INTERNATIONAL JOURNAL OF RESEARCH AND SCIENTIFIC INNOVATION (IJRSI)
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Case Report: Clinical Diagnosis of Pneumothorax–Loss of Syringe
Plunger Recoil and Recommendation on Waiting For Spontaneous
Closure of Broncho-Pleural Fistula
Anthony Chijioke Eze1, Augustine Chukwudi Onuh2, Okeke Miracle Chidiebere3
1 Cardiothoracic unit, Department of Surgery, Enugu State University Teaching Hospital, Parklane.
2* Radiation Medicine Department, University of Nigeria Teaching Hospital, Ituku-Ozalla, Enugu,
Nigeria.
3 Department of Internal Medicine, Enugu State University Teaching Hospital.
DOI: https://dx.doi.org/10.51244/IJRSI.2025.1210000071
Received: 02 October 2025; Accepted: 08 October 2025; Published: 04 November 2025
ABSTRACT
Tension-type pneumothorax in particular is a life-threatening emergency that requires prompt diagnosis and
treatment. Although imaging modalities—a chest CT scan being the gold standard—are frequently employed
for confirmation, clinical diagnosis is essential in cases when imaging delays could be lethal. A bronchopleural
fistula (BPF) complicated spontaneous pneumothorax in an obese patient with a body mass index of 43.6 kg/m².
Before the chest tube was inserted, the diagnosis was verified by a straightforward and repeatable bedside
diagnostic technique: loss of syringe plunger recoil following pleural entrance with a 16G trocar cannula. The
patient experienced a persistent air leak that was consistent with BPF after tube thoracostomy, and this was
meticulously watched. After three weeks of conservative treatment, the air leak eventually closed on its own,
negating the need for surgery. This case demonstrates how the syringe plunger recoil test can be used as a simple
and trustworthy bedside tool to support imaging in the quick diagnosis of pneumothorax, enabling prompt
treatment to start. It also implies that a cautious conservative approach may allow for the spontaneous closure
of a bronchopleural fistula with careful monitoring and the right safeguards, saving some patients from the
hazards associated with major surgery.
Keywords: pneumothorax, bronchopleural fistula, thoracostomy, plunger
INTRODUCTION
Pneumothorax is still a serious medical illness that needs to be identified and treated with urgency to avoid
potentially fatal consequences 1–3. Even while imaging techniques like computed tomography and chest
radiography are useful 4,5, bedside clinical indicators are still crucial for their early identification and intervention
to avoid death especially in tension pneumothorax 6,7. The disappearance of syringe plunger recoil during
aspiration is one such underreported bedside clinical test that could be a useful diagnostic hint. Additionally,
treating chronic air leaks—especially bronchopleural fistulae—often poses a therapeutic conundrum 8,9.
A simple bedside technique for identifying pneumothorax with a syringe and needle has been proposed over
time per clinical observations. In these situations, loss of resistance during aspiration and lack of plunger recoil
are reliably linked to pneumothorax, provided the needle is positioned correctly within the pleural cavity and
well fitted to the plunger to avoid aspiration of external air. In every case, the diagnosis of pneumothorax was
confirmed by subsequent chest tube placement.
This case study highlights the diagnostic use of syringe plunger recoil loss in pneumothorax and discusses the
recommendation to wait for spontaneous closure of a bronchopleural fistula in specific patients.
INTERNATIONAL JOURNAL OF RESEARCH AND SCIENTIFIC INNOVATION (IJRSI)
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“If The Needle Is Well Fitted To The Syringe And The Needle Is In The Pleural Cavity, If There Is No Elastic
Recoilof The Plunger Of The Syringe When It Is Pulled, There Is A Pneumothorax”
The following requirements must be fulfilled before using this method: the needle must be securely attached to
the syringe; it must penetrate the pleural cavity instead of staying inside the intercostal muscles or subcutaneous
tissue; in patients who are obese or have a thick chest wall, this can be ensured by first touching the rib with the
needle and then adjusting to pass just above it into the pleural cavity; in these patients, a wide-bore needle from
a cannula (16G or 18G) is advised.
