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Old 06-06-2012
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Default 3 cm secondary Pneumothorax...wat next?

A 27-year-old woman with a history of cystic fibrosis and a long-standing productive cough and multiple prior exacerbations of dyspnea is evaluated in the emergency department for the acute onset of shortness of breath and left-sided pleuritic chest pain. She has had no fever.

On physical examination, she is in moderate distress. Her temperature is 36.9 C (98.4 F), blood pressure is 132/66 mm Hg, heart rate is 126/min, and respiration rate is 24/min. Oxygen saturation is 93% with the patient receiving oxygen, 2 L/min, by nasal cannula. Auscultation of the chest shows absent air movement throughout the left chest and crackles on the right side.

Chest radiograph shows a left-sided pneumothorax that is 3 cm from the lung margin to the chest wall (>50% size) with no mediastinal shift or diaphragmatic depression.

Which of the following is the most appropriate next step in this patient's management?

A Intubation and mechanical ventilation
B Needle aspiration of the pneumothorax
C 100% oxygen and observation
D Tube thoracostomy
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Old 06-06-2012
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needle aspiration
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D Tube thoracostomy as it is most likely to expand/recur after needle aspiration
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D..tube thoracostomy because she is not in sever distress. If she BP was compromised, it would have been more urgent and the answer would have been needle insertion before chest tube.
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Originally Posted by usmledee View Post
D..tube thoracostomy because she is not in sever distress. If she BP was compromised, it would have been more urgent and the answer would have been needle insertion before chest tube.
This pneumothorax is not acute. You are confusing it with tension pneumothorax where there is a mediastinal shift etc.
In this patient it is secondary to a ruptured bullae due to chronic lung disease. Usually, you can treat a small secondary pneumothorax conservatively as the air gets absorbed. However in this case it is 3 cm from the margin, therefore, it is going to take a very long time for it to be absorbed. Her lung functions are already compromised so she needs every bit of the lung (function) made available to her. Moreover, it is quite possible that the pneumothorax may actually increase.
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Old 06-07-2012
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qbank expln...

This patient has a symptomatic pneumothorax and requires immediate chest tube placement (tube thoracostomy). Approximately 16% to 20% of adult patients with cystic fibrosis have an episode of pneumothorax at some time in their lives.
Secondary spontaneous pneumothorax (due to underlying lung disease) is more serious than primary spontaneous pneumothorax (no underlying lung disease) because pulmonary function is already compromised and secondary spontaneous pneumothorax can be life threatening.

Rapid chest tube placement is needed to quickly alleviate the patient's symptoms and manage the pneumothorax.

Needle aspiration in patients with a secondary pneumothorax is less likely to be successful than in patients with a primary spontaneous pneumothorax.

The size of the pneumothorax and the patient's presentation (significant shortness of breath and severe underlying lung disease) suggest that aspiration alone would not be adequate initial treatment.

Needle aspiration should be reserved for patients with minimal dyspnea who are under the age of 50 years and have small pneumothoraces (<2 cm from the lung margin to the chest wall)

Observation will result in absorption of a pneumothorax at the rate of 1.25% per day. Therefore, a 50% pneumothorax will take about 40 days to absorb, assuming there is no continued air leak. While administration of oxygen is an important adjunctive therapy and will increase the rate of absorption of the pneumothorax six-fold, this option is not adequate as initial therapy for a pneumothorax of this size, particularly in a patient with acute-onset shortness of breath and significant underlying lung disease. Intubation and mechanical ventilation are likely to worsen the patient's pneumothorax if there is a continued air leak to the pleural space, potentially resulting in tension pneumothorax.
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