Corrielle Caldwell

September 2013

Paul Lewis, MD

22-year-old patient with spontaneous acute chest pain

History

2

22 year old gentleman

History of spontaneous pneumothorax on the right 3 yrs ago

Presents with SOB and wheezing sensation on the left side of his chest.

States that it feels like the last time he had a pneumothorax.

No other past medical, surgical, or family history

No medications or allergies

01:51 Vitals - 98.1˚ 162/87 113 22 99% RA

02:12 CXR ordered

02:15 CXR read, result reported to the ED

03:00 Physical ExamCONSTITUTIONAL:  awake, alert and cooperativeENT:  normocepalic, without obvious abnormalityNECK:  supple, symmetrical, trachea midline, skin normal 

and  no stridorLUNGS:  no increased work of breathing, good air 

exchange  and diminished breath sounds throughout left lung

CARDIOVASCULAR:  tachycardic with regular rhythm

03:50 Placement of pigtail catheter

Events:

• Simple pneumothorax– History of spontaneous pneumothorax

• Tension pneumothorax– Clinical presentation not suggestive of tension pneumothorax but

if pneumothorax is suspected, tension must be ruled out

• Pneumonia

• Reactive airway disease

• Foreign body

• Trauma

• Pulmonary Embolism

Clinical Differential

CXR 08/25/2013 at 02:15 hours

Patient - PANormal PA

http://radiopaedia.org/cases/normal-chest-x-ray

CXR 08/25/2013 at 02:15 hours

Patient - LateralNormal Lateralhttp://radiopaedia.org/cases/normal-chest-x-ray

• Simple pneumothorax

• Tension pneumothorax

• Skin fold

• Pulmonary bullae

Radiographic Differential

http://www.ctsnet.org/sites/default/files/graphics/experts/Thoracic/venuta_giant_bullous/venuta06.jpg

http://www.learningradiology.com/medstudents/recognizingseries/recognizeptxnet_files/frame.htm

Simple vs Tension Pneumothorax

http://www.learningradiology.com/medstudents/recognizingseries/recognizeptxnet_files/frame.htm

https://en.wikipedia.org/wiki/File:Rt_sided_pneumoD.jpg

Simple vs Tension Pneumothorax

Compare our patient’s film to the examples

• No imaging! However, from the notes, this patient did not present with symptoms of a tension pneumothorax

Imaging for simple pneumothoraces:

• CXR

• Ultrasound

• CT

Imaging for Tension Pneumothorax

• Ultrasound is most widely used• Detects plural sliding

• M mode records motion over time and lack of motion of lung paranchema indicates pneumothorax

• False positives are caused by anything that causes lack of normal pleural sliding

• Mainstem intubation

• Blebs

• Severe COPD

• ARDS

• Pleurodesis

• Many others

Imaging for Pneumothorax

http://aucklandhems.com/2012/11/04/lung-ultrasound-for-pneumothorax-literature-for-practice-and-simulation/

• CT• Good for investigating pathology in stable,

complicated patients.

• The most sensitive imaging

• Would not have been appropriate for this patient

Imaging for pneumothorax

http://www.uptodate.com/contents/image?imageKey=PULM%2F88944&topicKey=PULM%2F6981&rank=1%7E150&source=see_link&search=pneumothorax+imaging&utdPopup=true

How common is tension pneumothorax in patients like ours?Clinical Manifestations of Primary Spontaneous Pneumothorax in

Pediatric Patients: An Analysis of 78 Patients• Older adolescent male patients who are tall and thin• Most common in the fall• 36% of these patients presented with a tension pneumothorax

Spontaneous tension pneumothorax: what is it and does it exist?Myth of tension spontaneous pneumothorax.

• These papers state that spontaneous tension pneumothorax is impossible to have by definition.

• They define tension pneumothorax not by mediastinal shift but by intrathoracic pressures and clinical findings

CXR, 09/04/2013 at 1030 hours

PA Lateral

References

Brown, S. G., E. L. Ball, and K. Perrin. "Myth of Tension Spontaneous Pneumothorax." Emergency Medicine Australias 24.1 (2012): 117. Web.

"Hydropneumothorax in Rheumatoid Arthritis." Up To Date. N.p., n.d. Web. 23 Sept. 2013.

"Lung Ultrasound for Pneumothorax: Literature for Practice and Simulation." Auckland HEMS. N.p., n.d. Web. 24 Sept. 2013.

"Normal Chest X-ray." Radiopaedia Blog RSS. N.p., n.d. Web. 23 Sept. 2013.

"Pneumothorax." Wikipedia. N.p., n.d. Web. 23 Sept. 2013.

"Recognizing a Pneumothorax." Learning Radiology. N.p., n.d. Web. 23 Sept. 2013.

Shih, C. H., H. W. Yu, Y. C. Tseng, Y. T. Chang, C. M. Liu, and J. W. Hsu. "Clinical Manifestations of Primary Spontaneous Pneumothorax in Pediatric Patients: An Analysis of

78 Patients." Pediatrics and Neonatology 52.3 (2011): 150-54. Web.

Simpson, G., S. Vincent, and J. Ferns. "Spontaneous Tension Pneumothorax: What Is It and Does It Exist?" Internal Medicine Journal 42.10 (2012): 1157-160. Web.