A pneumothorax is air in the pleural space. It may be spontaneous or related to trauma.

Clinical signs of a pneumothorax are reduced breath sounds/air entry on auscultation and being hyper-resonant to percussion. There may also be mediastinal shift if the pneumothorax is large enough. This can be detected by feeling for the trachea in the neck and determining if it is midline or not.

A big tension pneumothorax is a medical emergency. A large bore needle to aspirate the air must be inserted quickly to save the patient's life. This can be done by grabbing a large bore cannula (18 gauge or larger) and poking in the second intercostal rib space in the mid-clavicular line.

A tension pneumothorax should NEVER be confirmed by X-ray. If it is not obvious clinically, the patient is likely to be dead by the time the X-ray is taken.

This has happened to me as well. My doctor said it tends to hit tall skinny men, statistically. I got the same condescending treatment from my docs, although the culprit was a pack of unfiltered Camels.

People trying to hold their tobacco / pot / crack / meth smoke in will take a deep breath and hold it with a Valsalva maneuver. FWIW, we also do this every time we defecate. This puts stress on the lungs, and if you have any blebs or defects in your lung, they might blow out. The trauma-related version of this is what happens to Mark Wahlberg's character in Three Kings.

It feels like the end of the world. The key observation for those thinking, "Great: heart attack at 23!" would be that it hurts most when you breathe. Not that it matters when you can't get enough air.

I had a spontaneous pneumothorax a few months ago. Well, at least it could have been spontaneous. I had an injury a while ago which may or may not have made it traumatic.
 
But anyway, I'm male, six foot and 65 kilos. That makes me about a 19 on the BMI scale, which apparently puts me right in the group most at risk from the condition. I don't smoke or drink.
 
It was horrible, when it happened. I woke up on a Wednesday morning and couldn't breathe. At first it felt like a very bad stomachache. I moved around for a few minutes and eventually ended up face down on my bed again, because lying down always helps for stomachaches with me. Well, you can probably guess it didn't go away. And after a while I thought that maybe something was wrong with my heart. I tried scrabbling around for some aspirin.
 
After a few more minutes I staggered down to my housemates. They didn't make much of it, but after another few minutes they were getting ready to take me off to my GP. At first I was going to try making it to a bus stop. That didn't work. Every few steps I had to hunch down and try to take in more air. I thought I was going to die every few more steps I took. In they end they called me a cab, which took us to the GP. I staggered up to the reception and rasped out "doctor." She looked at me and said, "Do you want to make an appointment?" I rasped again, "now..."
 
After about 30 seconds worth of inspection and tapping me on the back the GP called an ambulance out. Anybody else find ambulance crews to be more like a stand-up comedy routine?
 
Well, at the hospital I was wheeled into the kiddie cubicle in A&E (ER for any Americans). It was good for me I suppose, because there was a mural of a giraffe on the ceiling, and I like giraffe. But another thing you should know about me is that I have an abject terror of needles. Cold sweat, just thinking about one.
 
I got x-rayed, and this was the worst part: me sat naked from the waist up, looking across the room at a group of nurses and doctors looking at my x-ray, unable to see it myself, and unable to read anything on their faces.
 
When they wheeled over a tray full of nasty looking implements I could sort of guess what the outcome was. The doctor (a very nice guy) pinned up x-ray, and I didn't really read it at first. I could see something massively wrong, but not as wrong as I first thought. What I first thought was that the gaping blackness on my right side was a lung without oxygen, or something like that. Then the doctor pointed out my lung, just like a shrivelled apricot hanging limply from my heart.

Total. Pneumothorax.

First they tried aspirating me. A needle phobic, being aspirated. It helped that I had a very attractive nurse whose hand I'm sure required x-raying afterwards.
 
My housemates were allowed in after they finished, and tried making me think a little more positively, as I'm a tad negative at the best of times, but this situation just gave me a field day.
 
I hate being right. Next of course came the chest drain. Well, I had the nurse again, so I really can't tell you much else, except she had really incredible eyes (and surgical knives must really be as sharp as they look).
 
After that I was wheeled into one of the critical care booths (away from my giraffes and eyes, sadly). I was sat clenching the sides of my bed, smelling my own blood and meat on my breath. And the sweat was pouring out of me. I still had my trousers on, and although I never looked, I knew they were covered with my blood and perspiration.

I must have sat for a couple of hours like that, scared. Everybody in there was moaning or whimpering. Pretty soon I was doing the same. A massive and fiery pain was right in the middle of my chest, and it just kept building and building. It would not stop, and at first I was just whimpering, trying not to let out how painful it really was. That didn't work very well, because it kept building and building, like someone had poured gasoline over my heart and struck a match.

