{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,4,16]],"date-time":"2026-04-16T06:09:37Z","timestamp":1776319777613,"version":"3.50.1"},"reference-count":23,"publisher":"Springer Science and Business Media LLC","issue":"1","license":[{"start":{"date-parts":[[2021,3,23]],"date-time":"2021-03-23T00:00:00Z","timestamp":1616457600000},"content-version":"tdm","delay-in-days":0,"URL":"http:\/\/creativecommons.org\/licenses\/by\/4.0\/"},{"start":{"date-parts":[[2021,3,23]],"date-time":"2021-03-23T00:00:00Z","timestamp":1616457600000},"content-version":"vor","delay-in-days":0,"URL":"http:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":["link.springer.com"],"crossmark-restriction":false},"short-container-title":["BMC Pulm Med"],"published-print":{"date-parts":[[2021,12]]},"abstract":"<jats:title>Abstract<\/jats:title><jats:sec>\n                <jats:title>Background<\/jats:title>\n                <jats:p>Pneumothorax is an extrapulmonary air accumulation within the pleural space between the lung and chest wall. Once pneumothorax acquires tension physiology, it turns into a potentially lethal condition requiring prompt surgical intervention. Common symptoms are chest pain and dyspnea; hence an electrocardiogram (ECG) is often performed in emergent settings. However, early diagnosis of pneumothorax remains challenging since chest pain and dyspnea are common symptomatology in various life-threatening emergencies, often leading to overlooked or delayed diagnosis. While the majority of left-sided pneumothorax-related ECG abnormalities have been reported, right-sided pneumothorax-related ECG abnormalities remain elucidated.<\/jats:p>\n              <\/jats:sec><jats:sec>\n                <jats:title>Case presentation<\/jats:title>\n                <jats:p>A 51-year-old man presented to the emergency department with acute-onset chest pain and dyspnea. Upon initial examination, the patient had a blood pressure of 98\/68\u00a0mmHg, tachycardia of 100 beats\/min, tachypnea of 28 breaths\/min, and oxygen saturation of 94% on ambient air. Chest auscultation revealed decreased breath sounds on the right side. ECG revealed sinus tachycardia, phasic voltage variation of QRS complexes in V4\u20136, P-pulmonale, and vertical P-wave axis. Chest radiographs and computed tomography (CT) scans confirmed a large right-sided pneumothorax. The patient\u2019s symptoms, all the ECG abnormalities, and increased heart rate on the initial presentation resolved following an emergent tube thoracostomy. Moreover, we found that these ECG abnormalities consisted of two independent factors: respiratory components and the diaphragm level. Besides, CT scans demonstrated the large bullae with a maximum diameter of 46\u2009\u00d7\u200949\u00a0mm in the right lung apex. Finally, the patient showed complete recovery with a thoracoscopic bullectomy.<\/jats:p>\n              <\/jats:sec><jats:sec>\n                <jats:title>Conclusions<\/jats:title>\n                <jats:p>Herein, we describe a case of a large right-sided primary spontaneous pneumothorax with characteristic ECG findings that resolved following re-expansion of the lung. Our case may shed new light on the mechanisms underlying ECG abnormalities associated with a large right-sided pneumothorax. Moreover, ECG manifestations may provide useful information to suspect a large pneumothorax or tension pneumothorax in emergent settings where ECGs are performed on patients with acute chest pain and dyspnea.