Transcript The Perfect Slide Show - University of Wisconsin–Madison

A 39 yo Man with Atypical
Chest Pain
General Internal Medicine
Primary Care Conference
K. Mae Hla, M.D.
October 11, 2006
The Case
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39 y.o. healthy epidemiologist with no
personal or family history of cardiac or
pulmonary disease
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Training for marathon: running 30 mins on
treadmill, lifting weights and biking 40 mins.
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Developed sharp right anterior chest pain
while walking home from work
I need to see “Dr. Hla”
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History of pain in the upper pectoralis
muscle past few days after a hard workout
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Denies trauma to the chest, travel hx, SOB,
cough, fever, leg pain or swelling, syncope
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Non-smoker
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PMH: labile hypertension with mild postural
dizziness
Exam- in the office
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tall male, mild distress, not dyspneic
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no hyper resonance, normal breath sounds,
no subcutaneous emphysema
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no murmurs or rubs, no intra-scapular
murmurs, BPs in both arms were normal
and equal
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point tenderness right pectoralis muscle
Clinical Course--at home
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Did not follow up with primary MD as
advised
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Continued to have pleuritic pain
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Stopped all weight lifting and minimized
exertion
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Switched to stationary biking due to notable
reduced exercise capacity
Clinical Course--in the ER
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4 days later, syncopal episode in bathroom
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Was seen in the ER and worked up for
possible cardiac syncope
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The admitting resident was surprised when
he looked up one of the routine tests
obtained
“This was the reason for my
muscle pain”
In retrospect…
He realized he had ceased all lifting and
exercise on the weekend prior to admission
because of shortness of breath
Clinical Course--in the
hospital
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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
“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?
Objectives
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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
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
Types of Spontaneous
Pneumothorax
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Primary spontaneous pneumothorax
 in healthy persons with no apparent
underlying lung abnormalities or underlying
conditions
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Secondary spontaneous pneumothorax
 Clinically apparent underlying lung disease
Global Incidence,
Morbidity & Mortality (U.K.)
Gender
Incidence Morbidity Mortality
100,000/yr 100,000/yr Per million
PSP
PSP+SSP PSP+SSP
Women
1.2-6
5.8
0.62
Men
18-28
16.7
1.26
U.S. Incidence
Olmsted 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
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
Effect of smoking on PSP
recurrence risk
Bense et. al. Chest 1987; 92:1009
No. of
cigarettes/day
Relative Risk
(men)
Relative Risk
(women)
1-12
7
4
13-22
21
14
>22
102
68
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
Genetic mutation and PSP
Gene for Familial cancer syndromechromosome17p11.2
• 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
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
Physical Findings
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Decreased chest excursions
Decreased breath sounds
Hyperresonant percussion
Subcutaneous emphysema
Pleural line on chest radiograph
Risk of Recurrence
Range 25 - >50%; 54% within first 4 years in
one study
Risk factors for recurrence in PSP
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smoking
tall stature
female gender
low body weight
Risk factors for recurrence in SSP
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age over 60 years
pulmonary fibrosis
emphysema
Cumulative freedom from recurrence
Lippert H et al. Eur Respir J 1991;4:324-31
Types of Treatment Options
1.
2.
3.
4.
5.
6.
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)
Choice of Treatment Options
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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
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)
Treatment Recommendations
based on Size
• Small < 15% SP and stable patients:
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observation and supplemental oxygen to facilitate
absorption of pleural air
• Large >15%
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Initial simple aspiration of the pleural space
Tube thoracostomy if persistent airleak and no
lung reexpansion
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)
Tube Thoracostomy Indications
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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
Pleurodesis Procedures
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Chemical pleurodesis
• Intrapleural instillation of sclerosing agents
• Tetracycline, doxycycline, talc, premedicate with
midazolam and an opiate
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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
Postgrad Med 2005;118(6) (online article)
Back to the Future…
Is he safe to fly?
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Safety of air travel following pneumothoraxa subject of debate
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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
BTS Air Travel Safety Review
and Recommendations
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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 preexisting lung disease
BTS recommendations. Air Travel Working Party-Thorax 2002;57;289-304 (Page 298)
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
What did the patient do?
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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!!!
Bibliography
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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