Primary Spontaneous Pneumothorax

Abstract

A 22 yo non-smoking patient with no prior medical history was brought into the ER for increasing left chest pain and dyspneea, which suddenly began as a slight discomfort approx. 12h before, in the absence of any form of trauma.On admission, blood tests were within range, SpO2 with oxygen was 92% and decreased breath sounds on auscultation of the upper half of the left hemithorax.The initial chest x-ray revealed a large left pneumothorax, slight contralateral mediastinal shifting and slight verticalization of the left main bronchus (Shown – Left image: PA chest x-ray with arrows marking the visceral pleural margins).Due to the one-way valve characteristic of the pleural rupture site, theintrapleural pressure builds up with every expiration phase, reaching critical levels fairly quick.A classic trocar-style tube thoracostomy was performed under local anesthaesia, with immediate alleviation of both respiratory symptoms and accute thoracic pain. The tube was connected to an underwater seal drainage and was mantained for 5 days under negative-pressure to promote lung re-expansion.A subsequent Thoracic CT-scan revealed complete reexpansion of the left lung with no evidence of bullae or blebs (Shown-Right image: MPR 17.1mm MIP - thoracostomy tube in situ).The patient was discharged after 6 days, with no recurrence at 5 months.The most frequent cause of a primary spontaneous pneumothorax is the rupture of small and often undetectable subpleural blebs, usually seen in young, tall and thin healthy males1.