<\/jats:p>\n              <\/jats:sec>","DOI":"10.1186\/s12890-021-01470-1","type":"journal-article","created":{"date-parts":[[2021,3,23]],"date-time":"2021-03-23T20:03:05Z","timestamp":1616529785000},"update-policy":"https:\/\/doi.org\/10.1007\/springer_crossmark_policy","source":"Crossref","is-referenced-by-count":11,"title":["Electrocardiographic manifestations in a large right-sided pneumothorax"],"prefix":"10.1186","volume":"21","author":[{"ORCID":"https:\/\/orcid.org\/0000-0003-4742-7653","authenticated-orcid":false,"given":"Hiroyuki","family":"Yamamoto","sequence":"first","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Kazuhiro","family":"Satomi","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Yoshiyasu","family":"Aizawa","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"297","published-online":{"date-parts":[[2021,3,23]]},"reference":[{"key":"1470_CR1","doi-asserted-by":"publisher","first-page":"1379","DOI":"10.1164\/arrd.1979.120.6.1379","volume":"120","author":"LJ Melton 3rd","year":"1979","unstructured":"Melton LJ 3rd, Hepper NG, Offord KP. Incidence of spontaneous pneumothorax in Olmsted County, Minnesota: 1950\u20131974. Am Rev Respir Dis. 1979;120:1379\u201382. https:\/\/doi.org\/10.1164\/arrd.1979.120.6.1379.","journal-title":"Am Rev Respir Dis"},{"issue":"2","key":"1470_CR2","doi-asserted-by":"publisher","first-page":"121","DOI":"10.1159\/000135932","volume":"76","author":"M Noppen","year":"2008","unstructured":"Noppen M, De Keukeleire T. Pneumothorax. Respiration. 2008;76(2):121\u20137. https:\/\/doi.org\/10.1159\/000135932.","journal-title":"Respiration"},{"issue":"3","key":"1470_CR3","doi-asserted-by":"publisher","first-page":"284","DOI":"10.4065\/mcp.2009.0560","volume":"85","author":"MC Kontos","year":"2010","unstructured":"Kontos MC, Diercks DB, Kirk JD. Emergency department and office-based evaluation of patients with chest pain. Mayo Clin Proc. 2010;85(3):284\u201399. https:\/\/doi.org\/10.4065\/mcp.2009.0560.","journal-title":"Mayo Clin Proc."},{"issue":"3","key":"1470_CR4","doi-asserted-by":"publisher","first-page":"375","DOI":"10.7326\/0003-4819-80-3-375","volume":"80","author":"A Walston","year":"1974","unstructured":"Walston A, Brewer DL, Kitchens CS, Krook JE. The electrocardiographic manifestations of spontaneous left pneumothorax. Ann Intern Med. 1974;80(3):375\u20139. https:\/\/doi.org\/10.7326\/0003-4819-80-3-375.","journal-title":"Ann Intern Med"},{"issue":"Suppl 6","key":"1470_CR5","first-page":"361","volume":"59","author":"R Krenke","year":"2008","unstructured":"Krenke R, Nasilowski J, Przybylowski T, Chazan R. Electrocardiographic changes in patients with spontaneous pneumothorax. J Physiol Pharmacol. 2008;59(Suppl 6):361\u201373.","journal-title":"J Physiol Pharmacol"},{"issue":"1","key":"1470_CR6","doi-asserted-by":"publisher","first-page":"38","DOI":"10.15441\/ceem.16.154","volume":"4","author":"W Lee","year":"2017","unstructured":"Lee W, Lee Y, Kim C, Choi HJ, Kang B, Lim TH, et al. Changes in electrocardiographic findings after closed thoracostomy in patients with spontaneous pneumothorax. Clin Exp Emerg Med. 2017;4(1):38\u201347. https:\/\/doi.org\/10.15441\/ceem.16.154.","journal-title":"Clin Exp Emerg Med."},{"issue":"1","key":"1470_CR7","first-page":"86","volume":"11","author":"MA Saks","year":"2010","unstructured":"Saks MA, Griswold-Theodorson S, Shinaishin F, Demangone D. Subacute tension hemopneumothorax with novel electrocardiogram findings. West J Emerg Med. 2010;11(1):86\u20139.","journal-title":"West J Emerg Med."},{"issue":"4","key":"1470_CR8","doi-asserted-by":"publisher","first-page":"535","DOI":"10.1378\/chest.70.4.535","volume":"70","author":"P Kuritzky","year":"1976","unstructured":"Kuritzky P, Goldfarb AL. Unusual electrocardiographic changes in spontaneous pneumothorax. Chest. 1976;70(4):535\u20137. https:\/\/doi.org\/10.1378\/chest.70.4.535.","journal-title":"Chest"},{"issue":"1\u20132","key":"1470_CR9","doi-asserted-by":"publisher","first-page":"143","DOI":"10.1111\/j.0954-6820.1979.tb06020.x","volume":"205","author":"B Hallengren","year":"1979","unstructured":"Hallengren B. Phasic voltage alternation in spontaneous left-sided pneumothorax. Acta Med Scand. 1979;205(1\u20132):143\u20134. https:\/\/doi.org\/10.1111\/j.0954-6820.1979.tb06020.x.","journal-title":"Acta Med Scand"},{"issue":"2","key":"1470_CR10","doi-asserted-by":"publisher","first-page":"109","DOI":"10.1016\/s0022-0736(97)80018-0","volume":"30","author":"M Kozelj","year":"1997","unstructured":"Kozelj M, Rakovec P, Sok M. Unusual ECG variations in left-sided pneumothorax. J Electrocardiol. 