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Bubbling and rattling sound when bending over turns out to be a pneumothorax

by A. de Koning

Looking back, the pain on the thorax and the slight increase in shortness of breath in the very tall and thin (2 meters and 57 kg) boy of 15 years old from this clinical class fit well with a pneumothorax. The boy is known to have an autism spectrum disorder and an immune disorder for which he receives immunoglobulins on a monthly basis. The boy’s mother mentioned to the triage nurse that she was afraid of a collapsed lung and based on the information the triage nurse had written down, the doctor also thought that the risk of a pneumothorax was definitely present prior to the consultation.

Due to the information obtained during the consultation and the physical examination, this diagnosis was found by the doctor to be unlikely and a wait-and-see policy was initiated. The symptoms remained mild and only after about 6 weeks so severe that the boy and his mother visited their own doctor. Then it turned out that there was a unilateral absence of breath murmurs based on a large pneumothorax. A drain was placed, and in the end the boy had to undergo several treatments/operations because the lung did not stay in place.
During the consultation in question, at the end of the evening, it became clear that the boy had had some pain on one side of his chest for three days, which may have arisen after sports. He was also a little more short of breath than usual, which did not worry mother because she knows this from her son, he regularly has respiratory infections. In the afternoon the pain had increased and he had heard a kind of rattling and bubbling sound when he bent over which could also be felt when you put your hand on it. 

During the consultation in the evening, the pain had already subsided a lot and the noise could no longer be generated. On physical examination, saturation was 98%, pulse 98/min, there were no signs of shortness of breath. Over the lungs, a symmetrical sonorous percussion  and normal breath murmurs were observed without any noises. The bubbling sound could not be aroused and there was nothing to feel when bending over. No abnormalities were heard about the heart. 
The doctor discussed that due to the normal physical examination, decrease in the symptoms and the atypical story of the sound, she did not have a high suspicion for a pneumothorax and did not think a chest X-ray was necessary at that time. She indicated that in case of alarm symptoms contact should be sought again and advised to go to your own GP if the symptoms persisted. 

The symptoms persisted, but were not very restrictive in the first few weeks and were not strange to the mother with her son. In the holidays that followed, he didn’t do much either, so he didn’t exert himself much for two weeks and didn’t notice that he might be short of breath. It was only after 6 weeks that the boy indicated that his shortness of breath was no longer okay and then the mother made an appointment with the doctor. Then it turned out that he had a large pneumothorax which unfortunately turned out to be difficult to treat.
Lessons learned from this case:

  1. A rattling and bubbling sound when bending over, possibly felt when placing your hand on it, may indicate a pneumothorax. When asking around among a group of general practitioners, no one had ever heard of this symptom in the practice or read/heard about it during the study. The boy’s mother said that the doctors in the hospital were aware of this phenomenon. And when you search google.nl, you will find several patients who describe the sound and feel.
  2. There are no figures known about this, but perhaps it is just wise to make a standard chest X-ray for every young man who has a habit like this boy and has pain attached to breathing, because of the higher a priori chance. Perhaps especially in a boy with an autism spectrum disorder who may find it more difficult to indicate the severity of pain and shortness of breath.
  3. A perfectly normal physical examination does not rule out a pneumothorax.
  4. Reduction of pain and shortness of breath also does not rule out a pneumothorax.
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