Question Of The Day #86

question of the day
420 - right pneumothorax1
Which of the following is the most appropriate next step in management for this patient’s condition?

Shortness of breath, also known as dyspnea, is a common reason for patients to visit the Emergency Department.  Dyspnea is often caused by a pulmonary or cardiovascular condition, but it is important to remember that dyspnea can be due to endocrine conditions, toxicologic conditions, neurologic conditions, hematologic conditions, musculoskeletal conditions, and psychiatric conditions. 

The initial approach to all patients with shortness of breath involves the primary survey, or “ABCs” (Airway, Breathing, Circulation).  This first involves checking the patient for a patent airway.  A simple method to assess the airway is to ask the patient to speak and listen for the voice.  A muffled voice, the presence of stridor, hematemesis, or a lethargic patient are clues that a patent airway may not be present.  Problems with the airway, such as an obstructing foreign body, inflammation (i.e., epiglottitis, anaphylactic shock), or vocal cord dysfunction can certainly cause shortness of breath.  Endotracheal intubation may need to be performed before moving forward.  Breathing is assessed by evaluating the function of the lungs.  Steps include looking at how the patient is breathing (fast or slow), measurement of an SpO2 level, and auscultation of both lungs for wheezing, crackles, rhonchi, or distant or absent sounds.  A low oxygen level should be immediately addressed with supplemental oxygen before moving forward.  The patient’s breathing rate and lung sounds can be very helpful in discovering the diagnosis and guiding treatment.  Lastly, circulation should be assessed.  Check the heart rate, blood pressure, peripheral pulses, skin color and temperature, and evaluate for any sites of hemorrhage.  The presence of hypotension or tachycardia should be addressed appropriately based on the presumed cause.  After the primary assessment (“ABCs”) and initial treatment actions, a more detailed history and physical exam should be conducted. 

Pertinent causes of shortness of breath for the emergency practitioner to know are outlined in the chart below. 

 

Select Causes of Shortness of Breath (Dyspnea)

Pulmonary

 

Tension pneumothorax, pneumonia, empyema, pleural effusion, pulmonary edema, asthma, COPD

Cardiovascular

 

Acute coronary syndrome (i.e., STEMI), pulmonary embolism, cardiac tamponade, Decompensated Congestive Heart Failure (acute pulmonary edema)

Endocrine

 

Diabetic ketoacidosis (Kussmaul breathing)

Toxicologic

 

Salicylate overdose, or any ingestion that causes a severe metabolic acidosis

Neurologic

 

Intracranial hemorrhage, Stroke, Spinal cord injury, Guillain-Barre syndrome, Myasthenia Gravis crisis (myasthenic crisis)

Hematologic

 

Severe anemia (i.e., GI bleeding, trauma, miscarriage, post-partum hemorrhage, ruptured ectopic pregnancy)

Musculoskeletal

 

Rib fracture, flail chest

Psychiatric

 

Anxiety, Panic attack

Airway Problem

Foreign body, epiglottitis, anaphylactic shock (laryngeal swelling), expanding neck hematoma

This patient arrives to the Emergency department with acute onset shortness of breath with pleuritic right sided chest pain.  On exam, there is mild tachypnea and a borderline low SpO2 of 95% on room air.  The chest X-ray demonstrates a small right sided pneumothorax (see location of red stars below).

Needle decompression to the right chest (Choice C) would be the right choice if the patient had a right sided tension pneumothorax.  Signs of a tension pneumothorax are hypotension, tachycardia, tracheal deviation, and mediastinal shift on Chest X-ray.  Tension pneumothorax should be diagnosed clinically without a chest X-ray and promptly treated with needle decompression with a 14-16 gauge needle at the 2nd intercostal space in the mid clavicular line.  Needle decompression can also be performed at the 4th or 5th intercostal space in the anterior axillary line. Needle decompression is always followed by placement of a formal chest tube.  This patient does not have the hemodynamic instability or chest X-ray findings of a classic tension pneumothorax. IV Azithromycin (Choice D) would be appropriate for a COPD exacerbation or for community-acquired pneumonia.  This patient does have a cough, but lacks fever, sputum production, and also has a pneumothorax on X-ray that can explain his symptoms.  An IV Heparin bolus and infusion (Choice A) would be the ideal treatment for a pulmonary embolism or acute coronary syndrome.  Again, the Chest X-ray provided shows support for an alternative cause for the patient’s symptoms.  The best next step is supplemental oxygen (Choice B).  100% supplemental oxygen helps decrease the time to lung expansion in patients with pneumothoraces.   A nonrebreather mask at 15L/min is the ideal method to providing this level of oxygen.

This patient has a small pneumothorax (<3cm between lung margin and chest wall).  Small primary pneumothoraces have two treatment options.  The first option is to administer 100% oxygen and place a pigtail catheter for rapid lung re-expansion.  The second option is to only administer 100% oxygen administration for a period of 4-6 hours followed by a repeat chest X-ray to evaluate for improvement of the pneumothorax.   If the pneumothorax is improving and symptoms are improving (less shortness of breath and chest pain), the patient can be discharged home with close outpatient follow up and no chest tube placement.  Deciding which treatment option is best should depend on the patient’s ability to follow up with a doctor, patient reliability, and resource availability.  This patient does have a small pneumothorax by measurement, but he likely has a secondary pneumothorax from his COPD.  Secondary pneumothoraces have a higher rate of recurrence and almost always require chest tube placement.  Regardless, the best initial step in treatment is supplemental oxygen (Choice B).

References

Cite this article as: Joseph Ciano, USA, "Question Of The Day #86," in International Emergency Medicine Education Project, April 29, 2022, https://iem-student.org/2022/04/29/question-of-the-day-86/, date accessed: May 29, 2022

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