Simultaneous Bilateral Spontaneous Pneumothorax: A Case Report

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1 136 Simultaneous Bilateral Spontaneous Pneumothorax: A Case Report Min-Po Ho 1, Chan-Ping Su 1, Chang-Ming Liu 1, Kuang-Chau Tsai 1, Yih-Chen Chang 2 Spontaneous pneumothorax is relatively common in clinical practice and occurs more frequently in young, tall thin men, and in smokers. However, simultaneous bilateral spontaneous pneumothorax is a rare clinical condition that often presents with significant respiratory distress. We report a case of simultaneous bilateral spontaneous pneumothorax in a 41-year-old woman who presented with chest pain and a dry cough followed by mild dyspnea for two weeks. She received simultaneous bilateral tube thoracostomies and video-assisted thoracoscopic surgery during hospitalization. She was discharged in relatively good condition on the 23 rd hospital day. Key words: simultaneous, bilateral, spontaneous pneumothorax Introduction Spontaneous pneumothorax is a relatively common condition that occurs most often in slender young men (1). The overall male to female ratio is 5:1 (2). The higher incidence in men has been attributed to higher rates of smoking, body habitus and different mechanical properties of the lungs (3). However, simultaneous bilateral spontaneous pneumothorax (SBSP) is a very rare clinical condition with an occurrence ranging from 1.3 to 1.9% of all cases of spontaneous pneumothorax (4,5). SBSP can be fatal once it progresses into tension pneumothorax (4,5). SBSP is mainly seen in patients with chronic obstructive pulmonary disease, tuberculosis, pneumonia, undefined interstitial pulmonary disease, connective tissue disease and pulmonary metastasis (6). We report a case of SBSP in a 41-year-old woman. She received simultaneous bilateral tube thoracostomies. Prompt diagnosis and tube thoracostomy are necessary for patients in this condition, which can be life-threatening. Bilateral video-assisted thoracoscopic surgery is a safe procedure in the treatment of spontaneous bilateral pneumothorax. Case Report A 41-year-old woman presented to the emergency department (ED) with chest pain, and a dry cough followed by mild dyspnea for two weeks without treatment. She was referred from a clinic for further evaluation and management. There was no relevant personal, psychiatric, or traumatic history or any underlying lung disease. She was not a smoker. On arrival, she had a blood pressure of 130/80mmHg, pulse rate of 106/min, respiratory rate of 22/min, and body temperature of Received: September 9, 2008 Accepted for publication: November 19, 2008 From the 1 Department of Emergency Medicine 2 Division of Chest Surgery, Department of Surgery, Far Eastern Memorial Hospital, Taipei, Taiwan Address reprint requests and correspondence: Dr. Kuang-Chau Tsai Department of Emergency Medicine, Far Eastern Memorial Hospital 21 Section 2, NanYa South Road, Panchiao 220, Taipei County, Taiwan (R.O.C.) Tel: (02) ext 1122 Fax: (02) hikali@mail.femh.org.tw

2 Simultaneous bilateral spontaneous pneumothorax 137 Her oxygen saturation was 96% on room air, and 99% with an oxygen mask at a flow of 8L/min. On examination, the patient was having some difficulty breathing, with decreased breath sounds bilaterally. No other abnormalities were found on physical examination. Arterial blood gas analysis revealed ph 7.40, PaO mmHg, PaCO mmHg, HCO 3 _ 21.8mEq/L, BE -2.4mEq/L, and Sao %. Complete blood count and biochemistry results were within normal limits. A 12-lead electrocardiogram showed sinus tachycardia with a rate of 110 beats/min and no ST-T changes. Chest radiography showed bilateral pneumothorax which was more prominent on the right side (Figure). On the basis of the radiographic findings, two emergency physicians simultaneously performed bilateral tubal thoracostomies. Subsequently, her chest discomfort and dyspnea improved. A chest surgeon was consulted and the patient was admitted to ward. Her left-side pneumothorax persisted, and computed tomography of the chest showed that the left lung was not fully expanded. It remained unresolved after 10 days. Videoassisted thoracoscopic surgery was therefore done. Blebs at the apices of both upper lungs were found, and multiple wedge resections with apical partial pleural abrasion was performed bilaterally. She had an uneventful recovery postoperatively. H i s t o p a t h o l o g i c a l e x a m i n a t i o n r e v e a l e d emphysematous blebs with septal fibrosis. She was discharged without complications on the 23 rd hospital day. There was no recurrence at 6 months follow up. Discussion Spontaneous pneumothorax is an abnormal collection of air in the intrapleural space without preceding trauma. If pneumothorax enlarges, the lung becomes contracted with decreasing vital capacity and thus a decreasing partial pressure of oxygen. Although young, healthy people can tolerate these changes fairly well, older people and those with underlying lung disease often have significant respiratory compromise. Spontaneous pneumothorax is a relatively common condition in Figure Chest radiograph showing bilateral pneumothorax which is more prominent on the right side

