Pneumothorax in the ED: Blown Away

-Case-
A 22-year-old tall, thin male walks into the ED complaining of sudden-onset sharp left-sided chest pain and shortness of breath that began while playing video games. He denies trauma, fever, or cough. On exam, he’s tachypneic, with decreased breath sounds on the left and hyperresonance to percussion. to the same side. Oxygen saturation is 95% on room air. CXR shows a visible pleural line with no lung markings beyond it. What’s going on?

-Evaluation-
Welcome to the world of pneumothoraces – when air escapes into the pleural space, collapsing part (or all) of the lung. They come in three main flavors:

• Primary Spontaneous Pneumothorax (PSP): occurs often without underlying lung disease, typically in young, tall, thin males. Blame subpleural blebs!
• Secondary Spontaneous Pneumothorax (SSP): occurs in patients with underlying lung disease (think COPD, CF, lung infections, etc.)
• Traumatic or Iatrogenic (Tension): think physical trauma (blunt or penetrating), barotrauma, or procedural mishaps (central lines, thoracentesis)

Symptoms range from mild dyspnea and pleuritic chest pain to life-threatening hypoxia and hypotension in a tension pneumothorax.

Key physical findings include:

• Decreased breath sounds
• Hyperresonance on percussion
• Tachypnea
• Tracheal deviation (later finding in tension pneumo)

Diagnosis:

• Chest X-ray: first-line; look for a pleural line without lung markings beyond it, atelectasis, tracheal deviation
• Ultrasound: rapid and sensitive; confirmed with absence of lung sliding, and/or barcode sign on M-mode
• CT scan: gold standard but usually not necessary unless diagnosis is uncertain or a tiny pneumothorax needs ruling in or out

-Management-

• Small, stable PSP (<2-3 cm w/minimal symptoms): may be managed conservatively with observation, O2, and repeat imaging
• Large or symptomatic PSP: needle aspiration or chest tube (pigtail catheters are becoming the mainstay across most ERs now)
• SSP: more likely to need chest tube and hospitalization due to decreased pulmonary reserve
• Tension Pneumothorax: immediate needle decompression followed by chest tube; don’t delay for imaging!

Patients with PSP should avoid air travel and diving until cleared. Recurrence rates are high, so surgical options (e.g., VATS with pleurodesis) are often considered after the first recurrence!

-Fast Facts-

• Tall, thin males are classic PSP candidates
• Ultrasound is highly sensitive in the right hands
• Air travel is contraindicated until complete resolution of a pneumothorax
• Don’t forget about iatrogenic causes (central lines, positive pressure ventilation)

A pneumothorax is one of those diagnoses that can go from “annoying” to “life-threatening” real quick. Keep your stethoscope and ultrasound probe handy, act fast when tension pneumo rears its ugly head, and remember: not all chest pain is created equal!

Want to learn more? Read our in-depth study guide and listen to our podcast episode on this topic!

Cheers,

Tamir Zitelny, MD

-References-

1. Hallifax RJ, Walker SP, Corcoran JP, et al. Aetiology and management of secondary spontaneous pneumothorax: a review. Lancet Respir Med. 2015;3(7):578-588.
2. MacDuff A, Arnold A, Harvey J; BTS Pleural Disease Guideline Group. Management of spontaneous pneumothorax: British Thoracic Society Pleural Disease Guideline 2010. Thorax. 2010;65(Suppl 2):ii18-ii31.
3. Weingart SD, DuCanto J, Trueger NS. Thoracic Trauma and the Emergent Airway. Ann Emerg Med. 2016;67(1):138-144.
4. Kelly AM, Clooney M, et al. Spontaneous pneumothorax: treatment by small-bore catheter aspiration. Emerg Med J. 2008;25(5):261-264.
5. Lichtenstein DA. Ultrasound in the management of thoracic disease. Crit Care Med. 2007;35(5 Suppl):S250-S261.