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BMJ Case Rep. 2009; 2009: bcr07.2009.2054.

Published online 2009 Dec 7. doi: 10.1136/bcr.07.2009.2054


PMCID: PMC3027950
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3027950/?report=classic
Reminder of important clinical lesson

Bilateral tension pneumothorax resulting


from a bicycle-to-bicycle collision
Frank Edwin,1 Lawrence Sereboe,1 Mark Mawutor Tettey,1 Ernest Aniteye,1 Patrick Bankah, and Kwabena
Frimpong-Boateng1

Abstract
Bilateral tension pneumothorax occurring as a result of recreational activity is exceedingly
rare. A 10-year-old boy with no previous respiratory symptoms was involved in a bicycleto-bicycle collision during play. He was the only one hurt. A few hours later, he was rushed
to the general casualty unit of the emergency department of our institution with respiratory
distress, diminished bilateral chest excursions and diminished breath sounds. The correct
diagnosis was made after a chest radiograph was obtained in the course of resuscitation at
the casualty unit. Pleural space needle decompression was suggestive of tension only on
the right. Bilateral tube thoracostomies provided effective relief. He was discharged from
hospital after a week in excellent health. This case illustrates the need for children to have
safety instruction to reduce the risks of recreational bicycling. Chest radiography may be
needed to establish the diagnosis of bilateral tension pneumothorax. Needle thoracostomy
decompression is not always effective.

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Background

collision just before the moment of


impact. Unfortunately, during one of such

Bilateral tension pneumothorax (BTP) of


any cause is rare. Clinical signs alone
may not be adequate to establish the
diagnosis. Barotrauma occasioned by
positive pressure mechanical ventilation
is responsible for most cases of BTP.
BTP following blunt trauma suffered
during recreational sporting activity is
exceedingly rare. We report such a case
in

young

boy

following

an

unsupervised recreational bicycle activity


to highlight the diagnostic challenges, the
problems with pleural space needle
decompression, and the necessity of
safety instruction for children engaged in
recreational outdoor activities.
Case presentation

runs, both riders swerved in the same


direction and collided. The game was
interrupted to attend to this 10-year-old
who complained of chest pain and some
shortness of breath; the other victim of
the collision suffered no ill effects. A few
hours later, the boy was noticed to be
increasingly breathless and restless. The
older siblings were informed, following
which the boy was rushed to the casualty
unit of our institution. At the casualty
unit, the history of the collision during
play was withheld; the boy was reported
to have been taken ill while at play. The
casualty doctor on call found the patient
to be restless with laboured breathing,
with a tachypnoea of 40/min and
bilaterally reduced chest excursions and

A 10-year-old boy was rushed to the

breath sounds. There was no tracheal

general casualty unit of the emergency

deviation. The percussion notes were

department of our institution with acute

judged to be resonant bilaterally. On high

respiratory distress of a few hours

flow oxygen (12 litres/min) by reservoir

duration. The boy had been in previous

bag, the Spo2 was 74%. He had a

good health with no prior lung disease.

tachycardia of 134/min and a blood

He had been involved in an unsupervised

pressure of 86/54 mm Hg. Lacking an

bicycle sport with friends at home a few

accurate history at the time, and on the

hours before onset of symptoms. The

basis of acute onset of reduced air flow to

goal of the sport was for two opponents

both lungs, an upper airway obstruction

to race their bikes at top speed toward

was (mis-) diagnosed. The decision to

each other and swerve to avoid a head-on

proceed to a tracheotomy (based on

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insufficient evidence of upper airway


obstruction)

was

erroneous.

The

tracheotomy attempt was soon abandoned


when subcutaneous emphysema became
obvious. The cardiothoracic team was
contacted while a chest radiographic
examination was arranged at the casualty.
Investigations
The chest radiographic examination (fig
1) was performed at the casualty unit
shortly before pleural space needle
decompression was attempted bilaterally.
The chest film was ready for viewing

Figure 1
Chest x-ray showing bilateral tension
pneumothorax.
Differential diagnosis

while a right sided chest tube insertion

Upper airway obstruction was the initial

was near completion. It showed bilateral

working diagnosis although the basis for

tension

this

pneumothorax

evidenced

by

was

questionable.

