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Counseling After Primary Spontaneous Pneumothorax: Opportunities to Reduce Recurrence Risk

Published:October 14, 2022DOI:https://doi.org/10.1016/j.amjmed.2022.09.024
      A 44-year-old healthy male smoker presented with acute-onset sharp, left-sided chest pain and mild dyspnea worsened by movement or deep inspiration. He denied prior episodes, history of trauma, cough, palpitations, nausea, vomiting, or constitutional symptoms. He is a current smoker with a 20-25 pack-year history. He has a comparably long history of crack cocaine inhalation (no intravenous use) and alcohol use, which he attributes to childhood exposure to drugs and violence, but had been abstinent for 2 months prior to presentation. He continues to smoke cigarettes to reduce cravings for crack cocaine or alcohol and participates in Alcoholics Anonymous. Physical examination demonstrated normal body habitus and symmetric chest expansion without signs of trauma. Hyperresonance to percussion and decreased breath sounds were noted in the left upper and middle lung fields. The diagnosis of left-sided primary spontaneous pneumothorax was confirmed with chest x-ray study (Figure, A) and noncontrast computed tomography (Figure, C and D). Due to the large-sized pneumothorax (50% collapse of the lung on computed tomography) and concern for respiratory collapse, a chest tube was placed, and he was admitted for observation. Repeat chest x-ray study 48 hours later revealed resolution and the chest tube was removed (Figure, B). Prior to discharge, we counseled the patient on smoking cessation and its potential to prevent recurrence.
      Figure
      Figure(A) Initial frontal upright chest radiography demonstrating left chest pneumothorax in the range of 30% (arrows). (B) Frontal upright chest radiography after removal of the left pleural drain 48 hours later demonstrates no pneumothorax. (C) Initial noncontrast computed tomography of the chest in the axial and (D) sagittal planes demonstrating a left-sided 50% pneumothorax (arrows) and no emphysematous blebs or bullae.
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