Case 34: Symptomatic Pneumothorax
Monday, October 17th, 2011Author: Dr Danielle Coleman
This is a case of a 22yr old female smoker who presented with a 3/7 history of left sided sharp chest pains and shortness of breath at rest and on exertion. Her observations were stable with a BP of 125/63, HR 83, RR 18, sats of 98% on air. Her CXR revealed the following:.
(Click on image to enlarge)
This showed a left sided pneumothorax.
1. According to the new 2010 BTS guidelines on pleural disease and pneumothorax, how do you measure the size of the pneumothorax?
Click to see the answerThe size is based on the measurement of the thickness of the rim of air around the lung at the level of the hilum; <2cm indicates a small pneumothorax, >2cm a large one. So in this case it is defined as a small pneumothorax.
2. What would be the management in this case?
Click to see the answerAs the patient is symptomatic with shortness of breath, regardless of the size of the pneumothorax, this requires intervention. In the case of a primary spontaneous pneumothorax this would be in the form of needle aspiration at the level of the 2nd intercostal space, mid-clavicular line with a wide bore cannula.
3. If this didn’t work?
Click to see the answerIn contrast to the old guidelines, needle aspiration would not be repeated unless there was a technical fault with the 1st attempt i.e. the cannula kinked, this patient would need to undergo chest drain insertion. Interestingly 1/3 patient’s chest wall thickness at this point is greater than 5cm and the average cannula length is 4.5cm.
4. This young lady had her last period start 24hours before the symptom onset, does this have any relevance?
Click to see the answerThe new guidelines have indentified an entity called a catamenial pneumothorax which occurs within 72 hours of females starting their periods and is thought to be secondary to small endometrial deposits in the pleural causing the pneumothorax. The initial management is the same.