Case Presentation
Mr. O.F., an Igbo man from Enugu State who is 66 years old and works as a minibus driver, came in with
dyspnea and chest pain that started suddenly. At presentation, he was 1.68 m tall, weighed 123 kg, and had a
BMI of 43.6 kg/m². He is a Roman Catholic. He woke up with severe chest tightness and breathing difficulties,
although appearing to be well before bed. He was treated with unknown drugs at a local hospital, made a brief
recovery, and was discharged the same day. A more serious recurrence struck nine days later, making it
impossible for him to travel even short distances without stopping. Because he wasn't getting better, he was
admitted for four days before being referred. An X-ray of the chest at the referring hospital showed a large right-
sided pneumothorax. Since air was aspirated without plunger recoil, the diagnosis was verified by aspiration
using a syringe attached to the trocar of a 16G cannula; recoil was noted when the needle lingered in soft tissue
outside the pleural cavity. After being placed at the patient's bedside, a 30F thoracic catheter caused a huge air
leak that instantly caused the attached urobag to bloat and bubble when it was later connected to an underwater-
seal drainage system.
The patient recovered, and the SPO2 on intranasal oxygen (INO2) increased from 85% to 91%. On the second
post-tube thoracostomy day, the air bubble stopped, but the patient's dyspnea deteriorated as saturation
decreased. Even though the thoracicic catheter was in place, a huge pneumothorax was still seen on a chest CT
scan, confirming that there was no pulmonary embolism, as suspected by pulmonary angiography. The CT scan
of the chest also showed lung collapse and bullae. Just beneath the original tube thoracostomy site, a second
Closed Tube Thoracostomy Drainage (CTTD) was performed using size 24F. Once more, a huge air leak
occurred, but the patient recovered and was weaned off of INO2 that same day. Within 10 hours of the second
chest tube, SP02 increased to 94% without oxygen (O2). Prior to the repeat thoracostomy, it was 88% without
02 and 90% with O2. When the initial chest tube was withdrawn during surgery, blood clots were observed to
be clogging it. Although the patient was stable and not on oxygen, the air leak continued, and a bronchopleural
fistula (BPF) was diagnosed. After that, he was prepared for a thoracotomy and fistula closure.
Fig 1:Initial chest x-ray showing pneumothorax and the patient after 2nd chest tube insertion
INTERNATIONAL JOURNAL OF RESEARCH AND SCIENTIFIC INNOVATION (IJRSI)
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Fig 2 : Chest CT-scan showing right pneumothorax with 1st chest tube in-situ but blocked before 2nd tube was
inserted.
The patient, an elderly man with class III obesity, was a high-risk surgical candidate. Furthermore, the procedure
could not be performed on the originally scheduled date due to logistical limitations. When the second chest tube
got clogged, a third was placed. Chest physiotherapy was continued and within 4-5 days before the next
operation date, the fistula closed spontaneously and air bubble stopped in the underwater-seal bottle. Chest
physiotherapy was carried out using a balloon exercise, in which the patient repeatedly inflated a balloon several
times a day. The improvised balloon device was made by securing a hand glove over the tip of a syringe (with
the needle removed) using adhesive tape, leaving a small portion of the syringe barrel at the opposite end as a
mouthpiece after removing the plunger completely. The patient was instructed to take a deep breath and exhale
forcefully into the glove in a single continuous blow until he could no longer sustain the effort, thereby promoting
deeper subsequent breathing. This exercise was performed multiple times daily. In addition, the patient was
mobilized out of bed and encouraged to ambulate while carrying the chest drainage bottle.
Following the insertion of the second chest tube (CTTD), he received intravenous ceftriaxone and metronidazole
for 48 hours, after which he continued with oral amoxicillin/clavulanic acid 1 g every 12 hours and metronidazole
400 mg every 8 hours, but when the bronchopleural fistula (BPF) persisted for more than one week, the
antibiotics was escalated to intravenous ceftriaxone 1 g every 12 hours, levofloxacin 500 mg once daily and
metronidazole 500 mg every 8 hours which he received for six days. The regimen was then converted to oral
amoxicillin/clavulanic acid 1 g every 12 hours and metronidazole 400 mg every 8 hours for five days.
Analgesic management initially consisted of intramuscular paracetamol 600 mg every 8 hours for 24 hours,
followed by oral paracetamol and arthrotec. However, with the insertion of another chest tube and persistence
of the BPF, he was commenced on intramuscular tramadol 100 mg every 8 hours and diclofenac 75 mg every
12 hours for 72 hours, after which he was switched to oral co-codamol (paracetamol 500 mg/codeine 8 mg) two
tablets every 8 hours and arthrotec (diclofenac 75 mg/misoprostol 200 µg) one tablet every 12 hours for five
days. For gastroprotection, intravenous omeprazole 40 mg daily was administered for 72 hours. Deep vein
thrombosis prophylaxis consisted of subcutaneous enoxaparin 40 mg daily for two weeks, with oral rivaroxaban
15 mg every 12 hours (stopped after six days), and subsequently dabigatran 150 mg daily was given as well.
