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PRIMARY SPONTANEOUS PNEUMOTHORAX WITH AN APICAL BLEB: CONTROVERSIES IN WORKUP AND MANAGEMENT

Published:September 12, 2022DOI:https://doi.org/10.1016/j.jemermed.2022.09.016
      A 16-year-old boy presented to the pediatric emergency department (ED) for evaluation of chest pain. Two days prior to arrival to the ED, he woke up with chest pain, cough, and shortness of breath. He attributed it to allergies and asthma, and used his albuterol inhaler. He described pain localized in his left chest that worsened with deep inspiration. He also felt lightheaded when taking a deep breath. He reported infrequent marijuana use and vaping. On presentation, the patient had stable vital signs with heart rate of 64 beats/min, respiratory rate of 18 breaths/min, and pulse oximetry of 100% on room air. On physical examination, he was coughing intermittently and had diminished breath sounds on the left side of his chest, but no crepitus, crackles, or wheezes were appreciated. Point-of-care ultrasound of the lung revealed absence of sliding sign, suggested by the barcode appearance on M-mode (Figure 1). Chest x-ray study showed a large, left-sided pneumothorax with mediastinal shift (Figure 2A). The patient was admitted and a left-sided pigtail chest tube was placed (Figure 2B). Chest computed tomography (CT) scan was performed to evaluate for e-cigarette or vaping use–associated lung injury and incidentally a large pleural bleb/bulla was found along the superior surface of the left upper lobe, measuring approximately 2.7 × 2.4 × 2.1 cm (Figure 3). General surgery was consulted to evaluate for possible blebectomy. Video-assisted thoracoscopy surgery (VATS) confirmed the bleb (Figure 4) and blebectomy with talc pleurodesis was performed. The patient had an uneventful postoperative stay and was discharged to home on day 4. At the time of publication, the patient has not had recurrence of pneumothorax.
      Figure 1
      Figure 1(A) Bedside ultrasound (M-mode) of our patient's lung suggesting pneumothorax with barcode sign (yellow arrow) due to lack of lung sliding. (B) Normal M-mode lung ultrasound demonstrating the appearance of waves and sandy beach with static subcutaneous tissues visualized as waves and mobile lung tissue below the pleural line producing a granular pattern visualized as sand on a beach.
      Figure 2
      Figure 2(A) Chest x-ray study (posteroanterior view) demonstrating collapsed lung tissue causing mediastinal shift (yellow arrow) and absence of lung markings (blue arrow). (B) Chest x-ray study after pigtail chest tube insertion (red arrow).
      Figure 3
      Figure 3Computed tomography of the chest demonstrating the pleural bleb (red arrow) in the coronal view (A) and axial view (B).
      Figure 4
      Figure 4Intraoperative photo demonstrating pleural bleb (black arrow).
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