Respiratory · Year 1 · from Respiratory
Case 1: Spontaneous Pneumothorax
Clinical Image
Source: Wikimedia Commons - Pneumothorax - Public Domain
Case Presentation
A 22-year-old tall, thin male presents to the emergency department with sudden onset of right-sided pleuritic chest pain and shortness of breath that began 2 hours ago while at rest. He has no significant past medical history and denies any trauma. He is a light smoker (5 cigarettes/day for 3 years). On examination, vital signs show heart rate 102 bpm, respiratory rate 22/min, blood pressure 118/72 mmHg, and oxygen saturation 94% on room air. Physical examination reveals decreased breath sounds over the right hemithorax with hyperresonance to percussion. The trachea is midline. Chest X-ray demonstrates a visible visceral pleural line on the right with absence of lung markings peripherally, consistent with a moderate right-sided pneumothorax. Given his symptoms and the size of the pneumothorax (approximately 2.5 cm from chest wall to visceral pleura at the level of the hilum), a small-bore chest tube is placed in the right fourth intercostal space at the anterior axillary line (within the "safe triangle"), avoiding the neurovascular bundle that runs along the inferior border of each rib. The tube is connected to an underwater seal, and repeat imaging shows lung re-expansion. He is monitored overnight and discharged the following day with instructions for follow-up.
Key Learning Points
- Primary spontaneous pneumothorax typically occurs in tall, thin young males due to rupture of apical subpleural blebs
- The pleural space is a potential space between the visceral and parietal pleura; air entry disrupts the negative intrapleural pressure that maintains lung inflation
- Chest tube insertion should be performed in the "safe triangle" (bounded by the lateral border of pectoralis major, lateral border of latissimus dorsi, and a horizontal line at the level of the nipple) with entry above the rib to avoid the intercostal neurovascular bundle
- The parietal pleura has somatic innervation and is pain-sensitive, explaining the pleuritic chest pain