Large spontaneous pneumothorax with relatively minor symptoms.

To cite: Morrison TEM. BMJ Case Rep Published online: [please include Day Month Year] doi:10.1136/bcr-2013009531 DESCRIPTION A 40-year-old gentleman presented to emergency department (ED) with sudden onset of right-sided chest pain, largely subsided on admission. He was an ex-smoker with a history of basal cell carcinoma and patella fracture. Trachea was central on examination, with absence of right-sided breath sounds. Observations were normal. Chest radiograph revealed a large right-sided primary spontaneous pneumothorax (PSP) (figure 1), which was aspirated unsuccessfully. A chest drain was inserted with uneventful recovery (figure 2). Global occurrence is greater in men, at 0.018–0.028% versus 0.0012–0.006%, with 54% risk of another pneumothorax within 4 years. Smoking poses a further 12% risk. Alveoli of taller subjects are also prone to greater distension pressure and development of subpleural blebs as negative pleural pressure gradient increases towards the lung apex. If present, signs include reduced lung expansion, absent breath sounds and hyper-resonance on the affected side. Although diagnosis and management should be guided clinically, an inspiratory chest x-ray is recommended. CT scanning, ‘gold standard’ for size estimation and detection of small pneumothoraces, is advised for uncertain cases. Treatment depends on: 1. Previous lung pathology. 2. Breathlessness. 3. Pneumothorax size. A. Insert chest drain if bilateral or haemodynamically unstable spontaneous pneumothoraces. B. If age >50, clinical/radiological lung pathology or significant smoking history, treat as secondary pneumothorax. C. If PSP >2 cm or shortness of breath, aspirate less than 1.5 l. If aspiration fails, insert chest drain. D. If <2 cm with no shortness of breath, or successful aspiration, consider discharge with 2–4 week follow-up.