Pneumothorax - Long case study With Questions & Answers

Presenting Complains: 

• Breathlessness for … days
• Right sided chest pain for … days
• Cough for … days.

History of present illness: According to the statement of the patient, he was alright … days back. Since then, he suddenly felt severe breathlessness associated with pain in right side of his chest.

Breathlessness is present in rest, more marked on lying on right side and also on lying flat. It is nonprogressive, not associated with wheeze and does not relieve by taking rest or drugs. He also complains of right sided chest pain, which is sharp and stabbing in nature, aggravated by deep breathing, coughing, with movement and lying on right side but no radiation. The patient also complains of cough with slight mucoid expectoration but no hemoptysis. There is no history of trauma or fever.

History of past illness: There is no history suggestive of COPD, or chronic bronchitis or bronchial

asthma. There is no previous attack of such illness.

Family history: Nothing contributory.

Socioeconomic history: He is a laborer, living in a slum area with poor sanitary facilities.

Personal history: He smokes 30 to 40 sticks/day for 20 years, but nonalcoholic.

General Physical Examination: 

• The patient appears anxious and slightly dyspneic
• Decubitus: patient prefers to lie on left lateral position
• He is mildly anemic
• No jaundice, cyanosis, edema, clubbing, koilonychia or leukonychia
• No lymphadenopathy or thyromegaly
• Respiratory rate: 34/min
• BP: 110/80 mm Hg
• Pulse: 108/min.

Respiratory System:(supposing right side)

- Inspection:

• Restricted movement on right side of the chest
• Intercostal spaces appear full.

- Palpation:

• Trachea—deviated to the left
• Apex beat—in left 6th intercostal space in anterior axillary line (shifted to left), normal in character
• Vocal fremitus—reduced in right side but normal on the left side
• Chest expansion—reduced on the right side of the chest.

 - Percussion: 

• Hyper-resonance in right side (tell where), but normal on the left side
• Upper border of the liver dullness—in the right 6th intercostal space in the midclavicular line.

 - Auscutation:

• Breath sound—diminished (or absent) on the right side of the chest (tell up to which space), but vesicular on the left side.
• Vocal resonance—diminished (or absent) on the right side of the chest (tell up to which space), but normal on the left side.

Examination of other systems reveals nothing abnormal.

1. What is your diagnosis?

My diagnosis is right sided pneumothorax

2. What are your differential diagnoses?

 As follows:

• Big pulmonary cavity
• Giant bullae.

3. Mention one single investigation for your diagnosis.

 X-ray chest P/A view.

4. What investigations do you suggest?

As follows:

• Complete blood count and ESR
• Chest X-ray P/A view
• Sometimes, CT scan of chest

5. What is pneumothorax?

Pneumothorax means presence of air in the pleural cavity.

6. What is the usual presentation of pneumothorax?

The patient usually presents with sudden onset of unilateral pleuritic chest pain and breathlessness.

7. What are the types of pneumothorax?

• Spontaneous: It may be primary and secondary
• Traumatic.

Spontaneous:

a. Primary: Without underlying lung disease. It is due to:

• Rupture of apical subpleural bleb due to congenital defect in connective tissue of alveolar walls. Common in young, 15 to 30 years of age. M:F ratio is 4:1. The patient is tall, lean and thin, there is 25% chance of recurrence.

• Rupture of emphysematous bullae or pulmonary end of pleural adhesion.

b. Secondary: Occurs in pre-existing lung disease. Causes are:

• Commonly COPD and tuberculosis.

• Others—lung abscess, acute severe asthma, bronchial carcinoma, pulmonary infarction,

all forms of fibrotic and cystic lung disease, Marfan’s syndrome, Ehlers-Danlos syndrome

and eosinophilic granuloma.

 Traumatic:

a. Iatrogenic—during aspiration of pleural fluid, thoracic surgery, lung biopsy or pleural biopsy,

positive pressure ventilation, thoracocentesis and subclavian vein catheterization.

b. Chest wall injury.

8. How would you grade pneumothorax?

According to British Thoracic Society:

• Mild—small rim of air around the lung, <20% of the radiographic volume
• Moderate—lung collapse, >20 to 50% of the radiographic volume
• Large—lung collapse, >50% of the radiographic volume
• Tension—pneumothorax with cardiorespiratory distress, features of shock.

9. What are the causes of recurrent pneumothorax (more than twice)? How to treat?

Causes are:

• Apical subpleural bleb or cyst (congenital)
• Emphysematous bullae
• Cystic fibrosis
• Others—Marfan’s syndrome, catamenial pneumothorax, Ehlers-Danlos syndrome, a1- antitrypsin deficiency and histiocytosis X, honeycomb lung.

