Endgames Case Report

A woman with periodic chest pain

BMJ 2012; 345 doi: https://doi.org/10.1136/bmj.e6869 (Published 29 October 2012) Cite this as: BMJ 2012;345:e6869
  1. A J Patel, foundation year 1 doctor1,
  2. R Som, general surgery specialist trainee year 32,
  3. G K Soppa, academic clinical lecturer, cardiothoracic surgery3,
  4. E E J Smith, consultant cardiothoracic surgeon3
  1. 1Maidstone Hospital, Maidstone, UK
  2. 2John Radcliffe Hospital, Oxford, UK
  3. 3Department of Cardiothoracic Surgery, St George’s Hospital, London, UK
  1. Correspondence to: R Som, 46 Whitehouse Way, London N14 7LT, UK rsom{at}doctors.org.uk

A 42 year old woman presented to the emergency department with a four hour history of central chest pain and breathlessness on exertion. She had been having similar chest pains on a periodic basis over the past year. Eight months before presentation, she had had a pneumothorax, which had not responded to chest aspiration or chest drain insertion, and had therefore undergone surgical pleurodesis.

On examination her breath sounds at the right base were reduced, with a hyper-resonant percussion note. She appeared comfortable at rest, with a respiratory rate of 16 breaths/min. Her blood pressure was 110/50 mm Hg and her heart rate was 60 beats/min, in sinus rhythm. Chest radiography was performed.


  • 1 If this were the patient’s first pneumothorax, how would you manage it acutely?

  • 2 What surgical procedure is used to treat recurrent pneumothorax?

  • 3 What underlying conditions might have caused recurrent pneumothorax in this patient?


1 If this were the patient’s first pneumothorax, how would you manage it acutely?

Short answer

For a first presentation of pneumothorax, if no underlying lung disease is evident clinically or radiologically, management depends on the size of the pneumothorax on chest radiography—if 2 cm or greater, needle aspiration should be attempted. If less than 2 cm, patients may be discharged with advice to seek urgent medical help if symptoms worsen. Patients should be followed up in two to four weeks in an outpatient setting.

Long answer

British Thoracic Society guidelines for spontaneous pneumothorax stipulate that primary spontaneous pneumothorax needs to be distinguished from secondary spontaneous pneumothorax to guide appropriate management.1 Secondary spontaneous pneumothorax occurs in the presence of underlying lung pathology. Active management is needed for all patients with pneumothorax who have severe …

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