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Case 8: Acute shortness of breath

This 24 year old man presented with sudden onset pleuritic right scapular region pain and shortness of breath. A chest xray was obtained and prompted the emergency department to perform a procedure.

1. What does the xray show?

The xray shows a right sided pneumothorax without evidence of tension (complete collapse, medisatinal shift, flattening of th dome of the diaphragm). A pigtail catheter has bben inserted however there is incomplete re-expansion of the lung.

2. How would you manage the problem in the emergency department?

The management of a symptomatic spontaneous simple pneumothorax is insertion of an intercostal catheter with connection to an underwater seal drain (UWSD). These drain chambers include the ability to apply regulated suction to the pleural cavity. Many surgeons would apply 20 cm water suction initially which can then be ceased 24 hours after re-expansion of the lung with daily chest xrays to confirm the abscence of recurrent collapse.

3. He returns 6 months later with the same problem. How would your management differ now?

Spontaneous pneumothorax typically occurs in thin fit young adults with a male preponderence. They also occur in patients with underlying chronic lung diseases in particular bullous emphysema and asthma.

Recurrence in a young man would be considered an indication for pleurodesis. VATS (video assited thoracoscopic surgery) pleurodesis is performed under general anaesthesia with double lumen intubation. Inspection of the apex of each lobe may reveal a congenital bulla which should be excluded from the bronchial tree by excision using and endoscopic stapler or simple endoloop application. The pleurodesis is then effected by abrasion and application of an irritant such as alcoholic iodine. two intercostal catheters are then left attached to the UWSD with suction.

Powerpoint Presentation - Dr Tom Forbes
Pleural Effusion Teaching Case
Pleural Effusion Case Presentation