A 16 yo female presents with shortness of breath that started 2 days ago and worsened today.  She denies cough, fever, myalgias and her COVID test is negative.

BP 122/86, HR 122, SpO2 92%RA, RR26, Tep 98.6F

X-ray is shown.  What's the diagnosis?  Scroll down for answer.

Diagnosis :  Spontaneous Pneumothorax (right sided, in this case)

Types

Primary - in patients without known lung disease

Secondary - in patients with known lung disease

Symptoms/signs

Sudden, sharp, pleuritic chest pain with associated shortness of breath

Tachycardia, hypoxia

Risk factors

Smoking, genetic predisposition, blebs, COPD, asthma, HIV, malignancy, cystic fibrosis, connective tissue disease 

Diagnosis

Physical exam - inconsistent, but may reveal diminished breath sounds on affected side

Chest x-ray - displaced pleural line with absent lung markings extending from visceral pleura (lung edge) to parietal pleura (chest wall)

Point of care ultrasound (POCUS) - absence of lung sliding and vertical reverberation (comet tail artifacts)

Complications

Hemothorax (2-7%)

Tension pneumothorax (a life threatening emergency)

Treatment

Supplemental oxygen - increases pleural air resorption

Small pneumothorax

Observe ~4 hours on oxygen and repeat x-ray

Follow up in 24 hours

Large pneumothorax (severe dyspneua, abormal vitals signs)

Needle aspiration (for primary spontaneous) - click here to review

may reduce hospitalization rate / shorten length of stay 

Chest tube thorocostomy - click here to review the procedure

References:

Tintinalli, JE. Tintinalli's Emergency Medicine: A Comprehensive Study Guide. 8th ed. New York, NY: McGraw-Hill Education LLC, 2016.

Wan C, Lyu M, Zhou J, Liu Y, Ji Y, Chest tuve drainage versus needle aspiration for primary spontaneous pneumothorax: which is better? J Thoracic Dis. 2017; 9(10): 4027-4038.

Zehtabchi S, Rios C. Management of Emergency Department Patients with Primary Spontaneous Pneumothoraz: Needle Aspiration or Tube Thorocostomy. Annals of Emergency Medicine. 2008; 51(1): 91-100.