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Case In Point: Spontaneous Pneumothorax in a Teenage Boy

Case In Point: Spontaneous Pneumothorax in a Teenage Boy

A 17-year-old Asian male with no significant medical history presented to the emergency department (ED) with acute shortness of breath and associated left-sided chest pain. Symptoms began while the patient was at rest: the pain was sharp and worsened with inspiration. He denied a history of fever, trauma, cough, or any other constitutional complaints.

In the ED, the patient's temperature was 37.8°C (100°F); heart rate was 100 beats per minute; respiratory rate, 28 breaths per minute; and blood pressure, 124/96 mm Hg. Oxygen saturation was 100% on room air. He had no nasal flaring but used accessory respiratory muscles. The trachea was in midline. Breath sounds were markedly diminished on the left side, with good air entry on the right. No crepitus, wheezing, stridor, or crackles were appreciated. Cardiac examination revealed a normal S1 and S2, without any murmurs, rubs, or gallops. Mediastinal shift could not be detected clinically. Chest films showed a left-sided tension pneumothorax (Figure 1).

A chest tube was placed, and symptoms resolved (Figure 2). The patient underwent surgery to resect an apical pleural bleb.

SPONTANEOUS PNEUMOTHORAX

A spontaneous pneumothorax (SP) is a collection of air or gas between the visceral and parietal pleura that causes the lung to collapse in the absence of a traumatic injury to the chest or lung. Primary spontaneous pneumothorax (PSP) occurs in persons with no previously known lung disease. Typically, the cause of this type of pneumothorax is the rupture of a subpleural bleb or cyst in the lung.

A secondary spontaneous pneumothorax (SSP) occurs in persons with known lung disease--most often chronic obstructive pulmonary disease in adults. In pediatric patients, cystic fibrosis, pneumonia, and asthma are the most common causes of SSP. Other conditions less commonly associated with SSP are tuberculosis, cystic adenomatoid malformation, Marfan syndrome, and certain types of interstitial lung disease.

SSP is generally more severe than PSP--and is often life threatening. Mortality associated with SSP is about 15%.1

Smoking greatly increases the risk of SP.2 Men who smoke a pack a day or less have a 20-fold increased risk of SP; in women, the risk rises by 10-fold. In men who smoke more than a pack per day, the risk of SP increases more than 80-fold; in women, the risk increases more than 40-fold.

SP also can be an inherited disorder, although this is not common. One literature review described 61 cases of familial SP in 22 families.3

SYMPTOMS

The major symptom is sudden-onset chest pain with breathlessness. This pain may be dull, sharp, or stabbing; it typically begins suddenly while the patient is at rest. Pain can be associated with dyspnea, tachypnea, and hypoxia; typically, it is exacerbated by breathing deeply or by coughing.

Patients with SSP may also experience dyspnea disproportional to the size of the pneumothorax as well as tachycardia, hypotension, and cyanosis.

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