Catamenial pneumothorax

Background
  • Definition: Spontaneous, recurrent pneumothorax in women of reproductive age, occurring in temporal relationship with menses[1]
  • Caused by endometriosis of the pleura[1]
  • 3-6% of pneumothoraxes in women[1]
  • A form of thoracic endometriosis syndrome

Clinical Features

Differential Diagnosis

Pneumothorax Types

Evaluation

Clinically Stable

Defined as having all of the following:

  • Resp rate < 24
  • Heart rate 60-120 beats per minute
  • Normal BP
  • SaO2 >90% on room air and patient can speak in whole sentences

Workup
  • CXR
    • Displaced visceral pleural line without lung markings between pleural line and chest wall
    • Upright is best
      • Expiratory films DO NOT improve accuracy[2]
      • Lateral decubitus films with suspected side up do increase sensitivity. Good approach in pediatrics to avoid CT
    • Supine CXR = deep sulcus sign
  • CT Chest
    • Very sensitive and specific

Lung ultrasound of pneumothorax
  • No lung sliding seen (not specific for pneumothorax)
  • May also identify "lung point": distinct point where you no longer see lung sliding (pathognomonic)
  • Evaluate other intercostal spaces because pneumothorax may only be seen in least dependent area of thorax
    • NO comet tail artifact
    • Bar Code appearance/"Stratosphere" sign on M-mode (absence of "seashore" waves)

Management

Supplemental oxygen (non-rebreather mask) initially for all

Unstable

Stable

Adult Chest Tube Sizes
Chest Tube Size Type of Patient Underlying Causes
Small (8-14 Fr)
  • Alveolar-pleural fistulae (small air leak)
  • Iatrogenic air
Medium (20-28 Fr)
  • Bronchial-pleural fistulae (large air leak)
  • Malignant fluid
Large (36-40 Fr)
  • Traumatic pneumothorax
    • 2012 study using 28-32 Fr tube just as good as 36-40 Fr tube. [3] This is reflected in the ATLS 2019 Guidelines: "ATLS ® -10 now recommends placement of a smaller 28F to 32F chest tube for any acute hemothorax that is visible on chest radiograph." [4]
  • Empyema
  • Bleeding (Hemothorax/hemopneumothorax)
  • Thick pus

Disposition
  • Admission

Complications

See Also

References
  1. NV Aikaterini, et al. "Catamenial pneumothorax: a rare entity? Report of 5 cases and review of the literature." Journal of Thoracic Disease. Vol 4, Supplement 1 (November 2012)
  2. Eur Respir J. 1996 Mar;9(3):406-9
  3. Inaba Et. al J Trauma Acute Care Surg. 2012 Feb;72(2):422-7.
  4. Advanced Trauma Life Support® Update 2019: Management and Applications for Adults and Special Populations.
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