ICE 014: Pleuritic Pain • LITFL • ICE Clinical Cases

A 24 year old woman presents to ED with a 12 hour history of shortness of breath and left sided pleuritic chest pain. She has no significant past medical history and is on no regular medications. Her vital signs are normal.

Questions:

Describe and interpret her chest X-Ray
What treatment is required ?
What follow up management and advice is needed ?

Reveal the ICE answer

The CXR shows a large left sided pneumothorax. The rim of lung is visible about 3cm from the chest wall at the lung apex and 2cm from the mid/upper zone laterally. There is no obvious underlying lung abnormality or chest wall trauma, and no displacement of midline structures that can indicate tension. Estimating pneumothorax size is well known to be difficult, with only broad estimates generally possible unless volume is formally measured with a CT scan (and this isn’t usually needed). As a rule, if the lung rim is only visible at the apex it is small (< 2 cm), if visible and larger than this it is large or complete.

The most appropriate management for spontaneous pneumothoraces of this size (and indeed of any size) is an area that generates substantial debate. Opinions will range from just observe and await spontaneous resolution at one extreme to insertion of a large bore intercostal catheter connected to underwater seal drainage at the other extreme. Unfortunately the evidence on which to base treatment for spontaneous pneumothorax is weak. What is clear is that needle aspiration and small intercostal catheters can be effective and the only absolute indications for drainage are significant underlying lung disease or respiratory compromise.

A follow up CXR (timed to document expected complete re-inflation) is useful. Consider issues like flying, diving and advice re smoking cessation.