Xray Vision: Chest Pain Answer

6-15 xray palat

Check out the original post here: Xray Vision: Chest Pain

Congratulations Dr. Grundmann! This patient has a primary spontaneous pneumothorax.

Classification

-size of pneumothorax can be calculated from various formulas such as the Light Index but it has not shown to be accurate

-per American College of Chest Physicians, a small pneumothorax is ≤3 cm from the thoracic apex to lung cupola

-per British Thoracic Society, small is considered to be <2cm from thoracic apex to lung cupola

Criteria for Stable Patient with Pneumothorax

Respiratory rate <24 breaths/min
No dyspnea at rest, speaks in full sentences
Pulse >60 and <120 beats/min
Normal blood pressure for patient
Oxygen saturation >90% on room air
Absence of hemothorax

Adapted from Henry M, Arnold T, Harvey J, et al: BTS guidelines for the management of spontaneous pneumothorax. Thorax 58: ii39, 2003; and Currie GP, Allrui R, Christie GL, Legge JS: Pneumothorax: an update. Postgrad Med J 83: 461, 2007.

Management

-depends more on clinical status than size of pneumothorax

-oxygen 3-10L helps increase resorption by 3-4 folds

Treatment of Pneumothorax

Condition Treatment Options
Small primary pneumothorax Observation for 6 h, discharge if no symptoms and return for check if symptoms reoccur or in 24 h

or

Small-size catheter aspiration with immediate catheter removal, then observe for 6 h, discharge if no symptoms and return for check if symptoms reoccur or in 24 h
or
Small-size catheter or small-size chest tube insertion, Heimlich valve or water-seal drainage, and admission
Small secondary pneumothorax Small-size catheter or small-size chest tube insertion, Heimlich valve or water-seal drainage, and admission
Large pneumothorax, either primary or secondary, or bilateral pneumothoraces Moderate-size chest tube and admission; large-size chest tube if fluid or hemothorax present; water-seal drainage and admission
Tension pneumothorax Immediate needle decompression followed by moderate or large-size chest tube insertion, water-seal drainage, and admission

References: Humphries RL, Young W, Jr.. Chapter 71. Spontaneous and Iatrogenic Pneumothorax. In: Tintinalli JE, Stapczynski J, Ma O, Cline DM, Cydulka RK, Meckler GD, T. eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 7eNew York, NY: McGraw-Hill; 2011.

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sliang

EM/IM Resident at Kings County/SUNY Downstate

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