3 138 clinical practice. It is generally ascribed to rupture of an intrathoracic gas-containing structure. Air enters the pleural space when a subpleural apical bleb or a pulmonary cavity ruptures (5). It remains a significant health problem. However, more is now known about its pathogenesis, there have been improvements in diagnostic procedures and both medical and surgical approaches to treatment. The most common symptoms of spontaneous pneumothorax are chest pain on the side of the pneumothorax and dyspnea. The chest pain is sharp and pleuritic. The clinical presentation of SBSP varies widely. Patients have presentations ranging from tension pneuemothorax, and cardiopulmonary failure to mild dyspnea (6,9). Physical signs range from a slight decrease in breath sounds to severe respiratory distress with diminished breath sounds bilaterally and ronchi in the mid-line of the chest (7). It can be asymptomatic and found incidentally during examinations for other conditions (8). The clinical manifestations of these patients are determined by the extent of lung collapse and underlying lung disease. Chest pain, dyspnea, tachycardia, tachypnea and general malaise are common. Hypoxia, respiratory distress, cyanosis and even respiratory failure may be seen in severe cases. On rare occasions, it has been described in pregnant women (10), during menstruation (catamenial pneumothorax) (11), with Marfan syndrome (12), in sarcoidosis (13), and therapeutic irradiation (14). Most cases of SBSP are symptomatic. Although unilateral spontaneous pneumothorax can occur without lung disease, SBSP is mainly seen in patients with chronic obstructive pulmonary disease, pneumonia, interstitial lung disease, tuberculosis, connective tissue disease and cancer or poisoning (5,6,18). Generally, if a spontaneous pneumothorax affects less than 20% of one lung, and there is no shortness of breath, active treatment is not necessary, and the patient may simply be kept under observation. The absorption rate of the air is about 1.25% (50-75ml)/day. However, if pneumothorax affects more than 20% of the lung, or if it increases during observation, chest tube drainage may be required (16). Simple aspiration can be used for spontaneous pneumothorax, but a tube thoracostomy is usually required for patients with SBSP because of the high likelihood of underlying lung disease. Open thoracotomy, or video-assisted thoracoscopic surgery is often necessary for persistent pneumothorax or suspected underlying disease. Prompt diagnosis and treatment are necessary because this condition can be life-threatening if there is respiratory compromise, or even fatal if it develops into tension pneumothorax (15-17). SBSP may present with various clinical symptoms and signs mimicking bronchial asthma or other lung diseases (19). In contrast to a large unilateral peumothorax, SBSP presents difficulties in diagnosis from clinical signs alone and definitive diagnosis requires chest radiography (15). Young patients without underlying disease should have surgery following alleviation of symptoms by tube drainage. Older patients and patients with malignancy should be treated with great care and individually. SBSP is rare; however, it is usually symptomatic and can be fatal if accurate diagnosis and treatment are not provided in time (20). Urgent chest radiography is very important for all patients with respiratory distress in the emergency room. We suggest that emergency physicians be aware of this critical condition, since misdiagnosis will lead to unwarranted sequelae. References 1. Teixidor Sureda J, Estrada Salo G, Sole Montserrat J, et al. Spontaneous pneumothorax apropos 2505 cases. Arch Bronconeumol 1994;30:131-5.

4 Simultaneous bilateral spontaneous pneumothorax Gupta D, Mishra S, Faruqi S, Aggarwal AN. Aetiology and clinical profile of spontaneous pneumothorax in adults. Indian J Chest Dis Allied Sci 2006;48: Taussig LM, Cota K, Kaltenborn W. Different mechanical properties of lung in boys and girls. Am Rev Respir Dis 1981;123: Athanassiadi K, Kalavrouziotis G, Loutsidis A, et al. Treatment of spontaneous pneumothorax: tenyear experience. World J Surg 1998;22: Graf-Deuel E, Knoblauch A. Simultaneous bilateral spontaneous pneumothorax. Chest 1994;105: Sayar A, Turna A, Metin M, et al. Simultaneous bilateral spontaneous pneumothorax report of 12 cases and review of the literature. Acta Chir Belg 2004;104: D o n o v a n P J. B i l a t e r a l s p o n t a n e o u s pneumothorax: A rare entity. Ann Emerg Med 1987;16: Ohara K, Yamazaki T, Sakaguchi K, et al. A case of simultaneous bilateral spontaneous pneumothorax. Kyobu Geka 1994;47: Lewis RL, Moore JM, Kline AL. Simultaneous bilateral spontaneous pneumothorax: a case report. Curr Surg 2002;59: Brantley WM, DelValle RA, Schoenbucher AK. Pneumothorax, bilateral spontaneous, complicating pregnancy. case report. Am J Obstet Gynecol 1961;81: Laws HL, Fox LS, Younger B. Bilateral c a t a m e n i a l p n e u m o t h o r a x. A r c h S u rg 1977;112: Gawkrodgen DI. Marfan syndrome presenting as bilateral spontaneous pneumothorax. Postgrad Med J 1981;57: Ross RJ, Empey DW. Bilateral spontaneous pneumothorax in sarcoidosis. Postgrad Med J 1983;59: S t o l z e n b e rg L, C l e n e n t s J P. B i l a t e r a l spontaneous pneumothorax during radiation therapy for metastatic disease from osteogenic sarcoma: a case report and review of the literature. Radiol Clin Biol 1970;39: Wilkie SC, Hislop LJ, Miller S. Bilateral spontaneous pneumothorax-the case for prompt chest radiography. Emerg Med J 2004;18: Sunam G, Gok M, Ceran S, et al. Bilateral pneumothorax: a retrospective analysis of 40 patients. Surg Today 2004;34: Takahashi S, Yokoyama T, Ninomiya N, et al. A case of simultaneous bilateral spontaneous pneumothorax developed into tension pneumothorax. J Nippon Med Sch 2006;73: M a z u r S, H i t c h c o c k T. S p o n t a n e o u s pneumomediastinum, pneumothorax and ecstasy abuse. Emerg Med 2001;13: H a y E, S t e r n f e l d M, R a s h i d A, e t a l. S i m u l t a n e o u s b i l a t e r a l s p o n t a n e o u s pneumothorax: case report. Am J Emerg Med 1992;10: YC Huang, SC Cheung, CW Tu. Simultaneous bilateral primary spontaneous pneumothorax, two cases report. J Taiwan Emerg Med 2006;8:110-3.

5 X (Video-Assisted Thoracic Surgery VATS) (02) (02) hikali@mail.femh.org.tw