Repeat CXR was done when the air bubble stopped. There was still lower lobe collapse but the saturation was
satisfactory. The two chest tubes (both patent and the blocked one) were clamped with two forceps in each tube
for more than 36hrs and there was no respiratory distress. SPO2 was 96-97% on the extubation date and remained
so after the chest tubes were removed. He was still observered in the hospital untill the next day and then
discharged home to be followed up in the clinic. SPO2 still 96-97% on the day of discharge. Durration on chest
tube was 22days (approx 3weeks)
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Fig 3 : Improvised balloon used for chest physiotherapy--deflated and inflated
Fig 4-CXR after 3rd CTTD showing lung expansion.Air bubble has stopped
Past Medical and Surgical History
He had a ventral abdominal hernia repaired and a bilateral inguinal herniorrhaphy, both of which resulted from
carrying a big object in Belgium. He has no known history of diabetes or hypertension, is married, has three
kids, does not smoke, drinks alcohol in moderation, and has no known medication allergies.
Fig 5: CXR 5 days and 1month after discharge respectively.
INTERNATIONAL JOURNAL OF RESEARCH AND SCIENTIFIC INNOVATION (IJRSI)
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DISCUSSION
The buildup of air in the pleural cavity, known as a pneumothorax, can occur spontaneously or as a result of
trauma 10,11. As the name implies, traumatic pneumothorax happens after a blunt or penetrating chest injury 7. It
can also be iatrogenic following medical procedures such intermittent positive pressure breathing or central line
insertion 11,12. Conversely, spontaneous pneumothorax occurs without any known trauma 13,14. It can be
categorized as secondary when linked to illnesses like emphysema or cancer, or primary when no underlying
lung disease is found 15,16, but there is a challenge of this definition among those who feel it is a continumm with
secondary pneumothorax 17. Older persons are more likely to get secondary pneumothorax; the maximum
prevalence has been documented between the ages of 60 and 64yrs 13,18. Primary spontaneous pneumothorax is
more common in children and young adults 13,15, frequently due to burst bullae 17,19, even if the underlying lung
disease is not usually diagnosed and may be connected to congenital abnormalities. Any type of pneumothorax
can be categorized as tension pneumothorax if there is cardiovascular compromise and mediastinal shift 7, or as
simple if there is neither. In the former case, intrapleural pressure rises above atmospheric pressure for the
majority of the respiratory cycle 7,10,20. Tension pneumothorax is a surgical emergency, and the patient's life
depends on a timely diagnosis and treatment6. Since chest X-rays are used to discover the majority of cases, it
is currently less usual to identify tension pneumothorax based solely on clinical indicators 21. However, in this
situation, an efficient, dependable, and readily repeatable clinical diagnosis is essential, especially in
underdeveloped nations and environments with limited resources, where delays in acquiring imaging may arise
from a lack of facilities or financial limitations. Some patients may die in these circumstances while undergoing
diagnostic testing.
Reduced tactile fremitus, a hyperresonant percussion note, decreased or missing breath sounds on the affected
side, and decreased chest excursion are clinical indicators of pneumothorax on chest examination 7,22,23. The
diagnosis is further supported by evidence of respiratory discomfort and tracheal deviation to the opposite side.
Disorientation, cyanosis, and hypotension might happen, especially when tension pneumothorax occurs 6,19,24.
Acute chest pain and dyspnea are the hallmark symptoms of spontaneous pneumothorax, occurring in as many
as 95% of patients 19,22. However, a lack of clinical acumen, patient instability in emergency situations, or
difficulty with examination might make clinical diagnosis difficult, particularly in obese people or those with a
thick, muscular chest wall (like our index patient) 18. Variability in interpretation also exists since results might
vary depending on how each person interprets what they hear or feel. Therefore, a more objective and repeatable
clinical evaluation is very beneficial—indeed, revolutionary and incredibly fulfilling. A well-described clinical
test is the presence of a hissing sound when a needle is inserted into the pleura in pneumothorax, or the deflection
of light paper or cotton wool when air escapes 25–27. These symptoms, however, could not always be present or
might not be fully recognized, which could lead to a lack of assurance regarding the diagnosis and a propensity
to request imaging, which has dangers and delays for the patient. Both the hissing sound and the cotton wool
deflection signs are highly subjective, difficult to demonstrate, and often leave uncertainty as to whether they
actually occurred. They are also not easily reproducible and require a large volume of air under pressure for
demonstration. In contrast, the loss of plunger recoil is far superior—it is objective, easy to demonstrate and
understand, and consistently reproducible.
A visible pleural line 28–30 and the lack of lung markings are used to diagnose pneumothorax on a chest X-ray
(CXR). However, interpretation is dependent on the experience of the doctor, and it is easy to overlook data.
