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A 39 yo Man with Atypical Chest Pain General Internal Medicine Primary Care Conference

A 39 yo Man with Atypical Chest Pain General Internal Medicine Primary Care Conference K. Mae Hla, M.D. October 11, 2006. The Case. 39 y.o. healthy epidemiologist with no personal or family history of cardiac or pulmonary disease

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A 39 yo Man with Atypical Chest Pain General Internal Medicine Primary Care Conference

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  1. A 39 yo Man with Atypical Chest Pain General Internal Medicine Primary Care Conference K. Mae Hla, M.D. October 11, 2006

  2. The Case • 39 y.o. healthy epidemiologist with no personal or family history of cardiac or pulmonary disease • Training for marathon: running 30 mins on treadmill, lifting weights and biking 40 mins. • Developed sharp right anterior chest pain while walking home from work

  3. I need to see “Dr. Hla” • History of pain in the upper pectoralis muscle past few days after a hard workout • Denies trauma to the chest, travel hx, SOB, cough, fever, leg pain or swelling, syncope • Non-smoker • PMH: labile hypertension with mild postural dizziness

  4. Exam- in the office • tall male, mild distress, not dyspneic • no hyper resonance, normal breath sounds, no subcutaneous emphysema • no murmurs or rubs, no intra-scapular murmurs, BPs in both arms were normal and equal • point tenderness right pectoralis muscle

  5. Clinical Course--at home • Did not follow up with primary MD as advised • Continued to have pleuritic pain • Stopped all weight lifting and minimized exertion • Switched to stationary biking due to notable reduced exercise capacity

  6. Clinical Course--in the ER • 4 days later, syncopal episode in bathroom • Was seen in the ER and worked up for possible cardiac syncope • The admitting resident was surprised when he looked up one of the routine tests obtained

  7. “This was the reason for my muscle pain”

  8. In retrospect… He realized he had ceased all lifting and exercise on the weekend prior to admission because of shortness of breath

  9. Clinical Course--in the hospital • A chest tube was inserted in the ER • Patient was admitted for observation and syncope workup • A TTE and a Holter Monitor showed no abnormalities • A cardiology consult recommended no further syncope workup • The pneumothorax was felt to be the cause of the syncope

  10. “Another Clinical Question”! How safe is it to fly to the west coast to present the “invited” talk at the meeting 10 days after my discharge?

  11. Objectives • Describe types and incidence of spontaneous pneumothorax • Review pathogenesis, clinical presentation • Evaluate evidence for recurrence risk and treatment options • Discuss guidelines on air travel safety in patients with recent pneumothorax

  12. Spontaneous Pneumothorax Definition: Air in pleural space, between the lung and the chest wall First coined as “pneumothorax simple” by Itard in 1803 No antecedent traumatic or iatrogenic cause

  13. Types of Spontaneous Pneumothorax • Primary spontaneous pneumothorax • in healthy persons with no apparent underlying lung abnormalities or underlying conditions • Secondary spontaneous pneumothorax • Clinically apparent underlying lung disease

  14. Global Incidence, Morbidity & Mortality (U.K.)

  15. U.S. IncidenceOlmsted County (1950-1974) 318 with diagnosis of pneumothorax • Age-adjusted annual incidence of primary pneumothorax: • 7.4 per 100,000 men • 1.2 per 100,000 women • Annual incidence of secondary pneumothorax • 6.3 per 100,000 men • 2.0 per 100,000 women

  16. Pathogenesis of PSP 90% of cases at thoracoscopy or thoracotomy 80% of cases on CT showed subpleural blebs or bullae Etiology of bullous changes in healthy: • airway inflammation from smoking • lifetime risk in smoking men 12% vs. 0.1% non-smokers • tall stature-subpleural blebs in apex

  17. Effect of smoking on PSP recurrence riskBense et. al. Chest 1987; 92:1009

  18. Pathogenesis of PSP (cont’d) Other causes • Marfan’s syndrome • Homocystinuria • Catamenial pneumothorax in thoracic endometriosis • Familial spontaneous pneumothorax: autosomal dorminant, recessive, polygenic and X-linked recessive inheritance

  19. Genetic mutation and PSP Gene for Familial cancer syndrome-chromosome17p11.2 • Birt-Hogg-Dube syndrome: benign skin tumors and renal cancer: high PSP incidence-23% in one study • Other mutations of FLCN-bullous lung disease and spontaneous pneumothorax only • Autosomal dorminant inheritance of bullous lung disease with 100% penetrance in a Finnish family

  20. Clinical Presentation Primary spontaneous pneumothorax • Usually occurs at rest • Peak age is early 20s; rare after 40 • Sudden onset of dyspnea and pleuritic chest pain • Severity of sx related to size of pneumothorax Secondary spontaneous pneumothorax • More severe sx for same size of pneumothorax

  21. Physical Findings • Decreased chest excursions • Decreased breath sounds • Hyperresonant percussion • Subcutaneous emphysema • Pleural line on chest radiograph

