History of Present Illness
A 35-year-old Caucasian man presented to the emergency room with sudden worsening of breathlessness, right chest pain, and dry cough.
Past Medical History
He worked as a construction engineer and was a current smoker (20 cigarettes/day). He had no previous exposure to noxious substances and no history of alcohol abuse or drug use. No allergies were known.
He had previous surgery for repair of testicular torsion and traumatic fracture of the humerus resulting from a traffic accident. There was no history of lung disease. In the past month, he had traveled by plane twice for work and had a little cough without fever or sputum.
Physical Examination and Early Clinical Findings
In the emergency room, the patient was found to be alert, cooperative, afebrile (body temperature 36.5° C [97.7° F]). Oxygen saturation (Sp O 2 ), measured with pulse oximetry, was 90% while the patient was breathing ambient air. Heart rate was 98 beats/min, respiratory rate was 22 breaths/min, and blood pressure was 140/85 mm Hg. Electrocardiography (ECG) showed sinus tachycardia.
At the physical examination of the lungs, expansion of the right hemithorax was found to be reduced. On this side, reduction of breath sounds and hyperresonance to percussion at the upper field were evident. The remainder of the examination was normal.
The arterial blood gas (ABG) analysis on room air revealed acute respiratory failure (pH 7.44; partial pressure of carbon dioxide [Pa CO 2 ] 35 mm Hg; partial pressure of oxygen [Pa O 2 ] 55 mm Hg; bicarbonate [HCO 3− ] 24 mmol/L); therefore oxygen therapy was started.
Blood tests showed mild leukocytosis (white blood cell [WBC] count was 9,940/mm3 with normal differential count); C-reactive protein (CRP) was 19.7 mg/L (normal values < 5 mg/L); and hemoglobin (Hb) was 16.1 g/dL. Cardiac enzymes (troponin and creatine kinase MB) were not altered.
Point-of-care ultrasonography of the chest showed absence of pleural sliding, but no clear lung point.
Chest radiography revealed right pneumothorax extending from the apex to the base, without a significant mediastinal shift ( Fig. 21.1 ).
The pulmonologist prepared for placing a chest tube. Platelet count and the international normalized ratio (INR) were acceptable. The patient was informed about the importance of the procedure and the potential risks and was able to provide signed informed consent. A single dose of prophylactic antibiotic (cefazolin 1 g intravenous) was administered. Trichotomy of the thoracic surface and skin disinfection were performed. After filling a syringe with lidocaine, the pulmonologist inserted the needle into the second right intercostal space, along the hemiclavicular line. The local anesthetic was injected into the subcutaneous tissue, then more deeply until air bubbles coming from the pleural cavity were evident inside the syringe. Subsequently, a small incision was made with a scalpel, and an 18-French (Fr) pleural drain was placed ( Fig. 21.2 ). The tube was connected to a collection chamber, and air immediately came out from the pleural space. The patient got relief from breathlessness. He was admitted to the pulmonology department for continuation of treatment and monitoring of the pleural drainage.
During the subsequent days, the patient did not have shortness of breath or cough. He asked for an analgesic (paracetamol) only a few times because of pain at the site of chest tube insertion. Sp O 2 increased to 99% with low oxygen support (fraction of inspired oxygen [Fi O 2 ]: 28%). However, there was continuous air leakage through the thoracic drainage. Chest computed tomography (CT) showed only partial resolution of the right pneumothorax and the presence of peripheral lung bullae ( Fig. 21.3 ). Therefore the thoracic surgeon proposed bullectomy through uniportal video-assisted thoracic surgery (U-VATS) ( Fig. 21.4 ).