A 60-year-old female presented to the emergency department (ED) for respiratory distress. Emergency medical services reports that the patient was in respiratory distress upon arrival, slowly becoming unresponsive en-route. They started the patient on continuous positive airway pressure, but she lost consciousness with oxygen saturation in the thirties and they switched to bag valve mask (BVM) ventilation, which improved saturations up to 100 percent. Narcan was administered without improvement as she was on narcotics following bronchoscopy earlier today at an outside hospital.
Vital Signs: HR 118; BP 118/76; RR 20; SpO2 99% with BVM
Pulmonary: No air movement bilaterally on auscultation
Cardiovascular: Tachycardic, palpable pulses throughout
Arterial blood gas (ABG):
- pH: 7.152
- pCO2: 64.9 torr
- pO2: 541 torr
Simultaneous spontaneous bilateral pneumothoraces (SSBP)
Single thoracic cavity/pleural-pleural communication or buffalo chest syndrome
Buffalo chest syndrome is a subtype of SSBP, a rare condition comprising only 1.6-1.9% of cases of spontaneous pneumothorax by most estimates [1, 2].
Termed “buffalo chest,” it pays homage to the buffalo, which, contrary to humans, have a singular thoracic cavity with communicating pleural cavities, making the animal particularly vulnerable to bilateral pneumothoraces when there is a single insult to either of these cavities.
An immediate chest X-ray (CXR) was obtained revealing bilateral pneumothoraces (shown above) and the patient underwent emergent bilateral needle chest decompressions with an immediate rush of air and re-expansion (shown below). A right-sided chest tube was successfully placed. Left-sided chest tube placement was attempted without success, but the left lung remained inflated. On further chart review, it was found that she had a past medical history significant for alpha-1 antitrypsin deficiency and had a bilateral lung transplant five years ago. She was transferred to the original transplant center where she eventually underwent R-sided pleurodesis and recovered well, eventually discharged home twelve days later.
We suspect that the patient had a residual intrapleural communication from her bilateral lung transplant as she had continued resolution of bilateral pneumothoraces with only one chest tube in place. Although rare, the immediate recognition, diagnosis, and treatment of SSBP and buffalo chest syndrome are crucial in the emergency setting as the consequences can be life-threatening. This may become even more important in the upcoming years if the rate of invasive mediastinal surgeries continues to increase.
Take-Home Points
- Buffalo chest syndrome and SSBP are a very rare, but potentially fatal types of the more common unilateral spontaneous pneumothorax.
- Risk factors include congenital abnormalities, underlying lung pathology (chronic obstructive pulmonary disease, alpha-1 antitrypsin deficiency, cystic fibrosis, pneumocystis jiroveci pneumonia), barotrauma, and invasive thoracic surgeries (heart/lung transplants, esophagectomy, coronary artery bypass, etc.).
- Management is similar to that of unilateral pneumothorax, with immediate needle decompression if there is concern for tension and chest tube placement, with the understanding that bilateral pneumothoraces may be treated with only one chest tube if it is the result of a pleural-pleural communication and that communication is still present.
- Akcam TI, Kavurmaci O, Ergonul AG, et al. Analysis of the patients with simultaneous bilateral spontaneous pneumothorax. Clin Respir J. 2018 Mar; 12(3): 1207-1211. PMID: 28544468
- Eguchi T, Hamanaka K, Kobayashi N, et al. Occurrence of a simultaneous bilateral spontaneous pneumothorax due to a pleuro-pleural communication. Ann Thorac Surg 2011; 92; 1124. PMID: 21871318
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