CME INDIA Case Presentation by Dr. Vijay Arora, MD, Consultant physician, Max Super Speciality Hospital Patparganj, Delhi.

CME INDIA Case Study

How Presented?

  • 27 yr. old male presented with the H/o chest pain left side while in gym which subsided after rest 6 days ago.
  • He had similar symptoms on 09-02-23, for these symptoms went to nearby hospital, where ECG was done & reported normal & was sent back.
  • But in the evening had pain again and came in triage.
  • ECG was done again and reported normal.
  • He was asked to attend OPD, where on auscultation there were decreased breath sounds on left side, X-ray chest was done & was admitted thereafter.
  • Trop-T-Negative. Echo-Normal.

ECG one day before admission (Feb 11, 2023)

How The Bus Was Missed After Chest Pain in Gym & ECG Found Normal?

Repeat ECG on Feb 12, 2023 at admission

How The Bus Was Missed After Chest Pain in Gym & ECG Found Normal?

What does CXR show?

How The Bus Was Missed After Chest Pain in Gym & ECG Found Normal?

Later on, CT thorax was advised

  • It confirms moderate left Pneumothorax.

What happened later?

  • ICD was done.
  • Patient became asymptomatic.

Quick Take-Aways

(Dr. Vijay Arora)

All Patients going to gym with c/o chest pain should not be sent home if ECG is normal.
Proper auscultation might lead us to a definite diagnosis.
What is the primary cause leading to Spontaneous Pneumothorax must be ascertained.
Emphasis on clinical examination is warranted as at two places patient went & both places ECG was done and then patient was advised to go back home.

CME INDIA Discussion

Dr. Arjun Khanna, Pulmonologist, Delhi:

  • Young male with Left sided pneumothorax.
  • USG / CT chest should be done, O2 to be started and ICD to be placed.

Dr. Sudipta Mondal, Sreechitra Hospital, Thiruvananthapuram, Kerala:

  • Left pneumothorax.

Dr. S. K. Goenka, Physician, Begusarai:

  • True, Inspection, Palpation, Percussion and Auscultation will never be irrelevant. However, missed these days, due to many reasons.
  • This case gives a very good message to all clinicians.

Dr. S. K. Gupta, Senior Consultant, Physician, Delhi:

  • I had a similar tall thin young male around 26 years patient who developed spontaneous pneumothorax and recovered soon with ICT but developed pneumothorax again 2 days after the chest tube was removed.
  • ICT Had to be put in again two days later.

Dr. Arjun Khanna, Pulmonologist, Delhi:

  • Primary Spontaneous Pneumothorax-A quick review
1. Usually these patients would give a history of smoking, most would have started smoking recently.
2. They should be clinically screened for marfans. 2D echo would be helpful too.
3. At most international centres and good centres even in our country the best way out is VATS (video-assisted thoracoscopy surgery) guided bleb removal as recurrence rates are to the tune of 30 percent.
4. If VATS is not an option (which usually is not in our country) ICD insertion should be mandatorily followed by Pleurodesis.
5. Recurrence can be on same side or opposite side, depending on where the blebs are.
6. Almost 99 percent patients will be tall thin males.
7. UK / USA they would send smaller pneumos home with strict watch. In our country we don’t do that. All patients with pneumothorax, irrespective of SpO2 levels should be given O2, as it helps in early absorption of the air.
8. ICD insertion if delayed can lead to pleural reaction and thickening which can cause trouble and may lead to incomplete resolution for which decortication may be needed.

Dr. S. K. Gupta, Senior Consultant, Physician, Delhi:

  • Putting talc as pleurodesis agent is difficult and injectable tetracycline is available for veterinary use. Difficult situation. What others use.

Dr. Arjun Khanna, Pulmonologist Delhi:

  • Steritalc is easily available, slurry is prepared and instilled.
  • Betadine and doxycycline are other easy options.

Dr. S. K. Gupta, Senior Consultant, Physician, Delhi:

  • Tetracycline is in veterinary use. Once I used the same, it led to so severe pain that an anaesthetist had to called to manage the same.
  • Betadine no experience.

Dr. Arjun Khanna, Pulmonologist, Delhi:

  • 40ml betadine + 5ml 2percent xylocaine + 10ml NS.
  • Doxy tabs crushed (10mg /kg), so 6 tabs for a 60kg patient plus Xylocaine plus NS.
  • Pain post pleurodesis is usually a sign that pleurodesis is working. If it gets too much to handle, tramadol can be given. One should refrain from giving NSAIDS as they would stop the inflammation and make pleurodesis useless.