When

the

collapse of both lungs, hyperexpansion of

cardiothoracic

both chest cavities, depression of both

spontaneous

hemidiaphragms, and compression of the

bilateral, was suspected though bilateral

lateral cardiac borders and mediastinum.

tension physiology was not considered.

team

was

pneumothorax,

contacted,
possibly

Rib fractures were not demonstrable. A


second chest tube was inserted on the left
side.

After

the

bilateral

tube

thoracostomies, a repeat x-ray showed


expansion of both lungs and relief of the
features of tension.

Treatment
Resuscitation included administration of
high flow oxygen by reservoir bag.
Needle decompression of the pleural
space using a 16 gauge over-the-needle
cannula (inserted full length, about 4.5
cm into the fifth interspace, mid-axillary
line) was performed. This produced a
brief hiss of air on the right but not on the
left side. Chest tube insertion was then
performed on the right and subsequently
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on the left side (fifth intercostal space

respiratory function and normal lung

mid-axillary line on both sides) with

fields on chest x-ray.

resolution of respiratory distress. Chest


tube decompression produced expulsion
of air under pressure indicating bilateral
tension pneumothorax. Expansion of both
lungs was confirmed radiologically (fig
2) afterwards.

Discussion
Although BTP of any aetiology is rare,
unilateral tension pneumothorax (UTP) is
not uncommon following blunt chest
trauma. A pneumothorax after blunt chest
trauma results when a fractured rib is
driven inwards to cause a lung puncture
or laceration. It may also result from
sudden compression of the chest with a
closed

glottis

without

rib

fracture.

Vianos group1 estimated that the force


for all impact speeds resulting in rib
fracture range from 5.511.2 kN; the
force required to cause a pneumothorax
in the absence of rib fracture is unknown.

Figure 2
Post-tube

thoracostomy

chest

x-ray

showing expansion of both lungs.


Outcome and follow-up

Sports- or recreational activity-related


chest trauma is uncommon, representing
only 2% of all chest injuries requiring
treatment.2 The largest series of sportsrelated pulmonary air leaks has been

The child made a smooth recovery

reported by Kizer and MacQuarrie.3 In

following tube thoracostomies and was

their report, the greatest number of cases

discharged home after seven days of

of sports related traumatic pneumothorax

hospitalisation. The full details of the

resulted from martial arts, bicycling, and

events leading up to the injury were

equestrian sports.3 To the best of our

obtained on the third day of admission

knowledge, this is the first report in the

when the patient himself could be

English literature of a bicycle-to-bicycle

interviewed in detail. The patient remains

collision resulting in bilateral tension

well 5 years after the event with excellent

pneumothorax.

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The amount of kinetic energy involved is

setting. Although we recognise that risk

a significant factor in impact injuries. In

is an inevitable downside to childhood

the case under discussion, riding the

play and activity, a closer look at

bicycle at top speed was a fundamental

childhood

determinant of the resulting injury.

patterns from which risk reduction

Barotrauma, the presumed mechanism of

strategies can be derived. In the case

injury,

under discussion, a simple directive to

transalveolar pressure of 35 mm Hg when

the sport (for example, each opponent

alveoli are over-distended and the more

swerving to their right just before impact)

fragile ones tend to rupture.4

could make the game less risky without

is

more

likely

above

injuries

displays

common

taking away the activity or the fun from


The

most

probable

mechanical

explanation for our patients injury is that


the moment of impact coincided with a
full inspiration against a closed glottis,
causing alveolar over-distension and
rupture without concomitant rib fracture.

the

sport.

We

certainly

encourage

childhood play and activity, and cycling


is a useful activity both for transportation
and recreation. But we believe children
need guidance to balance risk and
recreation.

