Acute, Severe Dyspnea in an Older Man With COPD

An 82-year-old man suddenly became extremely short of breath while helpinghis wife wash dishes. The dyspnea was not accompanied by pain, and it was notrelieved by sitting. He was taken to the emergency department after diaphoresisand cyanosis developed.HISTORY
The patient has chronic obstructive pulmonary disease (COPD) with baselinedyspnea on exertion when he walks 1 block or climbs 1 flight of stairs; thisis always relieved by stopping to rest. During 2 of the last 3 winters, he was hospitalizedfor 1 to 2 weeks for pneumonia and acute exacerbations of COPD.He also has a history of coronary artery disease. He sustained a myocardialinfarction 5 years earlier and had a single stent placed. An annual evaluationdone within the year revealed an ejection fraction of 40%; a stress test showedthe old, fixed inferior defect but no new abnormalities.Despite significant medical problems, the patient is a vibrant, self-sufficientman. His long-term medications include albuterol and corticosteroid inhalers.PHYSICAL EXAMINATION
A large-bore chest tube is placed in the right pleural space after an urgentchest radiograph reveals a large (greater than 90%) right pneumothorax. The patientis afebrile. Heart rate is 108 beats per minute; respiration rate, 20 breathsper minute; and blood pressure, 110/70 mm Hg. He complains of parietal chestdiscomfort related to the tube insertion, but he is much less short of breath.SUBSEQUENT IMAGING STUDIES
A second radiograph reveals a right pneumothorax of approximately 30%.This is managed with the chest tube (using water seal and suction) and appropriateanalgesics; his condition stabilizes. Daily chest films through day 6 revealpersistence of a 20% to 30% right apical pneumothorax. CT confirms the presenceof COPD and also shows several large bullae in both lungs, more markedin the right lung.Which of the following is the most appropriate management strategyA. Continued chest tube drainage for another 7 days to complete the lungexpansion and avoid surgery.B. Indefinite continuation of chest tube drainage; surgery is contraindicatedbecause of his age.C. Surgical thoracoscopy with staple bullectomy and a procedure to producepleural symphysis.D. Placement of a second chest tube in a complementary position, in anattempt to seal the broncho-pleural fistula that is causing the persistent airleak for this patient?CORRECT ANSWER: C
This case exemplifies the problems encountered inthe management of spontaneous pneumothorax, a relativelycommon condition. Pneumothoraxes that occur inthe absence of trauma are of 2 types:

• Primary (there is no clinically apparent lung disease).
• Secondary (lung disease-overwhelmingly, COPD-ispresent).¹This man has significant COPD; thus, his pneumothoraxis secondary.

Guidelines for appropriate management of spontaneouspneumothorax have been codified.

²

This patient meets several accepted criteria for admission and forplacement of a chest tube for drainage:

• Pneumothorax is secondary.
• Onset is sudden (his was explosive), symptomatic, andclinically worrisome.
• Pneumothorax is large, according to established criteria(eg, there is more than 3 cm between the apex and lungcopula, which is the case here).

Many primary pneumothoraxes, especially smallones, can be managed conservatively. However, almost allsecondary pneumothoraxes and most large primary onesare most safely managed by hospitalization and placementof a chest tube.More difficult issues here are whether-and when-surgical intervention is needed. The 2 main indications forsurgery are:

• To treat persistent air leaks.
• To prevent the recurrence of pneumothorax.

Both indications are present in this patient. After 6 or 7days, he continues to have an air leak and persistent pneumothorax.Most authorities agree that 4 to 7 days of observation(median, 5) is more than an adequate trial of chesttube drainage alone.

^2.

Beyond this point, delays in proceedingto surgery increase the risk of complications (eg, nosocomialinfection) and may even diminish the effectivenessof eventual thoracoscopy.

³

Thus, choice A is inappropriate.The placement of a second tube (choice D)-whichis sometimes useful in other pleural diseases, such asempyema or hemothorax-is rarely, if ever, indicated orused in pneumothorax. Choosing between medical andsurgical management of pneumothorax on the basis of patientage (choice B) was considered inappropriate bymore than 90% of the American College of Chest Physiciansconsensus panel.

²

Choice C

is the optimal management strategy for thispatient. He has a persistent air leak 6 or 7 days after pneumothoraxoccurred. He has significant and severe COPD,and a CT scan has revealed bullae. Such patients havebeen found to be at risk for fatal recurrence. Thus, therecommended therapy is thoracoscopy, staple bullectomy,and a procedure to effect pleural symphysis. Even in patientswithout a persistent air leak, results with surgical approachesseem superior to those achieved by instillationof sclerosing agents through a chest tube.

⁴

Outcome of this case.

The evening before the patient'sscheduled thoracoscopy, his temperature rose to38.5C (101.6F), a complete blood cell count revealedleukocytosis (leukocyte count of 33,000/L) with a leftshift, and a chest film showed a new infiltrate in the leftlower lobe. Antibiotics were initiated. Sputum culturessubsequently revealed Staphylococcus aureus. An 8-daycourse of vancomycin produced gradual improvement ofall clinical parameters. The patient subsequently underwentthoracoscopy and staple bullectomy with pleuralsymphysis and did extremely well. He was discharged onthe sixth postoperative day.

References:

REFERENCES:

1.

Light RW. Management of spontaneous pneumothorax.

Am Rev Respir Dis.

1993;148:245-248.

2.

Baumann MH, Strange C, Heffner JE, et al, for the AACP Pneumothorax ConsensusGroup. Management of spontaneous pneumothorax: an American Collegeof Chest Physicians Delphi consensus statement.

Chest.

2001;119:590-602.

3.

Massard G, Thomas P, Wihlm JM. Minimally invasive management for firstand recurrent pneumothorax.

Ann Thorac Surg.

1998;66:592-599.

4.

Baumann MH, Strange C. Treatment of spontaneous pneumothorax: a moreaggressive approach?

Chest.

1997;112:789-804.