Treatment:

1. Chemical pleurodesis. Done by injecting tetracycline (500 mg), kaolin or talc into the pleural

cavity through intercostal tube.

2. Surgical pleurodesis. Done by parietal pleurectomy or pleural abrasion during thoracotomy or

thoracoscopy. Indications are:

• All patients after a second pneumothorax
• Considered after first episode of secondary pneumothorax, if there is low respiratory reserve
• Patient who plan to continue activity, where pneumothorax would be particularly dangerous (e.g. flying or diving) should undergo definitive treatment after first episode of primary spontaneous pneumothorax.

10. What is tension pneumothorax? What are the causes? How to treat?

It is a valvular-type of pneumothorax, in which there is a communication between lung and pleural

cavity with one-way valve, which allows air to enter during inspiration and prevents to leave during

expiration. It causes shifting of mediastinum to the opposite side and compresses the heart and

opposite lung.

Features of tension pneumothorax:

•  Severe chest pain (pain is worse with cough and relieve on sitting position)
• Severe and progressively increasing dyspnea
• Cough
• Tachypnea, tachycardia, pulsus paradoxus
• Features of shock (hypotension, central cyanosis and tachycardia)
• Raised JVP, engorged neck vein due to compression of the heart
• Shifting of mediastinum to the opposite side.

Causes of tension pneumothorax:

• Traumatic
• Mechanical ventilation at high pressure
• Rarely, spontaneous pneumothorax.

Treatment:

• Immediate insertion of wide bore needle in second intercostal space in midclavicular line, with
• the patient is sitting position.
• Intrathoracic tube is inserted in fourth, fifth or sixth intercostal space in midaxillary line, and the
• tip of the tube should be advanced in apical direction. It is connected to a underwater seal or oneway
• Heimlich valve.
• The patient should be kept propped up with oxygen inhalation.
• Morphine 5 to 10 mg subcutaneously.
• If bubbling ceases, repeat chest X-ray. If the lung re-expands, tube may be removed after 24 hours.
• Tube should be removed during expiration or Valsalva maneuver (the tube need not be clamped
• before removing).
• If no response or continued bubbling for 5 to 7 days, surgical treatment may be necessary.

11. What are the indications of chest tube  drainage?

As follows:

• Tension pneumothorax
• Large second spontaneous pneumothorax if > 50 years
• Malignant pleural effusion
• Empyema thoracis or complicated parapneumonic effusion
• Hydropneumothorax
• Traumatic hemopneumothorax
• Postoperatively as for example thoracotomy, esophagectomy, cardiothoracic surgery

12. How to treat pneumothorax?

Depends on whether it is primary or secondary, open, closed or tension or presence of symptoms.

1. In primary small pneumothorax:

•  Spontaneous resolution occurs. Follow-up at 2-week interval (repeat chest X-ray)
•  Normal activity
•  Avoid strenuous exercise

2. In primary moderate to large with breathlessness: Percutaneous needle aspiration of air (2 to 5

litre. Stop, if resistance to suction is felt or patient coughs).

3. In secondary pneumothorax: Patient with COPD, even small pneumothorax can cause respiratory

failure. Hence, water seal drainage should be given.

4. Open pneumothorax: Surgery (as is due to bronchopleural fistula).

5. Tension pneumothorax (described as above).

Advice to the patient:

• Must stop smoking
• Avoid air travel for 6 weeks after normal chest X-ray
• Diving should be permanently avoided.

13. If you are working in a remote place and a patient presents with tension pneumothorax, what measures should you take?

Immediately I shall insert a wide bore needle (may be cannula/venflon) in the second intercostal

space in midclavicular line. This will allow the trapped air to escape (producing an audible hiss). Then I shall send the patient to the nearest hospital (do not remove the cannula, tape it securely).

14. How long the lung takes to re-expand?

Air is absorbed at the rate of 1.25% of the total radiographic volume/day. So, if there is 50% lung

collapse, it will take 40 days to expand.

15. What is hydropneumothorax? What are the causes? How to manage?

When there is accumulation of fluid and air in pleural cavity, it is called hydropneumothorax.

Its causes are:

• Iatrogenic (during aspiration of pleural fluid)
• Pulmonary tuberculosis
• Bronchopleural fistula
• Trauma (penetrating chest injury and thoracic surgery)
• Rupture of lung abscess
• Esophageal rupture
• Erosion of bronchial carcinoma.

Management: Water seal drainage and treatment of primary cause.