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Concept: Tension pneumothorax


A 61-year-old man with severe chronic obstructive pulmonary disease presented to our hospital with recurrence of a right-sided spontaneous secondary pneumothorax. Thoracoscopic abrasion of the parietal pleura was performed, but an important air leak persisted. Presumed to originate from a bulla in the right upper lobe, bullectomy and pleural decortication were performed, but leakage remained. Lobectomy was considered, and quantitative ventilation/perfusion SPECT was performed to predict the functional outcome.Fused high-resolution CT/Tc Technegas images localized leakage not only to a bleb in the right upper lobe but also to the subcutaneous emphysema in the thoracic wall. The air leak resolved after conservative treatment.

Concepts: Pulmonology, Lung, Emphysema, Pneumothorax, Thoracic cavity, Pleural cavity, Tension pneumothorax, Leak


To determine whether the reported clinical presentation of tension pneumothorax differs between patients who are breathing unassisted versus receiving assisted ventilation.

Concepts: Mechanical ventilation, Pneumothorax, Tension pneumothorax


Birt-Hogg-Dubé syndrome (BHDS) is a rare hereditary disease that presents with multiple lung cysts and recurrent pneumothorax. These cysts occupy predominantly the lower-medial zone of the lung field adjacent to the interlobar fissure, and some of them abut peripheral pulmonary vessels. For the surgical management of pneumothorax with BHDS, the conventional approach of resecting all subpleural cysts and bullae is not feasible. Thus, after handling several bullae by using a stapler or performing ligation as a standardized treatment, we applied to a pleural covering technique to thicken the affected visceral pleura and then to prevent recurrence of pneumothorax. We herein report the successful application of a pleural covering technique via thoracoscopic surgery to treat the recurrent pneumothorax of a 30-year-old man with BHDS. This technique is promising for the management of intractable pneumothorax secondary to BHDS.

Concepts: Tuberculosis, Pulmonary artery, Pneumothorax, Pleurodesis, Pleural cavity, Pleurisy, Tension pneumothorax, Visceral pleura


Air in the scrotum is an unusual clinical finding and a thorough search should be done in order to locate the air leak or source of gas production. We report an 81-year-old patient who developed severe acute respiratory failure after fiberoptic bronchoscopy and was intubated immediately. After tracheal intubation, excessive subcutaneous emphysema from the head to the scrotum was obvious. Chest tube thoracostomies were placed to treat pneumothorax. The emphysema was absorbed after 13 days without any sequela. Air or gas inside the scrotum may originate from intraperitoneal, extraperitoneal, or local sources. The majority of the cases can be managed conservatively, but emergent intervention is needed in life-threatening situations.

Concepts: Pulmonology, The Canon of Medicine, Mechanical ventilation, Intubation, Bronchoscopy, Pneumothorax, Natural gas, Tension pneumothorax


Introduction Needle thoracostomy is the prehospital treatment for tension pneumothorax. Sufficient catheter length is necessary for procedural success. The authors of this study determined minimum catheter length needed for procedural success on a percentile basis.

Concepts: Medical emergencies, Pneumothorax, Necessary and sufficient condition, Chest tube, Flutter valve, Tension pneumothorax, Subcutaneous emphysema


Chest ultrasonography can be a useful diagnostic tool for respiratory physicians. It can be used to complete and widen the general objective examination also in emergency situations, at the patient’s bedside. The aim of this document is to promote better knowledge and more widespread use of thoracic ultrasound among respiratory physicians in Italy. This document I is focused on basic knowledge of chest ultrasonography technique, physical basis, aims and characteristics, fields of application. Document I shows how chest ultrasonography can be useful to detect and monitor pleural diseases, pleural effusions and pneumothorax and how it can assess diaphragmatic kinetics and pathologies.

