What's the diagnosis? By Dr. Abby Renko
A 16 yo female presents with shortness of breath that started 2 days ago and worsened today. She denies cough, fever, myalgias and her COVID test is negative.
BP 122/86, HR 122, SpO2 92%RA, RR26, Tep 98.6F
X-ray is shown. What's the diagnosis? Scroll down for answer.
Diagnosis : Spontaneous Pneumothorax (right sided, in this case)
Primary - in patients without known lung disease
Secondary - in patients with known lung disease
Sudden, sharp, pleuritic chest pain with associated shortness of breath
Smoking, genetic predisposition, blebs, COPD, asthma, HIV, malignancy, cystic fibrosis, connective tissue disease
Physical exam - inconsistent, but may reveal diminished breath sounds on affected side
Chest x-ray - displaced pleural line with absent lung markings extending from visceral pleura (lung edge) to parietal pleura (chest wall)
Point of care ultrasound (POCUS) - absence of lung sliding and vertical reverberation (comet tail artifacts)
Tension pneumothorax (a life threatening emergency)
Supplemental oxygen - increases pleural air resorption
Observe ~4 hours on oxygen and repeat x-ray
Follow up in 24 hours
Large pneumothorax (severe dyspneua, abormal vitals signs)
Needle aspiration (for primary spontaneous) - click here to review
may reduce hospitalization rate / shorten length of stay
Chest tube thorocostomy - click here to review the procedure
Tintinalli, JE. Tintinalli's Emergency Medicine: A Comprehensive Study Guide. 8th ed. New York, NY: McGraw-Hill Education LLC, 2016.
Wan C, Lyu M, Zhou J, Liu Y, Ji Y, Chest tuve drainage versus needle aspiration for primary spontaneous pneumothorax: which is better? J Thoracic Dis. 2017; 9(10): 4027-4038.
Zehtabchi S, Rios C. Management of Emergency Department Patients with Primary Spontaneous Pneumothoraz: Needle Aspiration or Tube Thorocostomy. Annals of Emergency Medicine. 2008; 51(1): 91-100.