Dr. Vijay Arora, Phy Max hosp., Delhi:

  • Should we prefer Inj Doxycycline for the sake of avoiding any intergenic secondary infection on putting crushed doxycycline tab after mixing in NS & Xylocaine?

Dr. Arjun Khanna, Pulmonologist, Delhi:

  • There is no data with IV doxycycline. Animal studies with IV doxycycline where useless so only tabs are used.
  • IV doxycycline for pleurodesis is not approved.

Dr. D. P. Khaitan, Physician, Gaya:

I am only commenting on ECG findings. Top ECG demonstrates:

  • Limbs leads
  • A journey towards Low voltage
  • RT ventricular strain as evident by ST/T changes over inferior leads, most prominent in lead 111
  • No evidence of RVH
  • The diminution in R voltage over Left lateral leads, specially V5-6 with T flat / Just T inversion in V6

Please also compare with the bottom ECG/COMMENTS

  • If there is rt ventricular strain pattern on ECG with diminution of left lateral leads -V 5-6 +- ST/T alteration this should raise a strong suspicion of pashing the heart from left side from extracardiac cause specially in the absence of RVH criteria.
  •  Left lateral leads -R waves.

Dr. Vijay Arora, Phy Max hosp., Delhi:

  • Very correctly interpreted, these changes in 1st ECG were overlooked & Patient was sent home.
  • 2nd ECG on the day of admission didn’t have these changes.

Dr. S. N. Nagarajan, DM (Card) Tripur, TN:

  • What would be your advice to this patient, say after 3 months regarding exercise activity and chance of recurrence of pneumothorax on weight training program?

Dr. Arjun Khanna, Pulmonologist Delhi:

  • If he is alright, he can resume.
  • There is no evidence that exercise will cause pneumothorax.
  • Smoking is a known risk factor for the primary episode and also for recurrence.

Dr. S. N. Nagarajan, Tripur, TN:

  • Can he play, fly, scuba or play instruments like flute etc.

Dr. D. P. Khaitan, Gaya:

  • Yes, very rarely post exercise Spontaneous Pneumothorax is observed.

CME INDIA Learning Points

Primary spontaneous pneumothorax (PSP)

  • It is defined as the spontaneous occurrence of pneumothorax in patients without apparent underlying pulmonary disease.
  • Typically occurs:  In young, tall, thin, smokers. The precipitating factors may be atmospheric pressure changes.
  • Loud Sound Alert– A few cases have been found due to exposure to loud music.
  • PSP typically occurs at rest – It must be appreciated that avoiding exercise, therefore, should not be recommended to prevent recurrences.
  • No apparent underlying lung disease is present.
  • Most patients present with some abnormalities in the affected (and sometimes also at the contralateral) lung.
  • Subpleural blebs or bullae (emphysema-like changes, ELCs) are seen in most of the patients.
  • Air can enter after alveolar rupture with an air leak into the peribronchovascular interstitium and causing pneumomediastinum. It ultimately enters into the pleural space.
  • Presentation:
    • Almost all patients with PSP report a sudden ipsilateral chest pain, which usually spontaneously resolves within 24 h. Thus, chest pain is an important and reliable symptom that is present in 80 – 95% of cases.
    • Dyspnoea may be present but is usually mild.
    • Physical examination-It can be normal in small pneumothoraces.
    • In larger pneumothoraces-Breath sounds and tactile fremitus are typically decreased or absent. Percussion is hyper-resonant.
    • Rapidly evolving hypotension-Tachypnoea, Tachycardia and cyanosis, if present it should raise the suspicion of tension pneumothorax. (Extremely rare in PSP).
  • Confirm the Diagnosis:
    • It can be confirmed in the majority of cases on an upright posteroanterior chest radiograph.
    • In cases with a small PSP, CT Thorax may be necessary to diagnose the presence of pleural air.
    • Alert-It must be realised that a contralateral shift of the trachea and mediastinum is a completely normal phenomenon in spontaneous pneumothorax, and not at all suggestive for tension pneumothorax. If you come across this observation, it should in no way influence treatment strategies.
  • Management:
    • Most patients are treated with supplemental oxygen and removal of air from the pleural space, typically by chest tube thoracostomy.
    • It must be appropriated that initiation of 100% oxygen via a non-rebreather mask and continuous cardiopulmonary monitoring for patients with spontaneous pneumothorax is needed.
    • Oxygen increases the rate of absorption of the gas from the pleural space up to four-fold compared to the absorption of 1% to 2% of the volume per day without oxygen.
    • Clinically unstable patients with severe symptoms or symptoms suggestive of tension pneumothorax– It can be treated with emergent needle decompression as a bridge to tube thoracostomy placement.
    • For stable patients presenting with a small primary spontaneous pneumothorax for the first time-conservative management with supplemental oxygen and observation of at least 6 hours is recommended.
    • British Thoracic Society suggests that certain asymptomatic patients with large primary spontaneous pneumothorax may be considered for observation without active intervention.
    • The American College of Chest Physicians recommends aspiration for large or symptomatic primary spontaneous pneumothorax with a small-bore catheter (14F or smaller) or, if the initial aspiration fails, admission with a chest tube (16F to 22F).
    • Larger primary spontaneous pneumothorax can be further managed with video-assisted thoracoscopy surgery (VATS) or thoracotomy to perform bullectomy, pleurectomy, and mechanical pleurodesis (i.e., dry gauze abrasion).
    • VATS is less invasive than thoracotomy.
    • Patients with recurrent primary spontaneous pneumothorax – They should be admitted with thoracostomy tube placement as a bridge to VATS.
    • In patients that are unwilling to undergo VATS-These are poor surgical candidates-Chemical pleurodesis can be performed with the introduction of irritants such as tetracyclines (i.e., doxycycline, minocycline) or talc via the thoracostomy tube. (The inflammatory processes associated with chemical pleurodesis lead to the formation of pleural adhesions that effectively obliterate the pleural space.)