Concepts: Hospital, Pleural effusion, Respiratory system, Pneumothorax, Pleurodesis, Thoracic cavity, Pleural cavity, Tension pneumothorax


MDMA (3,4-methylenedioxymethamphetamine) or ‘Ecstasy’ is an illicit drug frequently used by young people at parties and ‘raves’. It is readily available in spite of the fact that it is illegal.1It is perceived by a lot of young people as being ‘harmless’, but there have been a few high-profile deaths associated with its use.2Known side effects of MDMA include hyperthermia, rhabdomyolysis, coagulopathy and cardiac arrhythmias.3Rarer side effects include surgical emphysema and pneumomediastinum, which have been better described with cocaine abuse.4-6We present a case of bilateral pneumothorax, surgical emphysema and pneumomediastinum in a young man after taking ecstasy.

Concepts: Pneumothorax, Controlled Substances Act, Methamphetamine, Illegal drug trade, Tension pneumothorax, Serotonin syndrome, Subcutaneous emphysema, Pneumomediastinum


An 82-year-old woman underwent a ventriculoperitoneal (VP) shunt placement to treat hydrocephalus secondary to a right thalamic intracerebral hemorrhage. Pneumothorax and subcutaneous emphysema was noted 2 hours later. No respiratory distress was noted. A chest computed tomography scan revealed that the shunt tube had penetrated the diaphragm and entered the pleural space. The shunt tube penetrated the lung parenchyma and exited the pleural space via the third intercostal space. She underwent chest drainage and VP shunt reposition. The VP shunt functioned properly and no infection was noted. Bending the shunt passer slightly and keeping the passer tip pointed upward and palpable during its advancement may prevent this complication. It may be acceptable to leave the shunt tube in place after chest drainage for pneumothorax.

Concepts: Pulmonology, Lung, Respiratory system, Pneumothorax, Hydrocephalus, Pleural cavity, Tension pneumothorax, Cerebral shunt


Subatmospheric pleural pressure (Ppl), which is approximately -3 to -5 cmH2O at functional residual capacity (FRC) makes pleura a unique organ in the human body. The negative Ppl is critical for maintaining the lungs in a properly inflated state and for proper blood circulation within the thorax. Significant and sudden pleural pressure changes associated with major pleural pathologies, as well as therapeutic interventions may be associated with life-threatening complications. The pleural pressure may show two different values depending on the measurement method applied. These are called pleural liquid pressure and pleural surface pressure. It should also be realized that there are significant differences in pleural pressure distribution in pneumothorax and pleural effusion. In pneumothorax, the pressure is the same throughout the pleural space, while in pleural effusion there is a vertical gradient of approximately 1 cm H2O/cm in the pleural pressure associated with the hydrostatic pressure of the fluid column. Currently, two main methods of pleural pressure measurement are used: simple water manometers and electronic systems. The water manometers are conceptually simple, cheap and user-friendly but they only allow the estimation of the mean values of pleural pressure. The electronic systems for pleural pressure measurement are based on pressure transducers. Their major advantages include precise measurements of instantaneous pleural pressure and the ability to display and to store a large amount of data. The paper presents principles and details of pleural pressure measurement as well as the rationale for its use.

Concepts: Heart, Pressure, Pneumothorax, Pleurodesis, Thoracic cavity, Pleural cavity, Pressure sensor, Tension pneumothorax


Occult pneumothorax is a condition in which a patient’s clinical examination and chest radiograph are normal; but there is pneumothorax on computed tomography (CT) scan. We here describe two cases of trauma whose initial survey and chest X-ray showed normal lung markings bilaterally; but CT scan done subsequently, showed pneumothorax which was managed by chest intubation. There is still an ongoing debate about the management of occult pneumothorax. Simple observation is recommended for an asymptomatic pneumothorax. However, chest intubation is recommended for patients undergoing a surgery or mechanical ventilation due to the fear of converting a close pneumothorax into a tension pneumothorax.

Concepts: Pulmonology, Hospital, Medical imaging, Mechanical ventilation, Pulmonary contusion, Radiography, Pneumothorax, Tension pneumothorax