Tension pneumothorax is best diagnosed with:
Correct Answer D: Tension pneumothorax is a pneumothorax causing progressive rise in intrapleural pressure to levels that become positive throughout the respiratory cycle and collapse the lung, shift the mediastinum, and impair venous return to the heart. Air continues to get into the pleural space but cannot exit. Without proper treatment, the impaired venous return can cause systemic hypotension and respiratory and cardiac arrest within minutes.
Tension pneumothorax most commonly occurs in patients receiving positive-pressure mechanical ventilation (particularly during resuscitation). It is rarely a complication of traumatic pneumothorax, when a chest wound acts as a one-way valve that traps increasing volumes of air in the pleural space with inspiration.
Tension pneumothorax is diagnosed clinically with hyper-tympany on the side of the lesion, deviation of the trachea away from the lesion, and decreased breath sounds on the affected side. There is usually associated elevated jugular venous pressure in the neck veins. This is a clinical diagnosis, and once made an immediate needle thoracostomy or tube thoracostomy should be performed to relieve the tension pneumothorax.
A 35-year-old male consults you about a vague chest pain he developed while sitting at his desk earlier in the day. The pain is right-sided and was sharp for a brief time when it began, but it rapidly subsided. There was no hemoptysis and the pain does not seem pleuritic. His physical examination, EKG, and oxygen saturation are unremarkable. A chest film shows a 10% right pneumothorax.
Which one of the following is true in this situation?
Correct Answer C:
The majority of patients presenting with spontaneous pneumothorax are tall, thin individuals under 40 years of age. Most do not have clinically apparent lung disease, and the chest pain is sometimes minimal at onset and may resolve within 24 hours even if untreated. Patients with small pneumothorax involving less than 15% of the hemithorax may have a normal physical examination, although tachycardia is occasionally noted. The diagnosis is confirmed by chest radiographs. Studies of recurrence have found that an average of 30% of patients will have a recurrence within 6 months to 2 years. The treatment of an initial pneumothorax of less than 20% may be monitored if a patient has few symptoms. Follow-up should include a chest radiograph to assess stability at 24-48 hours. Indications for treatment include progression, delayed expansion, or the development of symptoms. The majority of patients with spontaneous pneumothoraces, and perhaps almost all of them, will have subpleural bullae on a CT scan.
A 40-year-old male developed acute respiratory distress syndrome after a severe attack of pancreatitis. He was admitted to the ICU, intubated and ventilated with PEEP (Positive end-expiratory pressure) of 14 cm water, and FiO2 of 70%. Suddenly, his pulse increases from 90 to 150/min; systolic blood pressure drops from 120 to 60 mm Hg; central venous pressure increases from 20 to 50cm water. Physical exam shows tracheal deviation to the left side and absent breath sounds on the right side. JVD is noted.
What is the most appropriate next step in management?
Correct Answer E:
Tension pneumothorax is not an uncommon complication of mechanical ventilation when high PEEP is used. This occurs due to barotrauma.
Tracheal deviation + absent breath sounds + hypotension and JVD = Tension pneumothorax.
The patient is dying. There is no time for diagnostic tests. Needle thoracentesis is life saving.
A chest tube placement is appropriate after needle decompression of the pleural space.
A 25-year-old male comes to the emergency department with the sudden onset of moderate to severe right-sided chest pain and mild dyspnea. Vital signs are normal. A chest film shows a loss of markings along the right lung margins, involving about 10%-15% of the lung space. The mediastinum has not shifted.
The best INITIAL treatment would be:
Correct Answer B:
A small spontaneous pneumothorax involving less than 15%-20% of lung volume can be managed by administering oxygen and observing the patient. The pneumothorax will usually resorb in about 10 days if no ongoing air leak is present. Oxygen lowers the pressure gradient for nitrogen and favors transfer of gas from the pleural space to the capillaries. Decompression with anterior placement of an intravenous catheter is usually reserved for tension pneumothorax. Chest tube placement is used if observation is not successful or for larger pneumothoraces. Strict bed rest is not indicated.
A 69-year-old male presents to the emergency department with complaints of suddenly increased shortness of breath. He was diagnosed with COPD 10 years ago. His medications are tiotropium, formoterol, and albuterol. Usually when he is short of breath he uses albuterol, which alleviates the symptoms. However, "it has not helped much this time." He has smoked 40 packs of cigarettes a year for the last 45 years. On physical examination he has hyperresonance to percussion and decreased breath sounds on auscultation at the right side. His oxygen saturation is 87%.
Which of the following is the most appropriate next step in management?
This patient’s history of smoking and COPD, the presentation with shortness of breath, decreased breath sounds on the right, and hyperresonance to percussion point to a diagnosis of spontaneous pneumothorax. COPD is the most common cause of secondary spontaneous pneumothorax accounting for 60% of cases on average. Rupture of apical blebs is the usual cause. Out of the choices given, oxygen administration at 3L/min nasal cannula (choice E) is the most appropriate initial step in management of this patient. Oxygen treats hypoxemia and is associated with a 4-fold increase in the rate of pleural air absorption compared with room air alone. If the patient doesn't respond to oxygen supplementation, chest tube placement would be the most appropriate next-in-line treatment.
→ Albuterol inhaler, ipratropium, and oral prednisone (choice A) would be appropriate for the management of COPD exacerbation.
→ Sputum cultures and initiation of azithromycin (choice B) would be appropriate if community acquired pneumonia is suspected. This patient’s clinical scenario suggests spontaneous pneumothorax.
→ Order chest radiograph (choice C) should be part of the management plan of this patient’s condition, but oxygen should be given prior to imaging investigations.
→ Intubation and mechanical ventilation with 100% oxygen (choice D) is incorrect. The appropriate initial oxygen supplementation should be done by nasal cannula.
Key point:
Sudden increase of shortness of breath, unilateral decreased breath sounds on auscultation and hyperresonance to percussion in a patient with COPD history is suggestive of spontaneous pneumothorax. Oxygen supplementation (through a nasal cannula) is an appropriate initial treatment of spontaneous pneumothorax.
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