SESSION TYPE: Pleural Cases II
PRESENTED ON: Wednesday, October 24, 2012 at 11:15 AM - 12:30 PM
INTRODUCTION: Spontaneous pneumothorax is the presence of air in the pleural space as a result of a rupture of the lung parenchyma and visceral pleura with no demonstrable cause. Primary pneumothorax most often occurs in younger individuals (in their 20’s) at rest with no precipitating events while Secondary occurs as a complication of underlying lung disease. We present a case of a patient who presents with simultaneous spontaneous bilateral pneumothoraces; a relatively rare occurrence.
CASE PRESENTATION: A 58 year-old male with past medical history of mild mental retardation, alcohol abuse, and a 92 pack year history who reported sudden onset of shortness of breath with cough while eating pizza, that subsequently resolved on its own. The following morning, he reported that the shortness of breath returned and that it became progressively worse. The gentleman also reports that he had been experiencing dry cough for approximately 3-4 days, but that he had no chest pain, fevers, chills, sick contacts, or similar experiences in the past. In the emergency department, he was found to have an oxygen saturation of 92% on room air, heart rate of 82, blood pressure of 163/98, respiratory rate of 30, and was afebrile. On physical exam, he was noted to have bilateral scattered expiratory wheezing. Chest x-ray demonstrated bilateral pneumothoraces. CT scan provided additional information including the existence of bilateral blebs. Bilateral thoracostomies were performed with significant resolution, however pneumothoraces persisted. Bilateral video-assisted thorascopic surgery with apical bleb resections as well as bilateral talc pleurodesis was performed. Despite resolution of the right pneumothorax, the left pneumothorax persisted necessitating left thoracotomy with formal lung decortication, as well as parietal pleurectomy.
DISCUSSION: Bilateral spontaneous pneumothoraces is a rare occurrence, with potentially more complications in those with secondary pneumothoraces because of likely diminished pulmonary reserve due to underlying lung disease. The likelihood that our patient had pre-existing apical blebs with some degree of rupture secondary to coughing/possible aspiration with development of bilateral pneumothoraces is fairly high. Treatment involves placement of bilateral chest tubes for large pneumothoraces, and possibly mechanical ventilation with subsequent VATS. Prevention includes VATS with stapling of blebs and pleural abrasion. Chemical pleurodesis via chest tube can be done for poor operative candidates.
CONCLUSIONS: Simultaneous bilateral spontaneous pneumothorax is a rare cause of respiratory distress which needs prompt diagnosis and management to prevent high mortality.
1) Graf-Deuel E, Knoblauch A; Simultaneous bilateral spontaneous pneumothorax. Chest. 1994 Apr;105(4):1142-6
DISCLOSURE: The following authors have nothing to disclose: Muhammad Ali, Jacob Mathew, Aasiya Haroon, Nader Mahmood, M Anees Khan
No Product/Research Disclosure InformationSt. Josephs's Regional Medical Center/Seton Hall Universtiy, Paterson, NJ