This limitation is especially more noticeable in emergency situations involving unstable patients, when low
diagnostic accuracy 31 may nevertheless be achieved by combining clinical evaluation with an anteroposterior
(A-P) CXR. The diagnostic yield 32 can be enhanced by using oblique CXR. The aspiration and loss of plunger
recoil approach will be highly useful in ambiguous situations. Although the gold standard for detecting
pneumothorax, a chest CT scan is simpler to interpret 33,34, it is costly, necessitates patient transportation, and is
frequently inaccessible, especially in areas with limited resources where even basic CXR machines might not be
available or functional, requiring referral for imaging outside of the hospital.
When it is accessible, ultrasonography can also be used to diagnose pneumothorax at the patient's bedside. The
presence of a lung point, a particular spot where pneumothorax starts, is one of the sonographic findings. It is
characterized by lung sliding that is apparent on one side and absent on the other, which is just air. The absence
of lung pulse, which indicates the regular movement of the lung against the chest wall with each heartbeat 35–37,
INTERNATIONAL JOURNAL OF RESEARCH AND SCIENTIFIC INNOVATION (IJRSI)
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and horizontal hypoechoic B-lines (comet-tail artifacts) are other diagnostic indicators. With reported
sensitivities of 78.6–88.0% for ultrasound against 39.8–52.0% for CXR, the sensitivity of chest ultrasonography
in diagnosing pneumothorax is comparable to that of chest CT scan 35 and substantially greater than that of CXR.
With a specificity range of 98.4–99.0% for ultrasonography and 99.3–100% for CXR 38,39, both modalities are
comparably high.
As far as we are aware, aspiration and loss of plunger recoil have not been documented in the literature as a
means of clinically diagnosing pneumothorax. In order to facilitate early diagnosis and prompt initiation of
appropriate intervention for pneumothorax, we present this report with the hope that it will improve clinical
practice. This is especially important in emergency situations and resource-constrained settings where imaging
is not easily accessible. Additionally, we propose that aspiration with lack of plunger recoil, as previously
mentioned, offers a trustworthy supportive diagnostic tool³² in situations where CXR results are unclear.
If the border depth from the chest wall to the pleural line is less than 2 cm or the apical length is reduced by less
than 3 cm, the pneumothorax is considered minor; if it is more than 2 cm 19,40,41, it is considered large. Small
pneumothoraces can go away on their own without medical intervention 4. On the other hand, severe
pneumothorax frequently necessitates intervention such as aspiration 42,43 or tube thoracostomy 42,43. To close
BPF and treat the underlying cause of persistent or recurrent pneumothorax, however, thoracoscopy or
thoracotomy may be required in certain cases 44–47.
There is disagreement over the best time to wait for a bronchopleural fistula (BPF) to potentially close on its
own with CTTD alone before undergoing a major surgical procedure such a thoracotomy, and there is a lack of
documentation on this topic 44,48. The American College of Chest Physicians recommends 4days 49, Matthur and
colleages 50 recommended 7-9days waiting for closure of BPF from primary spontaneous pneumothorax and
Chee et al 51 noted in ther study that 100% of BPF from primary spontaneous pneumothorax closed within 15
days on CTTD and 79% for those from secondary. The risks and expenses of major surgery are avoided with
watchful waiting on CTTD, but there is a chance of developing empyema⁴¹ with extended surveillance. Even
though surgical closure has been demonstrated to yield excellent results 44, our experience with the index patient,
albeit an isolated case, indicates that BPF may spontaneously close with CTTD alone after waiting up to 21
days with proper analgesia, antibiotic coverage, and adequate chest physiotherapy, especially in high-risk
surgical candidates. However, a multicenter observational study or formal clinical trial is required to confirm the
effectiveness of this long-term conservative management strategy and potentially develop recommendations for
its application, particularly in high-risk patients.
CONCLUSION
Loss of syringe plunger recoil during aspiration is a helpful adjunct to CXR for confirmation and is a consistent
and repeatable clinical indicator of pneumothorax. In addition, individuals who are at high surgical risk may
benefit from a 21-day period of attentive waiting for the bronchopleural fistula to spontaneously close on CTTD
while taking appropriate measures.
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Disclosures and declarations
Ethics approval and consent to participate: The ethical approval for this study was gotten from the Research
and Ethical Clearance Committee of the Faculty of Basic Medical Sciences, College of Medicine, Enugu State
University of Science and Technology, Enugu.
Availability of data and materials: Data and material are available
Competing interests: The authors declare that they have no competing interests
Funding: There is no external funding for the research