James is a 1.93 m tall basketball player who is 22 years old and very fit. He has previously been in excellent health. After a game, he suddenly develops a severe, sharp stabbing pain in his upper right chest and pectoral regions, and begins to feel out of breath; both his heart and respiratory rates increase dramatically. His coach immediately takes him to hospital. James tells you that he suffered no major collisions or injuries during the game, and on examination you find no bruising. You suspect a primary spontaneous pneumothorax (PSP).
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1. What brings you to suspect PSP?
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Correct answer:
Primary spontaneous pneumothorax (PSP) is the most common form of pneumothorax, and is most usually observed in otherwise healthy young men, particularly those over 1.9 m in height. Your suspicion is aroused because James falls into such a category, and, in particular, by the sudden onset of sharp pleuritic pain and breathlessness.
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2. How do you confirm your diagnosis?
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Correct answer:
Diagnosis is confirmed by X-ray. Unless the pneumothorax is large, other clinical signs such as a hyperresonant chest may be difficult to detect.
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3. What causes PSP, and is it likely to happen to James again?
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Correct answer:
PSP occurs when an apical bleb on the surface of the lung ruptures, commonly in the upper lobes. This allows air from the airways to enter the space between the visceral and parietal pleura, causing partial or complete collapse of the lung. The pleural space is normally regarded as a ‘potential’ space, because it is usually filled with a thin layer of fluid that provides traction between the chest wall and lungs, so that the elastic recoil of the lungs is balanced by the outward recoil of the chest wall. The pleural pressure is therefore normally negative with respect to that in the airways and atmosphere (Chapter 3). The likelihood of developing PSP is more than 20 times greater in people taller than 1.9 m. The risk increases sharply (>60%) after a second episode.
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4. What treatment would you prescribe?
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Correct answer:
James is lucky in that in his case the PSP is less than 30% of lung volume. This should naturally resolve, so you prescribe analgesics for the pain and rest, and tell him to come back and see you over the next few weeks for serial chest X-rays to confirm resolution. If the PSP was more than 30% (moderate), the pneumothorax would be aspirated, and the patient prescribed oxygen and admitted overnight, with an X-ray in the morning to confirm lung re-expansion. Complete lung collapse would require a chest drain (Chapter 35).
If James were to suffer repeated PSP, consideration would have to be given to pleurodesis, where the visceral and parietal pleura fuse as a result of either insertion of bleomycin or talc into the pleural space, or surgical abrasion of the pleura.
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5. You advise him neither to play another game for at least some months nor to climb Mount Kilimanjaro, which he had intended to do for charity. Why?
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Correct answer:
Both the high exertion of a basketball game and the reduced barometric pressure and hence PO2 at the summit of Mount Kilimanjaro would strongly stimulate breathing. This would lead to much more negative pressures in the intrapleural space, which could substantially increase the risk of another PSP.
