Chest Disease Reports 2017; volume 5:6276

Case Report
Management of pneumothorax
Correspondence: Amit Panjwani, Salmaniya
Case #1 Medical Complex, Manama, Bahrain.
with oxygen therapy: a case
E-mail: [email protected]
series A 19-year-old male, non-smoker, pre-
sented with sudden onset left sided chest Key words: Pneumothorax, Spontaneous,
Amit Panjwani pain and dyspnea MRC 3. There was no Traumatic, Iatrogenic, Oxygen therapy.
Salmaniya Medical Complex, Manama, fever, wheeze, hemoptysis or cough. Patient
Bahrain denied any history of palpitations, syncope Received for publication: 7 September 2016.
or swelling of the limbs. These symptoms Revision received: 24 May 2017.
reduced in intensity over the next few days. Accepted for publication: 25 May 2017.
He decided to visit a general practioner
This work is licensed under a Creative
Abstract (GP) for persistence of symptoms. He was Commons Attribution NonCommercial 4.0
evaluated by the GP and referred to emer- License (CC BY-NC 4.0).
Pneumothorax is relatively common
gency department of our hospital. On eval-
condition affecting individuals of all ages.
uation, the chest pain and dyspnea had sig- ©Copyright A. Panjwani, 2017
Goals of treatment of pneumothorax are nificantly reduced in intensity, he was Licensee PAGEPress, Italy
removal of air from the pleural cavity and afebrile, pulse-82/min, respiratory rate (RR) Chest Disease Reports 2017; 5:6276
prevent its recurrence. The different strate- -20/min, SpO2-98% on room air and blood doi:10.4081/cdr.2017.6276
gies available at the disposal of the treating pressure (BP)-110/70 mm Hg. He was of
physician include observation, supplemen- average built and height. General and sys-
tal oxygen administration, needle aspira- temic examination was unremarkable
ograph (Figure 3) showed a right sided
tion, insertion of small bore chest drains and except for reduced breath sounds heard in
pneumothorax with no mediastinal shift.

ly
last but definitely not the least, surgery in the entire left hemithorax. Chest radiograph
The size of the pneumothorax estimated by
recurrent cases. Oxygen therapy is useful in (Figure 1) showed a left sided pneumotho-

on
the Rhea method was found to be 26% of
the treatment of all types of pneumothorax rax. The size of the pneumothorax estimat-
the pleural cavity. The computed tomogra-
where it is found to be safe, effective and ed by the Rhea method4 was found to be
phy (CT) of the chest revealed undisplaced
associated with reduced length of hospital 22% of the pleural cavity. He was admitted

e
fractures involving posterior right 6th, 7th, 8th
stay. Four cases of pneumothoraces are pre- in the hospital and complete blood counts
us and 9th ribs. Moderate right sided pneu-
sented here which were successfully man- with biochemical profile were found to be
mothorax and minimal pneumomedi-
aged with supplemental oxygen administra- normal. Patient was managed with oxygen
astinum was also seen (Figure 4). CT scan
tion only. administration and close monitoring for any
of the brain and cervical spine was found to
al
signs of worsening of pneumothorax.
be normal. Arterial blood gas analysis and
Oxygen was administered through the sim-
ci

electrocardiogram was normal. He was

ple face mask with the oxygen flow of
Introduction 10L/minute. The mask was worn continu- immediately initiated on parenteral anal-
er

Pneumothorax is the presence of air or ously, except during the meal times and vis- gesics and supplemental oxygen therapy.
gas between the parietal and visceral pleural iting times. He showed a gradual clinical He was offered insertion of the intercostal
m

surfaces. It may present with minimal and radiological improvement. The com- tube drainage for the treatment of pneu-
mothorax, which the patient refused. The
m

symptoms like mild chest pain and dyspnea, plete re-expansion of left lung was seen in 3
days (Figure 2) and the patient was dis- patient was closely monitored for signs of
which may go unnoticed by the patient for a
tension pneumothorax. Oxygen was admin-
co

