A 22-year-old man presents to the emergency department with sudden-onset, left-sided chest pain and shortness of breath that began one hour ago. He denies fever, recent illness, palpitations, or abdominal pain. He was diagnosed with Kawasaki disease at the age of 5 and was treated appropriately and did not have any complications. Follow-up with transthoracic echocardiogram was unremarkable. He does nt take any medications. Family history is significant for hypertension in his father years and diabetes in his mother. He does not smoke cigarettes, drink alcohol, or use any illicit drugs. Vital signs are blood pressure of 129/85 mmHg, pulse 89 beats/min, respirations 18/min, and temperature of 37.5° C (99.5° F). Pulse oximetry shows 92% on room air. On physical examination, he is noted to be a tall, thin male. Auscultation of the chest reveals decreased breath sounds in the left upper lung field as well as hyperresonance. A chest x-ray is performed and demonstrates a 2 cm pneumothorax at the level of the apex.
Which of the following is the most appropriate next step in management of this patient?
C) Close observation with 100% oxygen
This patient has primary spontaneous pneumothorax (PSP). There is no history of lung disease, and the physical exam and radiographic findings correspond with the diagnosis. PSP is categorized by size and stability. In the United States, a cutoff of 3 cm between the pleural line and the chest wall at the level of the apex on chest x-ray is typically used. 3 cm or less is considered small while over 3 cm is considered large. A stable patient has a normal blood pressure, respiratory rate less than 24 breaths per minute, heart rate between 60 and 120 beats per minute, room are oxygen saturation above 90%, and the ability to speak in whole sentences. If any of these are lacking, the patient is considered unstable. The patient in the vignette has a first episode of pneumothorax that is small, and the patient is clinically stable. Observation with or without supplemental oxygen is the appropriate approach to management.
Answer choice A: Antibiotics, is incorrect. This patient does not show signs of infection that would require antibiotics.
Answer choice B: Aspiration, is incorrect. Aspiration is appropriate for clinically stable patients with a large PSP.
Answer choice D: Intubation and mechanical ventilation, is incorrect. This patient is clinically stable and does not require airway protection or assisted ventilation.
Answer choice E: Tube thoracostomy, is incorrect. Tube thoracostomy is appropriate for clinically stable patients with PSP who fail observation or aspiration. It is also appropriate for unstable patients with pneumothorax and patients with recurrent PSP.
Key Learning Point
Patients with a first episode of primary spontaneous pneumothorax who are clinically stable and have a small pneumothorax defined as 3 cm or less at the apex on chest radiography may be treated with observation with or without supplemental oxygen.
