History

• 76 yo F Stage IV breast Ca with metastasis to the lungs and recurrent maligant pleural effusions
• Acute onset of dyspnea which progressed rapidly
• Denies: chest pain,cough, fever, leg swelling or pain, or hx of VTE

Physical Exam

T 98.7  BP 151/72  HR 71 RR 26  Pox 84% on RA

• Pt tachypneic and anxious appearing
• No JVD noted
• Diminished breath sounds on R, clear on L
• There is a capped chest tube in the R posterior axillary position
• Heart sounds normal no murmurs
• Abd soft NTND
• No LE edema

Bedside Diagnostics

• Bedside ultrasound: no lung sliding on R side

• ECG: Afib rate controlled, low voltage

• Portable CXR: Large R sided pneumothorax with mediastinal shift to the L, R sided chest tube in place, R sided SQ air

Diagnosis

• Post-procedural tension pneumothorax

Management

• Oxygen delivered by high flow nasal canula at 30 LPM and 100% FiO2 with O2 sats increased to 98%
• 2 18 gauge IVs placed
• Given hemodynamic stability of patient, immediate needle decompression deferred and pt was discussed with interventional pulmonology
• Unfortunately, adapter for PleurX catheter not immediately available to evacuate the pneumothorax
• Decision made in conjunction with patient to place urgent R sided small bore 8F pigtail chest tube

• Post-procedure chest portable CXR shows: resolution of R sided pneumothorax, mediastinal shift resolved, R sided anterior pigtail catheter in place, +R sided SQ air
• Pt quickly weaned to 2L NC, with rapid resolution of dyspnea and tachypnea

Discussion

• Tension pneumothorax (TPTX) is a rare condition which can rapidly result in hypoxemia, hypotention, and death
• It is usually diagnosed in trauma patients or patients undergoing mechanical ventilation
• The traditional signs and symptoms such as: hypotension, distended neck veins, and tracheal deviation are inconsistently present
• Traditional teaching has been to never wait for radiography to confirm the diagnosis, however a 2003 case series study of 30 ED patients found no increased mortality in hemodynamically stable patients with TPTX diagnosed on chest xray
• Indications for immediate needle decompression in patients with clincally suspected or POC ultrasound confirmed TPTX: Hypotension, hypoxemia refractory to )2 therapy, cardiac arrest, decreased level of consciousness, or RR <10
• If no indication for immediate decompression: placement of small bore chest tube, preferably in the anterior mid-clavicular 2nd intercostal space (because pleural air rises to the apical area), is the treatment of choice
• The PleurX catheter is designed for easy drainage of recurrent pleural effusions, however the adapter piece is proprietary and thus this chest tube is not easily accessed without a special kit: one option in an emergency is to cut the chest tube proximal to the drainage adapter and attach a Pleuravac directly to the tubing

Sources

Clark S et al. Is Mediastinal Shift Always an Emergency? Emergency Medicine 2003; 15:429-433.

Leigh-Smith S, Harris T. Tension Pneumothorax, Time for a Re-think? Emerg Med J 2005; 22:8-16.