ANSWER 73
The chest X-ray shows a large right pneumothorax. There is a suggestion of a bullous
lesion at the apex of the right lung. Pneumothoraces are usually visible on normal inspira-
tory films but an expiratory film may help when there is doubt. There is no mediastinal
displacement on examination or X-ray, movement of the mediastinum away from the side
of the pneumothorax would suggest a tension pneumothorax. Although she had symp-
toms initially, these have settled down as might be expected in a fit patient with no under-
lying lung disease. A rim of air greater than 2 cm around the lung on the X-ray indicates
at least a moderate pneumothorax because of the three-dimensional structure of the lung
within the thoracic cage represented on the two-dimensional X-ray.
The differential diagnosis of chest pain in a young woman includes pneumonia and pleurisy,
pulmonary embolism and musculoskeletal problems. However, the clinical signs and X-ray
leave no doubt about the diagnosis in this woman. Pneumothoraces are more common in
tall, thin men, in smokers and in those with underlying lung disease. Further investigations
such as computed tomography (CT) scan are not indicated unless there is a suggestion of
underlying lung disease.
There is a suggestion that she may have had a similar episode in the past but it may have
been on the left side. There is a tendency for recurrence of pneumothoraces, about 20 per
cent after one event and 50 per cent after two. Because of this, pleurodesis should be con-
sidered after two pneumothoraces or in professional divers or pilots.
The immediate management is to aspirate the pneumothorax through the second inter-
costal space anteriorly using a cannula of 16 French gauge or more, at least 3 cm long. Small
pneumothoraces with no symptoms and no underlying lung disease can be left to absorb
spontaneously but this is quite a slow process. Up to 2500 mL can be aspirated at one time,
stopping if it becomes difficult to aspirate or the patient coughs excessively. If the aspir-
ation is unsuccessful or the pneumothorax recurs immediately, intercostal drainage to an
underwater seal or valve may be indicated. Difficulties at this stage or a persistent air leak
may require thoracic surgical intervention. This is considered earlier than it used to be
since the adoption of less invasive video-assisted techniques. In this woman the apical
bulla was associated with a persistent leak and required surgical intervention through
video-assisted minimally invasive surgery.
Marijuana has been reported to be associated with bullous lung disease, and she should be
advised to avoid it. Tobacco smoking increases the risk of recurrence of pneumothorax.
- The patient should not be allowed to fly for at least 1 week after the pneumothorax has
resolved with full expansion of the lung (2 weeks after a traumatic pneumothorax). - The risk of recurrence will be reduced by stopping smoking.