1997;30(2):109\u201311. https:\/\/doi.org\/10.1016\/s0022-0736(97)80018-0.","journal-title":"J Electrocardiol"},{"issue":"5","key":"1470_CR11","doi-asserted-by":"publisher","first-page":"471","DOI":"10.2169\/internalmedicine.47.0785","volume":"47","author":"S Kurisu","year":"2008","unstructured":"Kurisu S, Inoue I, Kawagoe T. Phasic voltage variation on electrocardiogram in pneumothorax. Intern Med. 2008;47(5):471\u20132. https:\/\/doi.org\/10.2169\/internalmedicine.47.0785.","journal-title":"Intern Med"},{"issue":"1","key":"1470_CR12","doi-asserted-by":"publisher","first-page":"1495982","DOI":"10.1080\/20018525.2018.1495982","volume":"5","author":"DC Schmidt","year":"2018","unstructured":"Schmidt DC, Andersson C, Schultz HH. ECG with alternating electric axis in relation to left-sided tension pneumothorax: a case report and review of the literature. Eur Clin Respir J. 2018;5(1):1495982. https:\/\/doi.org\/10.1080\/20018525.2018.1495982.","journal-title":"Eur Clin Respir J."},{"issue":"6","key":"1470_CR13","first-page":"653","volume":"43","author":"NG Kounis","year":"1988","unstructured":"Kounis NG, Zavras GM, Kitrou MP, Soufras GD, Constantinidis K. Unusual electrocardiographic manifestations in conditions with increased intrathoracic pressure. Acta Cardiol. 1988;43(6):653\u201361.","journal-title":"Acta Cardiol"},{"key":"1470_CR14","doi-asserted-by":"publisher","first-page":"132","DOI":"10.1136\/hrt.65.3.132","volume":"65","author":"S Maeda","year":"1991","unstructured":"Maeda S, Katsura H, Chida K, Imai T, Kuboki K, Watanabe C, et al. Lack of correlation between P pulmonale and right atrial overload in chronic obstructive airways disease. Br Heart J. 1991;65:132\u20136. https:\/\/doi.org\/10.1136\/hrt.65.3.132.","journal-title":"Br Heart J"},{"key":"1470_CR15","doi-asserted-by":"publisher","first-page":"96","DOI":"10.1161\/01.cir.32.1.96","volume":"32","author":"TC Chou","year":"1965","unstructured":"Chou TC, Helm RA. The pseudo P pulmonale. Circulation. 1965;32:96\u2013105. https:\/\/doi.org\/10.1161\/01.cir.32.1.96.","journal-title":"Circulation"},{"issue":"1","key":"1470_CR16","doi-asserted-by":"publisher","first-page":"e000552","DOI":"10.1136\/openhrt-2016-000552","volume":"4","author":"MS Larssen","year":"2017","unstructured":"Larssen MS, Steine K, Hilde JM, Skj\u00f8rten I, Hodnesdal C, Liest\u00f8l K, et al. Mechanisms of ECG signs in chronic obstructive pulmonary disease. Open Heart. 2017;4(1):e000552. https:\/\/doi.org\/10.1136\/openhrt-2016-000552.","journal-title":"Open Heart."},{"key":"1470_CR17","doi-asserted-by":"publisher","first-page":"747","DOI":"10.1016\/0735-1097(94)90763-3","volume":"23","author":"JD Kaplan","year":"1994","unstructured":"Kaplan JD, Evans GT Jr, Foster E, Lim D, Schiller NB. Evaluation of electrocardiographic criteria for right atrial enlargement by quantitative two-dimensional echocardiography. J Am Coll Cardiol. 1994;23:747\u201352. https:\/\/doi.org\/10.1016\/0735-1097(94)90763-3.","journal-title":"J Am Coll Cardiol"},{"key":"1470_CR18","doi-asserted-by":"publisher","first-page":"329","DOI":"10.1253\/circj.cj-13-0654","volume":"78","author":"H Hayashi","year":"2014","unstructured":"Hayashi H, Miyamoto A, Kawaguchi T, Naiki N, Xue JQ, Matsumoto T, et al. P pulmonale and the development of atrial fibrillation. Circ J. 2014;78:329\u201337. https:\/\/doi.org\/10.1253\/circj.cj-13-0654.","journal-title":"Circ J."},{"issue":"1","key":"1470_CR19","doi-asserted-by":"publisher","first-page":"93","DOI":"10.1016\/j.jelectrocard.2013.09.002","volume":"47","author":"C Kishimoto","year":"2014","unstructured":"Kishimoto C, Tamaru K, Kuwahara H. Tall P waves associated with severe hypokalemia and combined electrolyte depletion. J Electrocardiol. 