Tips: young, fit, healthy male patient with SOB (D/D: pulmonary embolism)

 

Description:

• Hypertranslucent lung field

1. 1. devoid of bronchovascular marking
   2. with collapsed lung margin
   3. on the right side

• Trachea and heart shifted to the left
• Small opacity in right costophrenic angle ***
• Any underlying pulmonary disease (eg. COPD, PTB, Ca, Abscess)

 

• Diagnosis:
  • right sided
  • tension
  • pneumothorax, with 
  • angular effusion 

 

Causes (5)

1. Rupture of sub-pleural bleb (congenital)
2. Rupture of sub-pleural emphysematous bulla
3. COPD, asthma
4. PTB
5. Lung cancer
6. Lung abscess
7. Pulmonary infarcts
8. Fibrotic and cystic lung disease
9. Traumatic: following thoracic surgery or biopsy, chest wall injury 

 

D/D:

• large pre-existing emphysematous bulla
• the lung edge is convex in a pneumothorax, whereas the edge of a bulla is concave

 

Expected finding in one sentence

• silent, hyper-resonant chest

 

Treatment:

• Immediate treatment

• • Insertion of cannula (davidson)
  • in right 2nd intercostal space
  • in midclavicular line 

 

• Definitive management:

• • Intercostal tube insertion with
  • water seal drainage 
  • secured firmly to chest wall by stitches

• Treatment in recurrent case

• • pleurodesis by pleural abrasion or parietal pleurectomy at thoracotomy or thoracoscopy.

 

CXR in case of suspected small pneumothorax: CXR at the height of expiration

 

Management from Davidson

• Spontaneous/primary

• • < 2 cm, no breathlessness →  resolves spontaneously (wait and F/U)
  • >2 cm, or <2 cm but with SOB → P/C needle aspiration of air → F/U

• • • if patient remains breathlessness
    • have persistent large pneumothorax despite aspiration 
    • >2.5 L air aspiration
      • then, go for intercostal tube (ICT) drain

 

• Secondary: having underlying chronic lung disease; all patient need hospital admission for observation
  • <2 cm, no breathlessness → aspiration → F/U 
  • ICT drain, if

• • • patient in breathlessness
    • > 2 cm
    • remain > 1 cm after aspiration 

 

Intercostal tube (ICT) Management

• intercostal drains are inserted in the triangle of safety, 
• connected to an underwater seal or one-way Heimlich valve, and 
• secured firmly to the chest wall with stitches. 
• Clamping of an intercostal drain is potentially dangerous. 
• The drain should be removed the morning after the lung has fully re-inated and bubbling has stopped. 
• Continued bubbling after 5–7 days is an indication for surgery, though in practice CT and surgical referral occurs after 48 hours. 
• If bubbling in the drainage bottle stops before full reination, the tube is either 

• • blocked 
  • kinked or 
  • displaced. 

• Supplemental oxygen may speed resolution

 

 

Advice:

• Patients with a closed pneumothorax should be advised not to fly, as the trapped gas expands at altitude. 
• British Thoracic Society guidelines suggest that flying should be delayed until 7 days after X-ray confirmation of full inflation. 
• Stop smoking 
• Diving is contraindicated following a pneumothorax, unless a surgical pleurodesis has sealed the lung to the chest wall. 

 

 

Recurrent spontaneous pneumothorax 

• After primary pneumothorax: 

• • prompt definitive treatment. 

• • Surgical pleurodesis is recommended following a second pneumothorax 

 

• Secondary pneumothorax: Surgical pleurodesis should be considered following the first episode if low respiratory reserve makes recurrence hazardous. 
• Pleurodesis can be achieved by pleural abrasion or parietal pleurectomy at thoracotomy or thoracoscopy.

 

 

Advice:

1. Not to fly until 7 days after X ray confirmation of full inflation
2. Stop smoking
3. Avoid diving, unless a surgical pleurodesis has sealed the lung to the chest wall.

 

Short Answer Question (SAQ). A 16-year-old male, non smoker, presented with left sided chest pain for the last 6 hours. There was no history of previous trauma, illicit drug use, fever, cough or shortness of breath. On query, He said near objects appear clear, but objects farther away look blurry. Family history was negative for lung disorders. On examination, pulse 122/min, BP 60/40 mmHg, there was decreased breath sounds on the left hemithorax. The patient was tall and thin, long tapered extremities, arachnodactyly.

 

Q. What is the likely diagnosis?

• Marfan’s syndrome with Tension pneumothorax.

 

Q. Mention Immediate treatment option for developing complication. 

• Needle / cannula insertion in left 2nd ICS in mid clavicular line.

 

Q. Mention Definitive Management for developing complication.

• Intercostal tube insertion in the triangle of safety, with water seal drainage or one-way valve, secured firmly to the chest wall with stitches followed by pleurodesis.

 

Q. Mention 3 Investigations for this patient.

• Genetic study
• Chest X-ray
• Echocardiography