Volume 3, Case 13
Loren G. Yamamoto, MD, MPH
Kapiolani Medical Center For Women And Children
University of Hawaiʻi John A. Burns School of Medicine
A 15-year old male presents to the E.D. with a one hour history of pain in his chest and back occurring after lifting his mother. He describes the pain as knife-like and non radiating. His pain worsens with deep inspiration. His pain is currently less severe than at onset. He has a past history of chest pain episodes, usually at night while sleeping in bed.
Exam VS T37 (tympanic), P76, R24, BP 131/65. Oxygen saturation 100% in room air. He is alert and active in no distress. He is tall and thin. Heart regular, no murmurs. Lungs clear, but diminished breath sounds bilaterally. Abdomen benign. Peripheral pulses are full. Color and perfusion are good. Hands significant for long thin fingers (arachnodactyly).
A chest radiograph is ordered.
View CXR.
This CXR shows a long thorax with hyperexpanded lungs. The aortic shadow is not obviously widened. The cardiac silhouette is not enlarged. There is no obvious pneumothorax, pneumomediastinum, or subcutaneous emphysema.
Aortic dissection is suspected because of his Marfanoid appearance. A CT scan of the chest and aorta is ordered.
View CT scan.
The CT scan demonstrates a small left-sided pneumothorax. The arrows point to the visceral pleura of the lung. An air space is evident within the pleural space. The aorta is normal.
Upon closer inspection of subsequent CXR's, the pneumothorax is visible as a thin rim of air over the apex of the left lung. It is more obvious on erect and expiratory views. Pneumothoraces may be difficult to see on a supine or a partially supine film. The patient should be upright or in the lateral decubitus position to see it best.
View close-up of left apex and expiratory view.
After reviewing the previous case of aortic dissection, chest pain in a tall slender patient suggesting Marfan's Syndrome, is highly suggestive of another aortic dissection. Marfan's Syndrome is a connective tissue disorder prone to aortic dissection. Patients with Marfan's Syndrome classically have a body stature similar to that of Abraham Lincoln. Although such tall slender individuals with chest pain raise the possibility of aortic dissection, such individuals are also at a higher risk of a spontaneous pneumothorax. Other activities associated with an increased risk of air leaks include coughing, valsalva maneuvers (eg., musical instrument playing and carrying one's mother), substance abuse, positive pressure devices, etc. Patients with chronic lung disease such as bronchopulmonary dysplasia, cystic fibrosis, bronchiectasis, metastatic disease, etc., are at greater risk for a spontaneous pneumothorax.
Patients with a spontaneous pneumothorax may present with chest pain or symptoms of respiratory difficulty. The chest pain may be similar to that of chest wall pain in that the pain is usually worse when taking in a deep breath. Crepitance may be palpable if air is dissecting into the soft tissues of the neck or the chest wall. Diminished breath sounds may be noticeable if the pneumothorax is large enough. Small pneumothoraces may not be detectable by auscultation.
An immediate chest tube is indicated only if the patient is in severe distress. Otherwise, it may be best to obtain a chest radiograph to establish a diagnosis before performing an invasive procedure. This pneumothorax was difficult to see on this recumbent CXR view. If a pneumothorax is still suspected, an expiratory erect view would accentuate the radiographic findings, making it easier to identify a small pneumothorax. As demonstrated in this case, CT scan is very sensitive at identifying a pneumothorax, but it is usually not necessary since pneumothoraces can usually be identified on plain radiographs.
If the pneumothorax is small and the patient is doing well, it is usually not necessary to evacuate it with a thoracentesis or a tube thoracostomy. If no deterioration is noted during an observation period in the emergency department (that meets with the comfort level of the physician and family), it may not be necessary to hospitalize the patient (especially with teenagers) with a small pneumothorax, if follow-up is reliable and the family lives near a medical facility. Elective consultation with a surgeon may be beneficial if a tube thoracostomy is anticipated.
References
Templeton JM. Thoracic Emergencies. In: Fleisher GR, Ludwig S (eds). Textbook of Pediatric Emergency Medicine, third edition. Baltimore, MD, Williams and Wilkins, 1993, pp. 1348-1349.