2014;47(1):93\u20134. https:\/\/doi.org\/10.1016\/j.jelectrocard.2013.09.002.","journal-title":"J Electrocardiol"},{"issue":"2","key":"1470_CR20","doi-asserted-by":"publisher","first-page":"154","DOI":"10.1016\/0002-8703(70)90162-6","volume":"80","author":"NC Saha","year":"1970","unstructured":"Saha NC. Study of the P wave in normal and obstructive lung disease in Delhi. Am Heart J. 1970;80(2):154\u201361. https:\/\/doi.org\/10.1016\/0002-8703(70)90162-6.","journal-title":"Am Heart J"},{"issue":"3","key":"1470_CR21","doi-asserted-by":"publisher","first-page":"697","DOI":"10.1378\/chest.107.3.697","volume":"107","author":"NS Shah","year":"1995","unstructured":"Shah NS, Koller SM, Janower ML, Spodick DH. Diaphragm levels as determinants of P axis in restrictive vs obstructive pulmonary disease. Chest. 1995;107(3):697\u2013700. https:\/\/doi.org\/10.1378\/chest.107.3.697.","journal-title":"Chest"},{"issue":"6","key":"1470_CR22","doi-asserted-by":"publisher","first-page":"1068","DOI":"10.1097\/SLA.0000000000001073","volume":"261","author":"DJ Roberts","year":"2015","unstructured":"Roberts DJ, Leigh-Smith S, Faris PD, Blackmore C, Ball CG, Robertson HL, et al. Clinical presentation of patients with tension pneumothorax: a systematic review. Ann Surg. 2015;261(6):1068\u201378. https:\/\/doi.org\/10.1097\/SLA.0000000000001073.","journal-title":"Ann Surg."},{"issue":"1","key":"1470_CR23","doi-asserted-by":"publisher","first-page":"173.e1","DOI":"10.1016\/j.ajem.2018.09.036","volume":"37","author":"C Kelly","year":"2019","unstructured":"Kelly C, Carlberg M, Madsen T. Spontaneous pneumothorax resulting in tension physiology. Am J Emerg Med. 2019;37(1):173.e1-2. https:\/\/doi.org\/10.1016\/j.ajem.2018.09.036.","journal-title":"Am J Emerg Med"}],"container-title":["BMC Pulmonary Medicine"],"original-title":[],"language":"en","link":[{"URL":"http:\/\/link.springer.com\/content\/pdf\/10.1186\/s12890-021-01470-1.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"text-mining"},{"URL":"http:\/\/link.springer.com\/article\/10.1186\/s12890-021-01470-1\/fulltext.html","content-type":"text\/html","content-version":"vor","intended-application":"text-mining"},{"URL":"http:\/\/link.springer.com\/content\/pdf\/10.1186\/s12890-021-01470-1.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2021,3,23]],"date-time":"2021-03-23T20:03:19Z","timestamp":1616529799000},"score":1,"resource":{"primary":{"URL":"https:\/\/bmcpulmmed.biomedcentral.com\/articles\/10.1186\/s12890-021-01470-1"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2021,3,23]]},"references-count":23,"journal-issue":{"issue":"1","published-print":{"date-parts":[[2021,12]]}},"alternative-id":["1470"],"URL":"https:\/\/doi.org\/10.1186\/s12890-021-01470-1","relation":{},"ISSN":["1471-2466"],"issn-type":[{"value":"1471-2466","type":"electronic"}],"subject":[],"published":{"date-parts":[[2021,3,23]]},"assertion":[{"value":"4 December 2020","order":1,"name":"received","label":"Received","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"17 March 2021","order":2,"name":"accepted","label":"Accepted","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"23 March 2021","order":3,"name":"first_online","label":"First Online","group":{"name":"ArticleHistory","label":"Article History"}},{"order":1,"name":"Ethics","group":{"name":"EthicsHeading","label":"Declarations"}},{"value":"Authorization for the use of case information and materials was obtained from the Institutional Review Board of Narita-Tomisato Tokusyukai Hospital. We also obtained informed consent from the patient.","order":2,"name":"Ethics","group":{"name":"EthicsHeading","label":"Ethics approval and consent to participate"}},{"value":"The authors confirm that written consent for submission and publication of this case report, including the images and associated tables, has been obtained from the patient. A copy of the written consent is available for review by the Editor-in-Chief of this journal.","order":3,"name":"Ethics","group":{"name":"EthicsHeading","label":"Consent for publication"}},{"value":"The authors have no conflicts of interest to disclose.","order":4,"name":"Ethics","group":{"name":"EthicsHeading","label":"Competing interests"}}],"article-number":"101"}}