CME INDIA Tail Piece

How can Music do such a disaster?

The rupture of the interface between the alveolar space and pleural cavity in these patients may be linked to the mechanical effects of acute transpulmonary pressure differences caused by exposure to sound energy in association with some form of distal air trapping.
It has been speculated that repetitive pressure changes in the high energy-low frequency range of the sound exposures is more likely to be responsible. Do take history of exposure to loud music in patients with spontaneous pneumothorax.
Propagation of sound pressure waves through the respiratory system is a complex three-dimensional problem. It   is bound to result in pressure differences at the interface between media of different densities. (Air, alveolar surface water and tissue).
These pressure differences could tear the alveolar or ELC walls resulting in an air leak into the pleural space.

What are the causes of Secondary Pneumothorax?

Chronic obstructive pulmonary disease
Asthma
Cystic fibrosis
Pneumonia (e.g., necrotizing, Pneumocystis jirovecii)
Pulmonary abscess
Tuberculosis
Malignancy
Interstitial lung disease (e.g., idiopathic pulmonary fibrosis, sarcoidosis, lymphangioleiomyomatosis)
Connective tissue disease (e.g., Marfan syndrome, Ehlers-Danlos syndrome, rheumatoid arthritis)
Pulmonary infarct
Foreign body aspiration
Catamenial (i.e., associated with menses secondary to thoracic endometriosis)
Birt-Hogg-Dube syndrome

References:

  1. Noppen M, Verbanck S, Harvey J, et al. Music: a new cause of primary spontaneous pneumothorax. Thorax 2004; 59: 722–724
  2. M. NoppenSpontaneous pneumothorax: epidemiology, pathophysiology and cause
  3. European Respiratory Review Sep 2010, 19 (117) 217-219; DOI: 10.1183/09059180.00005310
  4. Luh S. Diagnosis and treatment of primary spontaneous pneumothorax. J Zhejiang Univ Sci B 2010;11(10):735-744. [http://dx.doi.org10.1631/jzus.B1000131]   
  5. Noppen M. Spontaneous pneumothorax: Epidemiology, pathophysiology and cause. Eur Respir Rev 2010;19(117):217-219. [http://dx.doi.org/10.1183/09059180.00005310] 
  6. Schnell J, Beer M, Eggeling S, Gesierich W, Gottlieb J, Herth FJF, Hofmann HS, Jany B, Kreuter M, Ley-Zaporozhan J, Scheubel R, Walles T, Wiesemann S, Worth H, Stoelben E. Management of Spontaneous Pneumothorax and Post-Interventional Pneumothorax: German S3 Guideline. Respiration. 2019;97(4):370-402.
  7. Wong A, Galiabovitch E, Bhagwat K. Management of primary spontaneous pneumothorax: a review. ANZ J Surg. 2019 Apr;89(4):303-308.
  8. Santos C, Gupta S, Baraket M, Collett PJ, Xuan W, Williamson JP. Outcomes of an initiative to improve inpatient safety of small bore thoracostomy tube insertion. Intern Med J. 2019 May;49(5):644-649.


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