few days, on one hand and life threatening charged from the hospital.
istered through the mask with the flow of
cardiorespiratory collapse requiring imme-
Case #2 10L/min. He gradually improved and over a
diate intervention, on the other. The treat-
period of 4 days there was a complete lung
on

ment of pneumothorax depends on the A 23-year-old male, non smoker, no his-

tory of addictions, had a fall from his re-expansion (Figure 5).
degree of cardiorespiratory impairment,
motorcycle in the early hours of the morn-
N

severity of symptoms and size of the pneu-

ing. He was immediately shifted to the Case #3
mothorax. Treatment strategies include
emergency department of our hospital. The A 61-year-old male, non-smoker, had
observation, oxygen therapy, needle aspira-
patient complained of severe right sided undergone an open nephrectomy under gen-
tion or intercostal chest tube (ICT) inser- eral anaesthesia as a donor for renal trans-
chest pain and dyspnea MRC 4. There was
tion.1 Oxygen therapy is useful in the treat- plantation. He developed low grade fever
no cough, hemoptysis, fever or noisy
ment of traumatic2 and spontaneous pneu- and cough with purulent expectoration on
breathing. There was no major injury to any
mothorax3 where it is found to be safe, effi- 3rd post-operative day. He had no chest pain,
other part of the body. On examination, he
cacious and associated with reduced length dyspnea, wheeze or hemoptysis. He had no
was an obese individual who was afebrile,
of hospital stay. Hospitalised cases of pneu- pulse-85/min, RR-24/min, SpO2-96% on significant co-morbidities. On examination,
mothorax who are not subjected to needle room air and BP-120/80 mm Hg. He was temperature-100°F, pulse-110/min, RR-
aspiration and ICT drainage, due to any rea- conscious, oriented to time, place and per- 20/min, BP-130/80 mm Hg and SpO2-97%
son, may be managed with supplemental son. Respiratory examination revealed ten- on room air. There were reduced breath
oxygen therapy administered at high con- derness over right side of the chest and sounds in right susprascapular area with no
centrations. Four cases of pneumothorax reduced breath sounds in right infraclavicu- other abnormalities seen on systemic exam-
that were successfully managed with oxy- lar and mammary areas. Otherwise the sys- ination. The complete blood counts and bio-
gen therapy are presented here. temic examination was unremarkable. chemical profile were unremarkable. Chest
Complete blood counts with biochemical radiograph showed a loculated right apical
profile were found to be normal. Chest radi- pneumothorax with collapse of the right

[page 6] [Chest Disease Reports 2017; 5:6276]

 Case Report

upper lobe. He was managed with parenter- arrive at the conclusion.6 Other methods to
al antibiotics, mucolytics, chest physiother- estimate the size of pneumothorax includes
apy and supplemental oxygen administra- the Rhea method4 and the Collins method7
tion with a flow of 10L/min delivered which utilize a nomogram based on the
through the simple face mask. He showed a average of the interpleural distances meas-
remarkable improvement with a complete ured at the apex, midpoint of the upper part
right lung re-expansion seen over the next of the lung and midpoint of the lower half of
two days. the lung on an erect chest radiograph. Both
these methods are good for estimating the
Case #4 size of small pneumothoraces however,
A 31-year-old lady, non smoker, pre- Collins scores over the Rhea method in
sented to the out-patient department of our accurately estimating the size of larger
hospital with exertional dyspnea since 1 pneumothorax.8 Alternatively, an easier way
month and central non radiating chest pain to differentiate between a large and small
since 1 week. On evaluation she was found pneumothorax is the presence of a visible
to have an anterior mediastinal mass for rim of air more than 2 cm. between the lung
which she was subjected to a CT-guided margin and chest wall at the level of the
hilum.9
Figure 3. At the time of admission. Chest
needle biopsy. Post-procedure check CT of
radiograph showing a right sided pneu-
the thorax showed a minimal pneumothorax Supplemental oxygen is recommended
mothorax.

