A 30 year old, previously well male patient was admitted to the casualty ward with sudden onset of left side chest pain. The pain was severe in the beginning. On admission the patient was complaining of pleuritic type of chest pain. On examination, his respiratory rate was 18 breaths per minute, and saturation was 100% without oxygen. His vocal fremitus and air entry was reduced on left side of the chest. His heart sounds were difficult to auscultate too. The clinical diagnosis of pneumothorax was made and an emergency chest x ray was taken. The chest x ray showed a left sided pneumothorax. The patient was immediately referred to the chest physician who put an intercostal tube to the left side of the chest to take out the air.
Pneumothorax
Air in the pleural space is called pneumothorax. Air can accumulate within the pleural space as a result of injury to the chest wall or as a result of injury to the lungs.
Spontaneous pneumothorax
Spontaneous pneumothorax is commonly seen among young, tall and thin men. This is mainly due to a rupture of a pleural bleb. The male to female ratio of spontaneous pneumothorax is 6:1.
Pneumothorax in a diseased lung
Pneumothorax is common among people with an already diseased lung. Patients with COPD, asthma, carcinoma of the lung, bronchopulmonary fistula etc are at a higher risk of developing pneumothorax. Pneumothorax in such patients should be taken seriously regardless of the size.
The following x ray shows a right sided small pneumothorax in a COPD lung. This lung also shows a band of bronchiectasis in the right upper zone.
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| Right sided pneumothorax in a COPD lung |
Tension Pneumothorax
Sometimes a valve mechanism develops which allows air to fill in the plueral space during inspiration and prevents air from getting out of pleural space during expiration. As a result, each time the patient breaths, the air accumulates within the pleural space and the pressure gradually increases causing the mediustinum to shift to the other side. The patient gradually becomes breathless and tachycardic and can even die unless the pressure is not relieved immediately. This is an emergency and requires immediate aspiration of the air.
Aspiration of pneumothorax
Aspiration of a pneumothorax is performed by first taking informed consent from the patient. Then 2% lidocaine is injected in to the pleural space. Then 3-4 cm of 16 french guage needle is inserted in to the pleural space in the second intercostal space midclavicular line. The cannula is connected to a three way tap and 50 cc syringe. Upto 2.5 liters of air can be aspirated through the syringe.