Presumably, a one way valve mechanism


resulted in both pleurae to give rise to

While the diagnosis of UTP may be

BTP in the interval between impact and

difficult to establish, the occurrence of

presentation

bilateral

at

the

casualty.

Other

tension

complicates

the

possible mechanisms include occult rib

diagnosis even further. The diagnosis of

fractures

and

BTP using clinical signs alone may be

barotrauma resulting from air forced

difficult.5 Reduced chest wall excursions

down an open glottis during high speed

and diminished breath sounds occurring

cycling.

bilaterally may be confused with other

causing

pneumothorax

entities such as severe asthma6 or upper


Wearing of protective gear by children
using

bicycles

as

means

of

transportation and recreation has been


advocated

and

adopted

in

several

countries. This advocacy has not been


paralleled by safety education towards
risk reduction by children in the same

airway obstruction. In the reported case,


the diagnosis of upper airway obstruction
was based on insufficient evidence; good
clinical
indicated

examination
the

pneumothorax.
clinician,

would

have

likelihood

of

The

however,

unsuspecting
is

unlikely

to

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establish the diagnosis of BTP in this

Presumably the cannula was obstructed

case. Others7 have reported on the

by blood or tissue and could not drain. A

inconsistencies in eliciting the commonly

larger cannula (14 gauge) may have been

taught

effective, although this was not readily

classical

signs

of

tension

pneumothorax in the emergency setting.

available at the time.

A prompt chest radiograph may be useful


in establishing the diagnosis of BTP and

The limitations of needle decompression


as a rule out investigation for tension

prevent fatality.

pneumothorax

must

be

appreciated.

Needle decompression followed by tube

Absence of the classic hiss of air with

thoracostomy is widely advocated by

needle thoracostomy does not rule out

many as the optimal approach to the

tension

patient with tension pneumothorax. It is

appreciate this fact in a patient with

also widely conceived as a rule out

tension pneumothorax is likely to result

investigation

in unnecessary morbidity and mortality.

suspected

in

the

patient

tension

with

decompression may prove ineffective


in

to

established

tension

Learning points

without chest radiography.

failure of needle decompression in


pneumothorax

have

been

Bilateral tension pneumothorax


may be a difficult diagnosis

pneumothorax. The reasons underlying


tension

Failure

pneumothorax.

However, as our case illustrates, needle


even

pneumothorax.5,8

Needle thoracocentesis does not

described by other workers. Among the

provide

factors that may result in failure of

decompression or confirmation

decompression,

for tension pneumothorax.

chest

wall

thickness

consistently

effective

relative to the needle, obstruction of the


cannula caused by blood, tissue or

Children need to have safety

kinking of the cannula are important. In

instruction to reduce the risks of

this patient, it is likely that the presence

recreational bicycling.

of subcutaneous emphysema may have


presented a relatively thicker chest wall
for penetration, although this does not

Footnotes
Competing interests: none.

explain the effectiveness of needle


decompression

on

the

right

side.

Page

Patient

consent:

Patient/guardian

consent was obtained for publication

three years. Am J Sports Med 1996; 24:


2279 [PubMed]
5. Leigh-Smith S, Harris T. Tension

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Biomechanics

of

the

human

chest,

abdomen and pelvis in lateral impact.


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Bilateral pneumothorax: a retrospective

KW,

MacQuarrie

34: 81721 [PubMed]


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Med 1997; 30: 53941 [PubMed]


Kizer

re-think?

analysis of 40 patients. Surg Today 2004;

[PubMed]

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for a

MB.

Pulmonary air leaks resulting from


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eyes

may

be

more

diagnostic than ears. Emerg Med J 2003;


20: 4956 [PMC free article] [PubMed]
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tension

pneumothorax.

Resuscitation

2005; 65: 1035 [PubMed]

51720 [PubMed]
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Pulmonary barotrauma:

diagnosis

in

American football players. Three cases in

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