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1
Question:

A 22-year-old man comes to the emergency department due to sudden-onset dyspnea 2 hours ago while watching television.  The patient's dyspnea is gradually improving but he still has sharp right-sided chest pain that is worse with deep inspiration or cough.  His medical history is unremarkable.  The patient smokes 4-5 cigarettes daily and occasionally drinks alcohol.  Temperature is 36.7 C (98 F), blood pressure is 140/80 mm Hg, pulse is 86/min, and respirations are 18/min.  Pulse oximetry shows 98% on room air.  He weighs 68 kg (150 lb), is 188 cm (6 ft 2 in) tall, and has a BMI of 19.3 kg/m2.  Physical examination is unremarkable.  Chest x-ray reveals a small right apical pneumothorax.  Which of the following is the most appropriate management of this patient?

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Explanation:

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Pneumothorax

Spontaneous pneumothorax

Tension pneumothorax

Associated features

  • Primary: no preceding event or lung disease; often thin, young men
  • Secondary: underlying lung disease (eg, COPD, CF)
  • Life-threatening
  • Often due to trauma or mechanical ventilation

Signs & symptoms

  • Chest pain, dyspnea
  • ↓Breath sounds, ↓chest movement
  • Hyperresonant to percussion

Same as spontaneous plus:

  • Hemodynamic instability
  • Tracheal deviation away from affected side

Imaging

  • Visceral pleural line
  • Absent lung markings beyond pleural edge

Same as spontaneous plus:

  • Contralateral mediastinal shift
  • Ipsilateral hemidiaphragm flattening

Management

  • Small (≤2 cm): observation & oxygen administration
  • Large & stable: needle aspiration or chest tube
  • Urgent needle decompression or chest tube placement

CF = cystic fibrosis; COPD = chronic obstructive pulmonary disease.

This young man without prior medical problems who presents with a pneumothorax likely has a primary spontaneous pneumothorax (PSP).  PSP occurs in patients without a history of lung disease and is most common in tall, thin men in their early 20s.  Other risk factors include smoking, Marfan syndrome, and thoracic endometriosis.  PSP occurs due to rupture of subpleural blebs and commonly develops while patients are at rest.  Clinical manifestations include dyspnea, hypoxemia, reduced chest excursion and breath sounds on the affected side, and hyperresonance to percussion.  Diagnosis is confirmed by identifying a visceral pleural line on chest x-ray with absent lung marking beyond the line.

The management of PSP depends on the size of the lesion and the clinical status of the patient.  Radiographically, pneumothoraces are categorized as small (≤2 cm) or large.  Small pneumothoraces in clinically stable patients, such as this patient, can be managed with observation and supplemental oxygen (regardless of oxygen saturation), which enhances the speed of resorption.  Stable patients with large pneumothoraces should undergo decompression with a large-bore needle (eg, 14- to 18-gauge) inserted in the second or third intercostal space in the midclavicular line or at the fifth intercostal space in the mid or anterior axillary (Choice C).  Patients who are hemodynamically unstable should undergo emergent placement of a tube thoracostomy (Choice A).  If tube thoracostomy is not available or will be delayed, urgent needle decompression can be performed.

(Choice B)  Chest CT scan is not necessary unless diagnostic uncertainty exists after a plain radiograph or if there is concern for tube thoracostomy placement or a loculated pneumothorax.

(Choice E)  If the lung fails to adequately re-expand (eg, <90% expansion) and a persistent air leak is present, placement of a one-way valve, creation of a blood patch, or video-assisted thoracoscopic surgery (VATS) can be used.  For patients with recurrence, VATS pleurodesis or chemical (eg, tetracycline derivative, talc) pleurodesis can be performed.

Educational objective:
Primary spontaneous pneumothorax (PSP) occurs in patients without a history of lung disease and is most common in tall, thin men in their early 20s.  Management of small PSP in clinically stable patients includes observation and supplemental oxygen, which enhances the speed of resorption.