When Pneumothoraces Become Cyclic

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Author: Kaila Pomeranz, OMSIV
Midwestern University, Arizona College of Osteopathic Medicine

This post was peer reviewed.
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A 34-year-old Caucasian female presents to the emergency department with acute onset breathing difficulty and right-sided, stabbing chest pain. Physical exam reveals decreased breath sounds over the right hemithorax and chest x-ray confirms a right pneumothorax. This is her third occurrence of right-sided pneumothoraces.

What can be considered a cause of recurrent pneumothoraces?
Upon further questioning, the patient’s past medical history consists of clinically diagnosed endometriosis treated with NSAIDs. She has no history of asthma, COPD, chest injury, or history of smoking. The patient has no history of Marfan’s syndrome, which may increase the risk of pneumothoraces due to apical blebs or bullae.

The Case of the Buffalo Chest

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Author: Jeffrey Chen, MSIII
UCSF School of Medicine

Case:
A 73-year-old man with a history of severe multi-vessel CAD status post CABG surgery 9 weeks ago presents after a high-speed motor vehicle collision with worsening SOB and chest pain. On exam, he is in acute distress, with a pulse of 102, blood pressure of 129/64, respiratory rate of 28, and saturating at 91% on 100% Oxygen NRB. The left chest has decreased breath sounds and is hyperresonant to percussion. Trachea is midline. A rapid chest X-ray shows a fractured left 7th rib and a corresponding large pneumothorax on the left with no evidence of tension. A chest tube is placed without any complications and connected to suction; his oxygen saturation improves to 98%, and his other vitals stabilize. A repeat CXR confirms successful placement of the tube, mild reinflation of the left lung, and a small pneumothorax on the right side that was not noted on the previous X-ray.

Diagnosis and Management:
In this gentleman who suffered a blunt traumatic pneumothorax on the left, there are a few possibilities to explain why he subsequently developed a pneumothorax on the right. First is a small traumatic pneumothorax that was already there on the right that was not visualized on the first film. Next is mediastinal damage during the placement of the left-sided chest tube, though there were no complications described in this case.