Respiratory · Year 1 · from Respiratory
Case 3: Spontaneous Pneumothorax
Clinical Image
Source: Wikimedia Commons - Pneumothorax - CC BY-SA 3.0
Patient Presentation
A 22-year-old tall, thin man presents to the emergency department with sudden onset of right-sided chest pain and shortness of breath that began 2 hours ago while he was at rest watching television. The pain is sharp and pleuritic. He had a similar episode 1 year ago on the left side that resolved with observation. He smokes approximately half a pack of cigarettes daily.
Demographics
- Age: 22 years
- Sex: Male
- Past Medical History: Left-sided spontaneous pneumothorax 1 year ago (resolved with observation)
- Medications: None
- Social History: Smokes 0.5 PPD for 4 years, recreational marijuana use
- Physical characteristics: 193 cm tall, 68 kg (BMI 18.3)
Chief Complaint
Sudden right-sided chest pain and dyspnea
Physical Examination
- Blood pressure: 122/78 mmHg
- Heart rate: 102 bpm
- Respiratory rate: 22/min
- Oxygen saturation: 94% on room air
- General: Alert, mildly anxious, speaking in full sentences
- Respiratory:
- Decreased breath sounds right hemithorax
- Hyperresonance to percussion on right
- Decreased tactile fremitus on right
- Trachea midline
- Cardiovascular: Tachycardic, regular rhythm
Workup
- Chest X-ray (upright, inspiratory): Right pneumothorax with visible visceral pleural line, approximately 3 cm from chest wall at hilum level (large by BTS criteria)
- No mediastinal shift
- CT chest (obtained given recurrent pneumothorax): Multiple small apical blebs bilaterally, right pneumothorax confirmed
Diagnosis
Recurrent Primary Spontaneous Pneumothorax (Right side)
Treatment
- Immediate management: Supplemental oxygen (accelerates air resorption)
- Chest tube insertion (indicated for large pneumothorax + symptoms):
- Small-bore chest tube (14 Fr) connected to water seal
- Monitor for air leak and lung re-expansion
- Definitive intervention (indicated for recurrence):
- Video-assisted thoracoscopic surgery (VATS):
- Bleb resection (stapling of apical blebs)
- Mechanical pleurodesis (abrasion or partial pleurectomy)
- Consider bilateral procedure given bilateral blebs
- Smoking cessation counseling (smoking increases recurrence risk 20-fold)
- Discussion of activity restrictions (flying, diving) until resolved
Physiological Principles Demonstrated
- Primary spontaneous pneumothorax pathogenesis: Rupture of subpleural blebs (small air spaces) in young, tall, thin individuals - likely due to increased mechanical stress at lung apex where transpulmonary pressure is highest.
- Recurrence risk: 30% recurrence after first episode, 50% after second, 80% after third - justifying surgical intervention after second episode.
- Smoking effect: Cigarette smoke causes inflammation and destruction of small airways, promoting bleb formation; 20-fold increased risk.
- Supplemental oxygen rationale: Breathing 100% oxygen creates a large nitrogen gradient between blood and pleural space, accelerating air resorption by 4-fold.