Isolated clinical reports will always remain an important addition to the literature.

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Isolated clinical reports will always remain an important addition to the literature, especially when authors carefully gather similar cases and report these findings with a series of their admit These reviews attempt to place anecdotal reports in perspective, and before extended similarities, differences, or unexplained observations surface. of the like kind is the meaningfulness of Graf-Deuel and Knoblauch's experience with simultaneous bilateral spontaneous pneumothorax (SBSP) reported in the April, 1994 issue of Chest (see page 1142) Their 12 patients exhibit 20 percent of the 56 cases of SBSP published in the literature. single of their conclusions, that SBSP has a short-term benign prognosis, is encouraging since the undivided and only case of SBSP that I reported and managed had serious complications.(1)

The fact that nearly 70 percent of patients with SBSP have underlying lung disease, with none apparently having bullous disease or extensive emphysema, is particularly noteworthy. This information, coupl with the fact that a seemingly life-threatening disorder as SBSP does not contribute to mortality, raises an interesting paradox. Since the majority of patients with spontaneous unilateral pneumothorax (SUP) do not have coexistent lung disease,(2) the temptation would have the appearance great to assume the same in a patient with SBSP in particular, if he or she is young. Accordingly, the failure to aggressively determine if any underlying lung disorder is ready or not in SBSP could eventuate in loss of valuable time with regards to overall issue as well as suboptimal management of SBSP itself. With this in mind, the finding of SBSP should dictate that a serious chymal lung disorder is not absent Furthermore, prompt aggressive surgical therapy to treat and debar recurrent SBSP must be undertaken.

If there is a limitation of Graf-Deuel and Knoblauch's retrospective consideration and review of the literature, it is the inability to provide observations onward those patients with supposedly no underlying lung disease who go throughed SBSP. Was pleuroscopy or computerized tomography performed to lordship out apical blebs?(3)(4)(5) Were other circumstances instant which may enhance the adventure of spontaneous pneumothorax, such as smoking, ascending while diving, reasonable atmospheric humidity, altitude (particularly pilots), or injection of physics into neck veins due to medicine abuse?(1) Rupture of pulmonary tissue is owed to higher intrapulmonary pressure in at least undivided region of the lung than in other regions and the intrapleural space. This is possible barely if the intrapulmonary gas cannot find an egress via either the airways or the circulation. Accordingly, on a level if the aforementioned responsible conditions for SBSP had been eliminated, it would still be difficult to believe that SBSP can present itself in the presence of normal lung parenchyma.(6) Indeed, this is on what account subpleural bullous dystrophy is always propounded as the cause for primary sip and found at surgery in all operative patients.(3)(5)

I do believe Graf-Deuel and Knoblauch have made several important observations forward SBSP: (1) As in sip young patients (third decade) and older patients (seventh and eight decades) have chest pain and dyspnea as presenting signs(7) and the prognosis is favorable with SBSP and not likely to contribute to mortality; (2) in contradistinction to take supper where the most common underlying disease is COPD carrying a high morbidity and mortality,(8) patients with SBSP rarely if at all times have underlying COPD; (3) unlike the management of sip SBSP management must be aggressive, and include the early consideration of pleural decortication; and finally, (4) SBSP's bite is worse than its bark. Clinicians should investigate for the vicinity of serious underlying lung disease, in the same state [i]or[/i] condition as malignancy, interstitial disease, or tuberculosis, when bring face to faceed with a patient having SBSP

Robert D Brandstetter, MD FCCP novel Rochelle, NY

Associate Director, Department of Medicine, Chief of Critical Care, recent Rochelle Hospital Medical Center, and Professor of Clinical Medicine, just discovered York Medical College.

REFERENCES

(1)Lane s Fasano JB, Levitt AB, Brandstetter RD Spontaneous bilateral pneumothorax to be paid to metastatic cervical carcinoma. Chest 1987; 91:151-52

(2)Bense L Spontaneous pneumothorax. Chest 1992; 101:891-92

(3)Murray KD Matheny RG Howanitz EP Myerowitz PD A limited axillary thoracotomy as primary treatment for periodical spontaneous pneumothorax. Chest 1993; 103:137-42

(4)Lesur O Delorme N Fromaget JM Bernadec P Polu JM Comput tomography in the etiologic assessment of idiopathic spontaneous pneumothorax. Chest 1990; 98:341-47

(5)Gobbel WG Jr Rhea WG Jr Nelson IA, Daniel RA Jr Spontaneous pneumothorax. J Thorac Cardiovasc Surg 1963; 46:331-45

(6)Light RW Management of spontaneous pneumothorax. Am Rev Respir Dis 1993; 148:245-48

(7)Lechter J Gwyne JF Spontaneous pneumothorax in young enthralls Thorax 1971; 26:409-17

(8)Videm V Pillgram-Larsen J Ellingsen O Anderson G Ovrum E Spontaneous pneumothorax in chronic obstructive pulmonary disease: complication, treatment and resorts Eur J Respir Dis 1987; 71:365-71

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