Double trouble

Diagnostic Challenge

CJEM 2002;4(3):215

A 22-year-old man was referred to the emergency department by his family physician for evaluation of a suspected pneumothorax. Eighteen hours earlier, while sitting in a bus, the patient had experienced the sudden onset of right-sided pleuritic chest pain. He denied shortness of breath, cough or fever, and had no history of trauma, injection drug use or HIV. He was taking no medications and had no history of a prior pneumothorax.

Physical examination revealed a well-appearing young man with a respiratory rate of 24 breaths/min and an oxygen saturation of 97% on room air. Auscultation revealed absent breath sounds over the right chest. There were no signs to suggest tension pneumothorax.

Results of a chest x-ray revealed a large pneumothorax (Fig. 1). A pleural catheter was inserted and attached to a Heimlich valve. One hour later, a repeat x-ray confirmed 90% re-expansion. The patient was discharged home with follow-up arranged for the next day.

Fig. 1. Initial x-ray, revealing a large pneumothorax.  [enlarge]

The patient returned, as instructed. He was feeling well, had normal vital signs and equal air entry bilaterally. A repeat chest x-ray was done (Fig. 2).

Fig. 2. X-ray performed 24 hours later. [enlarge]

Optimal management at this time is:

A. Discharge home with reassessment in 1-2 days.
B. Attach the pleural catheter to suction.
C. Insertion of a large bore chest tube.
D. Placement of another pleural catheter.

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