  22. Risk of Recurrence Range 25 - >50%; 54% within first 4 years in one study Risk factors for recurrence in PSP • smoking • tall stature • female gender • low body weight Risk factors for recurrence in SSP • age over 60 years • pulmonary fibrosis • emphysema

  23. Cumulative freedom from recurrence Lippert H et al. Eur Respir J 1991;4:324-31

  24. Types of Treatment Options • Observation and supplemental oxygen • Aspiration of the pleural space • Tube thoracostomy • Tube thoracostomy with pleurodesis • Thoracoscopy • Open thoracotomy • British Thoracic Society (2003) and American College of Chest Physicians guidelines (2001)

  25. Choice of Treatment Options • Size of pneumothorax • Symptoms • Clinical stability: <24/min resp rate, HR >60-<120, normal BP, pulse ox >90%, can speak whole sentences in between breaths • Recurrence risk, underlying conditions • Patient occupation

  26. Size of Pneumothorax Small < 2cm between lung margin and chest wall (BTS) < 3 cm apex-to-cupola distance (ACCP) < 15% of the hemithorax (UpToDate) Large > 2 cm between lung margin and chest wall (BTS) > 3cm apex-to-cupola distance (ACCP) > 15% of hemithorax (UpToDate)

  27. Treatment Recommendations based on Size • Small < 15% SP and stable patients: • observation and supplemental oxygen to facilitate absorption of pleural air • Large >15% • Initial simple aspiration of the pleural space • Tube thoracostomy if persistent airleak and no lung reexpansion

  28. Manual Aspiration vs. Thoracostomy Meta-analysis of 3 randomized controlled trials (194 patients) • Similar Clinical outcomes at 1 week and 1 year • Manual aspiration group--shorter hospital stay A randomized controlled trial (137 patients) • Similar rates of immediate success (62% vs. 68% in 1 day and 89% vs. 88% in 1 week) • Aspiration associated with shorter hospital stay (1.8 vs. 4 days)

  29. Tube Thoracostomy Indications • PSP that fails aspiration treatment • Recurrent spontaneous pneumothorax • Presents with hemopneumothorax • Small chest tube in most (5.5 or 7.0 French) • Clamp chest tube when no bubbles emanate from a patent tube in 12 hours • Remove after 24 hours if no clinical or x-ray evidence of recurrence

  30. Pleurodesis Procedures • Chemical pleurodesis • Intrapleural instillation of sclerosing agents • Tetracycline, doxycycline, talc, premedicate with midazolam and an opiate • Open or surgical pleurodesis • thoracoscopy vs. a limited or full thoracotomy • Indications: lung remains unexpanded after 3 days of chest tube, bronchopleural fistula, recurrence after chemical pleurodesis, bullae resection, patient occupation

  31. Postgrad Med 2005;118(6) (online article)

  32. Back to the Future… Is he safe to fly? • Safety of air travel following pneumothorax-a subject of debate • Concerns during air travel (speculative): • ? expansion of trapped air at high altitude • ? pressure change at ascent and descent • ? change in barometric pressure may open a sealed air leak • lack of appropriate medical care

  33. BTS Air Travel Safety Review and Recommendations • Airlines recommend 6 week-waiting period-arbitrary • Evidence for timing of maximum risk of a recurrence (review 37 papers) • Data on recurrence: variable, no data on timing • Recurrence risk >54-72% in first 1-2 yrs, higher in smokers, COPD • Surgical/pleurodesis intervention makes risk negligible • Recurrence while flying more likely to suffer serious consequences especially in patients with pre-existing lung disease BTS recommendations. Air Travel Working Party-Thorax 2002;57;289-304 (Page 298)

  34. Safety in flying--what’s the evidence? A small prospective study (n=12) of pts with traumatic pneumothorax in a Level I Trauma Center, Orlando, Fl, 14 day waiting period after resolution in adults • 10/12 patients flew >14 days (mean 17.5 days) remained asymptomatic • 2/12 flew in < 14 days: 1 developed sx suggestive of pneumothorax in flight Cheatham, et al. The Am Surgeon 1999;65:1160-1164

  35. What did the patient do? • Like a true epidemiologist, decided the data on waiting period and increased recurrence risk during air travel was not supported by good evidence • Decided to fly 12 days after his re-expansion • Completed an uneventful trip!!!

  36. Bibliography • BTS guidelines for the management of spontaneous pneumothorax. Henry M. et al. Thorax 2003;58 (Suppl II):ii39-ii52. • Management of spontaneous pneumothorax An AACP delphi concensus statement. Baumann MH, et al. Chest 2001;119:590-602. • Air travel following traumatic pneumothorax: when is it safe? Cheatham ML, Safcsak K. Am Surg 1999;65(12):1160-4. • Managing passengers with respiratory disease planning air travel BTS recommendations. Air Travel Working Party. Coker RK, et al. Thorax 2002;57:289-304 pp 298. • The Intricacies of Pneumothorax Management depends on accurate classification. Dincer HE, Lipchik RJ. Postgrad Med 2005;118(6) (online article). • Primary spontaneous pneumothorax in adults. Light RW. 2006 UpToDate

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