on right side. Patient had no increase in the as a treatment option in all types of pneu-
intensity of symptoms. She was admitted in mothoraces.2,9 The rate of re-absorption of
air in the pneumothorax is 1.25-1.8% of the
the hospital for observation. On examina-

ly
tion, she was afebrile, pulse-82/min, RR-
20/min, SpO2-98% on room air and BP-

on
110/70 mm Hg. General and systemic
examination was normal. She was treated
with supplemental oxygen administration

e
delivered through a simple face mask with a
flow of 10 L/min. There was a complete
resolution of the pneumothorax noted by
us
the next day and discharged from the hospi-
al
tal.
ci
er

Discussion
m

Pneumothorax is a relatively common

clinical condition which affects individuals
m

Figure 4. Computed tomography volumet-

of all ages. It may be classified as primary,
ric rendering technique-shaded surface
co

secondary, iatrogenic or traumatic, based on

display showing undisplaced fractures

the underlying cause.1 In the present case

Figure 1. At the time of admission. Chest involving posterior right 6th, 7th, 8th and 9th
ribs.
series, there were two cases of iatrogenic
radiograph shows a left sided pneumotho-
rax with a central mediastinum.
on

pneumothorax and one each of traumatic

and primary spontaneous pneumothorax.
Treatment goals of pneumothorax are
N

removal of air from the pleural cavity and

prevent its recurrence.5 The different strate-
gies available at the disposal of the treating
physician are dependent on the clinical
presentation of the patient. Active interven-
tion is recommended in patient presenting
with significant breathlessness associated
with any size of the pneumothorax. Needle
aspiration and small bore ICT are the usual
options in these situations. Patients with
small pneumothorax (usually less than 15%
of the hemithorax) or those with large ones
with minimal symptoms can be managed
with observation and administration of sup-
plemental oxygen. Estimating the size of
pneumothorax is traditionally done with
help of Light’s Index which utilizes the
Figure 2. Day 3 after admission. Follow up Figure 5. Day 4 after admission. Chest

diameters of the lung and the hemithorax to

chest radiograph showing a complete re- radiograph showing a complete resolution
expansion of the left lung. of pneumothorax on right side.

[Chest Disease Reports 2017; 5:6276] [page 7]

Case Report

volume of hemithorax every 24 hours. mental oygen use was not associated with a
There is a four-fold increase in this rate of faster resolution of spontaneous pneumoth- Conclusions
re-absorption of air with the administration orax.18,19 Occasionally we may encounter The successful outcome of treatment
of supplemental oxygen.10 In pneumotho- asymptomatic patients with pneumothorax with supplemental oxygen administration in
rax, the gases move in and out of the pleural of large size refusing placement of ICT and four cases of pneumothorax of different eti-
space from the capillaries in the visceral surgery. These patients cannot be sent home ologies has been presented here. Oxygen is
and parietal pleura. The movement of each without treatment. They need to be a safe, effective and easily available treat-
gas depends upon the gradient between its observed in the hospital for worsening of ment modality which does not require any
partial pressure in the capillaries and the pneumothorax. During the observation peri- expertise in its use. It may be helpful in all
pleural space, amount of blood flow and the od, these patients may be subjected to oxy- types of pneumothorax of small size (less
solubility of each gas in the surrounding tis- gen administration and it has been found to than 30%) and does not have any serious
sue.11 The partial pressure of all gases, on be useful in most of the situations. Oxygen complications associated with its use. It
room air, in the capillaries of the pleural administration as a sole treatment modality should be used with caution in patients hav-
space is around 706 mm Hg. Administration is used more often in patients with primary ing a pre-existing chronic lung disease with
of 100% oxygen causes denitrogenation of spontaneous pneumothorax when compared respiratory failure where its administration
blood. The PN2 in the blood in the pleural to secondary pneumothorax.20 Care should may worsen the hypercapnea.
capillaries approaches zero while the PO2 in be taken during oxygen administration to
fully oxygenated blood is about 100 mm patients with COPD and pneumothorax, as
Hg, the total gas pressure in the blood there- they may have worsening of carbon dioxide
fore becomes significantly less than that in levels.
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[Chest Disease Reports 2017; 5:6276] [page 9]