous distensionTracheal deviationMedical emergencyCase 1
Pertinent History
The patient is an 18-year-old male who presents to the emergency department with right-sided chest pain. He states that he was simply watching a soccer game when he developed acute onset right-sided chest pain. The pain radiates into his back and is worse with breathing and coughing. It is not exacerbated by movement, and he has no recollection of any muscular injury. The pain was accompanied by dyspnea. He has had no preceding illnesses or similar symptoms in the past.
Pertinent Physical Exam
Except as noted below, the findings of the complete physical exam are within normal limits.
Vitals: Blood pressure 156/71, pulse 82, temperature 98.1 °F (36.7 °C), respiratory rate 22, SpO2 100%. SpO2 desaturates to 90% while speaking.
Constitutional: Appears uncomfortable while seated. Tall, thin body habitus.
HEENT: No stridor.
Cardiovascular: Normal rate and regular rhythm. 2+ radial and dorsalis pedis pulses bilaterally.
Pulmonary/Chest: No significant respiratory distress. No use of accessory muscles during respiration. Mildly diminished breath sounds on right. No wheezes, rhonchi, rales. No chest wall tenderness or crepitus on palpation.
Extremities: No peripheral edema noted.
Past Medical and Surgical History
Unremarkable and non-contributory aside from a penicillin allergy.
Social History
The patient recently started college and has been training daily with the college water polo team. He has been exposed to tobacco smoke since a young age, but he denies tobacco, alcohol, and illicit drug use.
Family History
Both the patient’s father and cousin have previously required hospitalizations for “tubes in the chest.”
Pertinent Test Results
An ECG showed normal sinus rhythm with no evidence of ischemic changes.
The chest X-ray demonstrates a right-sided pneumothorax.
ED Management
The emergency department physician placed an 8 French catheter-style chest tube complete with Heimlich valve. The patient remained in the emergency department for further observation following the placement of the catheter.
Case 2
Pertinent History
A 63-year-old male presents to the emergency department after a motor vehicle accident. The patient was an unrestrained driver in a head-on collision at moderate speed. On presentation, the patient complained of sharp, unrelenting left-sided chest pain. EMS reports that the patient’s breathing became much more labored since their initial evaluation. The patient had no loss of consciousness and reports no additional complaints or injuries.
Pertinent Physical Exam
Except as noted below, the findings of the complete physical exam are within normal limits.
Vitals: Blood pressure 82/50, pulse 115, temperature 99.3 °F (37.4 °C), respiratory rate 42, SpO2 92% on non-rebreather mask.
Constitutional: Appears in significant respiratory distress.
HEENT: No stridor. There was evidence of jugular venous distension and tracheal deviation on examination.
Cardiovascular: Tachycardic and regular rhythm. 2+ radial and dorsalis pedis pulses bilaterally.
Pulmonary/Chest: Severe respiratory distress. Diminished breath sounds on the left with obvious signs of chest trauma.
Past Medical and Surgical History
The patient has a history of COPD, and type 2 diabetes mellitus for which he takes metformin and multiple inhaled medications. The patient continues to smoke and uses alcohol socially. The remainder of his history is non-contributory.
Pertinent Test Results
An ECG revealed sinus tachycardia with no acute ischemic changes. The treatment team performed a bedside ultrasound to assess for pneumothorax. The first ultrasound image of the right lung shows normal lung sliding with the normal appearance of the “seashore” sign on M-mode. The second ultrasound image shows the left lung and the presence of a pneumothorax. There is absent lung sliding as evidenced by the “bar-code” sign on M-mode.
ED Management
The team of emergency physicians quickly identified tension pneumothorax pathology, and a 14-gauge angiocatheter was placed in the left second to third intercostal space in the mid-clavicular line for immediate decompression. Upon completion of the initial trauma survey, a 36 French chest tube was placed in the fifth intercostal space in the mid-axillary line. The chest tube was placed to water seal and vacuum.
Learning Points
Priming Questions
- 1.
What is a pneumothorax?
- 2.
How are pneumothoraces classified?
- 3.
What conditions predispose patients to develop pneumothoraces?
- 4.
What management options are present for pneumothoraces?
- 5.
Are there outpatient options available for pneumothorax treatment?
Introduction/Background
- 1.
What is a pneumothorax?
A pneumothorax occurs when air becomes trapped between the visceral and parietal pleura. This may occur due to compromise of either pleural membrane.
- 2.
Pneumothorax Classification:
A pneumothorax can be spontaneous, traumatic or iatrogenic in etiology. Spontaneous pneumothoraces are further categorized as primary or secondary.
Primary spontaneous pneumothoraces occur in patients without clinically apparent lung disease (often young, tall men, aged 20–40 years, who usually smoke). Of note, the onset of a primary pneumothorax has not been correlated with physical activity and muscle effort [1].
Secondary pneumothoraxes are a complication of preexisting underlying pulmonary disease, trauma or medical treatment.
Underlying pulmonary diseases such as COPD, pneumonia particularly Pneumocystis jiroveci pneumonia, cystic fibrosis, asthma, and tuberculosis can be predisposing factors.
Traumatic pneumothorax can be due to either blunt or penetrating chest trauma.
Iatrogenic pneumothorax may occur during subclavian or internal jugular line placement, thoracentesis, or following lung or pleural biopsy. A pneumothorax may also result from barotrauma during positive pressure ventilation.
Pneumothorax Size Classification:
By the British Medical Society definition, a large pneumothorax is differentiated from a small pneumothorax by measuring greater than 2cm from the lung margin to the chest wall at the level of the hilum. Although subject to multiple limitations including pneumothorax localization and lung shape, the 2cm guideline is thought to estimate a 50% pneumothorax by volume [2].
- 3.
Incidence:
Primary spontaneous pneumothorax has been estimated to have an incidence of 7.4 and 1.2 per 100,000 per annum for males and females, respectively. Likewise, the incidence of secondary spontaneous pneumothorax has been estimated to be 6.3/100,000 per annum for males and 2.0/1000,000 per annum for females [3]. In a United Kingdom study, emergency hospital admissions for pneumothorax were 16.7 and 5.8 per 100,000 per year for men and women, respectively [4].
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