A couple of nurses came over right away when I started screaming through clenched teeth (it's possible I tell you!). They quickly got a doctor, who ironically, would be the source of far more pain than she ended up curing just then. She told me the pain was probably the tube knocking into my heart. So she took away the bandages and started to slowly pull it out. She kept asking me, "Any better, any better?" and I kept saying no until instantly one second the pain stopped and I could focus again. I was patched up again and left alone, until my housemates showed up. They'd gone home and got a couple of books for me. I spent the rest of the evening reading Braudel and listening to a doped up 12 year old girl scream at nurses and security officers.

I had honestly thought I would be out in a few hours time. I thought I was going to recuperate in A&E for the night and be out in the morning. I was quite shocked when they wheeled me up to critical care around midnight. Maybe this was worse than accident and emergency even: utter silence on the ward. Sometimes it would be broken by an alarm going off and crash carts flying down the corridor. The odd death here and there I thinkā€¦

I read about ancient Islam until five in the morning when I took another trip: this time to a specialist chest care unit. My home for the next four or five days. People weren't dying on this ward (at least not visibly so) but everybody on there is probably dead by now. Tracheas to the left of me, TB to the right, here I am stuck in the middle with my drain. All old people too. Nobody under about 75 or 80 years old.

I didn't sleep. I was still scared. The worst was still to come though, when I was taken for my first 'post-op' x-ray. I wanted the best, but I guess I could feel it wasn't coming.

Like I said, the doctor who temporarily relieved my pain actually ended up lengthening it. The tube had been pulled out too much and the lung was still an apricot. I was told I would have to have an entirely new drain put in. This time I was wheeled down the corridor to a small operating room. And I didn't have a nurse this time. It was far worse. I had a trainee doctor. She held my hand, but actually made it worse by just intently staring at what was going on underneath my arm. I think I came close to blacking out when the doctor unceremoniously stuck her finger in me while she readied the new drain. Eventually it was over, but I could not move for the pain. I had to go straight down to x-ray to check the pipe was in place, and in time I managed to inch my way off the table and into a wheel chair, complete with oxygen (hadn't been off oxygen since I had got into the ambulance). Thankfully the porter was very careful manoeuvring around the corridors, because I couldn't move or mutter a sound with the numb pain coursing through my entire chest.

Back up to the ward half an hour later, and luckily it was in, and seemed to be working. I've never been so thankful to hear someone tell me I'm 'swinging' in my entire life.

Once I was settled for the night (and started on Ancient Africa in Braudel) they told me they were going to put me on suction to speed up the process. Fair enough I thought. They can't do any worse than what I've been through.

Yeah. Right.

I woke up as if it was all happening again sometime in the very early hours. This time it wasn't like in A&E when my moaning got slowly louder. I went straight for the full pitch this time, because instead of just pouring gasoline over my heart, someone was now shoving red-hot needles into it. The nurses came pretty sharpish even without me pressing the emergency button (they ignored it anyway; the guy next door literally pressed it every few seconds, in between banging the switch against his bed).

They got me syringes of morphine to be taken orally, and I swilled them down like water. A male nurse sat next to me, shouting at me to stay conscious, and I really do believe his hand was x-rayed afterwards. I was totally immobilised with pain. Absolutely rigid. I tried shifting me knees, from ninety degrees to more like one hundred and twenty, but that was it. I think I was like that for a few minutes, maybe fifteen at the most. It seemed like hours. I must have fallen asleep again finally. The morphine may not do anything for the pain, but it sure knocks you out.

As I found out the next morning (after the doctors had finished standing at the bottom of my bed, discussing me with a clinical eye) the suction they had put me had been put too high. It was supposed to be ten; I was on thirty. A nurse told me that if they hadn't disconnected it as quick, it would probably have killed me as quick as my original pneumothorax.

But after all this, the days went by and I got progressively better. In fact, on the last night, I even seem to remember asking the nurses if they wanted to come and have a party in my cubicle (they did, probably to get away from 'Fred', the button pusher next door).

What I really want to know is how many needles I eventually had stuck into my side in total. I should have kept count. It would have been quite amusing. Must have been somewhere in the vicinity of twenty at least.

But I got out. Dazed, but I didn't really feel much pain. What was worse is what comes after I guess. Not being able to exert yourself. No flying, period.

And now I can't do things that I had wanted to, like scuba dive. I've started exercising properly again now, but it seems whatever I do I'm always thinking about my lung. Will it, won't it? Like some kind of bad television programme where characters have will they, won't they romances, my lung now has a will it, won't it relationship with me. The chances of it happening again are still low. Just ten times more likely. Sounds like a lot, but it still isn't much percentage wise.

But it'll always be there, that chance, just like the long scar which runs underneath my arm.
 

Pneu`mo*tho"rax (?), n. [Gr. air + E. thorax.] Med.

A condition in which air or other gas is present in the cavity of the chest; -- called also pneumatothorax.

 

© Webster 1913.

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