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EMJ "Bilateral spontaneous pneumothorax? The case for prompt chest radiography "

S C Wilkie(1), L J Hislop1 and S Miller(2)

(1) Department of Accident and Emergency Medicine, Royal Alexandra Hospital, Paisley PA2 9PN
(2) Department of Anaesthetics and Intensive Care, Royal Alexandra Hospital

Correspondence to: Dr Hislop, Consultant in Accident and Emergency Medicine(stewart_wilkie@hotmail.com)

Simultaneous bilateral spontaneous pneumothorax is a rare condition occurring in up to 1.9% of cases of spontaneous pneumothorax.1 Risk factors include male sex, smoking, height and underlying lung conditions. An increase in the incidence is seen in AIDS patients with underlying pneumocystis carinii infection.2 In contrast with a large unilateral pneumothorax, simultaneous bilateral spontaneous pneumothorax presents difficulties in diagnosis from clinical signs alone and definitive diagnosis requires chest radiography.

A 39 year old man self presented to the accident and emergency department with acute dyspnoea. On arrival at the department he was in severe respiratory distress and unable to give any history. Initial examination found him to be extremely agitated, cyanosed and tachypnoeic. Although he was maintaining his own airway and his trachea was central, air entry was poor into both sides of his chest. Both hemithoraces were resonant to percussion and scattered crackles were audible on auscultation throughout both lung fields. Arterial oxygen saturation was only 60% despite administration of 15 litres oxygen via a non-rebreathing mask with a reservoir bag. Cardiac output at this time was not impaired. Intravenous access was secured and a chest radiograph obtained. Arterial blood gases revealed a type 2 respiratory failure with pH 6.99, PO2 6.49 kPa, PCO2 9.80 kPa, and base excess was -14.7.

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