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The following is a summary of “Losing Your Breath During the Storm: Spontaneous Pneumothorax and Subcutaneous Emphysema as a Complication of a COPD Exacerbation During Thyrotoxicosis,” published in the October 2024 issue of Pulmonology by Breton-Arias et al.  

Pneumothorax, where air leaks into the lung cavity, can cause lung collapse and breathing difficulties, occur spontaneously or due to underlying health issues. 

Researchers conducted a case study investigating a rare case of pneumothorax and subcutaneous emphysema in a patient experiencing a thyroid storm, demonstrating the potential link between systemic illness and pulmonary complications. 

The case involved a 70-year-old female chronic smoker with hyperthyroidism who presented with a 1-week history of worsening shortness of breath and a dry cough. In acute distress with fever, tachycardia, and tachypnea, she exhibited absent breath sounds and decreased wall movement on the right side, receiving non-invasive positive pressure ventilation before later requiring endotracheal intubation and mechanical ventilation due to severe respiratory distress. A right-sided thoracostomy tube was placed, indicating an air leak. Initial chest x-ray (CXR) showed blunting of the left costophrenic sulcus, suggesting a small pleural effusion and an 8 mm lucency at the right lung periphery.  

The follow-up CXR confirmed thoracostomy tube placement and right lung reexpansion. Tests revealed neutrophilia, anemia, transaminitis, low TSH, and high free T3 and T4. After intubation, she received fluids, antibiotics, and treatment for thyrotoxicosis. In the ICU, she was diagnosed with acute hypercapnic respiratory failure, right pneumothorax, and thyroid storm. A follow-up CXR showed improvement in the right basilar pneumothorax and a stable 1.9 cm right apical pneumothorax. Despite treatment, her condition deteriorated, leading to chest tube exchange. Days later, she developed anterior neck swelling and crepitus. A chest computed tomography (CT) scan without intravenous (IV) contrast revealed right hemo and pneumothorax with the intercostal drainage tube in situ and diffuse subcutaneous emphysema in the bilateral chest wall. The patient was managed conservatively, extubated, and transferred to the ward. 

In discussion, the importance of considering secondary pneumothorax in patients with underlying conditions, particularly with suspected COPD exacerbation, was evident, although rare, pneumothorax during a thyroid storm posed significant management challenges. 

Investigators highlighted the challenges of managing pneumothorax in patients with hyperthyroidism, particularly when complicated by subcutaneous emphysema, emphasizing the need for further research and guidelines to improve understanding and treatment. 

Source: journal.chestnet.org/article/S0012-3692(24)02671-0/fulltext