Friday, November 27, 2009

A Case of Sudden onset of breathlessness

" Aduh...sakitnya dada..." keluh Abdullah. Tangannya mengusap-usap dadanya.

" Kenapa ni Dollah?" Rosli mula risau..kellihatan Abdullah berada dalam kesakitan yang amat. Dahinya berkerut dan nafasnya makin susah..

Tanpa melengahkan masa lagi..dia segera di bawa ke kecemasan...

Dr Ira was working at the A&E at the time...

The case: Abdullah, 39 year old malay gentleman, who has no known medical illness, but was a heavy smoker had presented to the emergency department with sudden onset of chest pain and shortness of breath...

o/e not breathless at the moment, diminished breathsounds and hyperresonant note on the right lower side of the chest

provisional diagnosis;
How would you investigate this patient?


provisional diagnosis;pneumothorax

Chest X RAy
Blood gases

A pneumothorax refers to a collection of gas in the pleural space resulting in collapse of the lung on the affected side.

What are the causes of pneumothorax
Primary spontaneous pneumothorax
    • Spontaneous pneumothorax is heavily associated with smoking, with 80-90% of primary spontaneous pneumothorax cases occurring in smokers.
    • Physical height: It has been noted that typical patients tend to have a tall and thin body habitus. Whether height affects development of subpleural blebs or whether more negative apical pleural pressures cause preexisting blebs to rupture is unclear.
    • Valsalva results in increased intrathoracic pressure. However, contrary to popular belief, most spontaneous pneumothoraces occur while the patient is at rest.
    • Changes in atmospheric pressure, proximity to loud music, and low frequency noises have also been reported to be associated with pneumothorax
    • Familial associations have been noted in more than 10% of patients. Some are due to rare connective tissue diseases, but recently, mutations in the gene encoding folliculin (FLCN) have been described. These patients may represent an incomplete penetrance of a genetic disorder. Birt-Hogg-Dube syndrome is characterized by benign skin growths, pulmonary cysts, and renal cancers and is caused by mutations in the FLCN gene.
  • Secondary spontaneous pneumothorax
  • Iatrogenic pneumothorax
    • Transthoracic needle aspiration procedures (most common cause, accounting for 32-37% of cases)
    • Subclavian and supraclavicular needle sticks
    • Thoracentesis
    • Mechanical ventilation (directly related to peak airway pressures)
    • Pleural biopsy
    • Transbronchial lung biopsy
    • Cardiopulmonary resuscitation (Consider the possibility of a pneumothorax if ventilation becomes progressively more difficult.)
    • Tracheostomy
  • Pneumomediastinum
    • Acute production of high intrathoracic pressures (often as a result of inhalational drug use)
    • Smoking marijuana
    • Inhalation of cocaine
    • Asthma
    • Athletic competition
    • Respiratory tract infection
    • Parturition
    • Emesis
    • Severe cough
    • Mechanical ventilation
    • Trauma or surgical disruption of the oropharyngeal, esophageal, or respiratory mucosa

Radiological findings
 Object name is ocona239210.f3a.jpg

 Object name is ocona239210.f3b.jpg

Fig 3
(left) Loculated left sided pneumothorax in a patient with severe chronic obstructive airways disease. Placement of chest drain into fifth intercostal space (arrow) might have entered lung parenchyma and would most likely not have achieved complete drainage of this loculated collection. (right) Percutaneous pigtail catheters (arrows) placed in apical and basal components of pneumothorax under fluoroscopic guidance. After several days of drainage the lung re-expanded completely
BMJ. 2005 June 25; 330(7506): 1493–1497.
doi: 10.1136/bmj.330.7506.1493.

A true pneumothorax line. Note that the visceral pleural line is observed clearly, with the absence of vascular marking beyond the pleural line.



Emergency Department Care

Immediate attention to the ABCs while assessing vital signs and oxygen saturation is paramount. ED care depends on the hemodynamic stability of the patient. All patients should receive supplemental oxygen to increase oxygen saturation and to enhance the reabsorption of free air. Treatments for primary and secondary spontaneous pneumothorax are the following:

  • Primary spontaneous pneumothorax
    • If the pneumothorax is smaller than 15% (or estimated as small, see Imaging Studies) and the patient is symptomatic but hemodynamically stable, needle aspiration is the treatment of choice.
    • If the pneumothorax is smaller than 15% and if the patient is asymptomatic, many consider observation to be the treatment of choice. (If the patient is admitted, administer oxygen, since this has been shown to speed resolution of the pneumothorax.)
    • If the pneumothorax is greater than 15% (or estimated as large, see Imaging Studies), aspiration using a pigtail catheter left to low suction or water seal is recommended.
  • Secondary spontaneous pneumothorax
    • Tube thoracostomy is the procedure of choice.
    • Pleurodesis decreases the risk of recurrence, as does thoracotomy or video-assisted thoracoscopy to excise the bullae.
  • Iatrogenic pneumothorax: Aspiration is the technique of choice for iatrogenic pneumothoraces because recurrence usually is not a factor. Tube thoracostomy is reserved for very symptomatic patients.
  • Most patients with pneumomediastinum should be admitted and observed for signs of serious complications (eg, pneumothorax, tension pneumothorax, mediastinitis). If the pneumomediastinum occurred from the inhalation of cocaine or smoking of marijuana, observation in the ED for progression may be indicated.


No comments: