Transcript Spontaneous tension pneumothorax

22-year-old patient with
spontaneous acute chest pain
September 2013
Corrielle Caldwell
Paul Lewis, MD
History
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
2
Events:
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 Exam
CONSTITUTIONAL: awake, alert and cooperative
ENT: normocepalic, without obvious abnormality
NECK: supple, symmetrical, trachea midline, skin normal and
no stridor
LUNGS: 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
Clinical Differential
• 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
CXR 08/25/2013 at 02:15 hours
Normal PA
http://radiopaedia.org/cases/normal-chest-x-ray
Patient - PA
CXR 08/25/2013 at 02:15 hours
Normal Lateral
http://radiopaedia.org/cases/normal-chest-x-ray
Patient - Lateral
Radiographic Differential
•
•
•
•
Simple pneumothorax
Tension pneumothorax
Skin fold
Pulmonary bullae
http://www.learningradiology.com/medstudents/recognizingseries/recognizeptxnet_fil
es/frame.htm
http://www.ctsnet.org/sites/default/files/graphics/experts/Thoracic/venu
ta_giant_bullous/venuta06.jpg
Simple vs Tension Pneumothorax
https://en.wikipedia.org/wiki/File:Rt_sided_pneumoD.jpg
http://www.learningradiology.com/medstudents/recognizingseries/rec
ognizeptxnet_files/frame.htm
Simple vs Tension Pneumothorax
Compare our patient’s film to the examples
Imaging for Tension Pneumothorax
• 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 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
http://aucklandhems.com/2012/11/04/lung-ultrasound-for-pneumothoraxliterature-for-practice-and-simulation/
Imaging for pneumothorax
• CT
• Good for investigating pathology in stable,
complicated patients.
• The most sensitive imaging
• Would not have been appropriate for this patient
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.