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1
Question:

A 65-year-old man with a history of moderate chronic obstructive pulmonary disease (COPD) is brought to the emergency department with progressive dyspnea, productive cough, and fever over the past 2 days.  Initial evaluation shows that the patient is in respiratory distress.  Temperature is 38.8 C (101.8 F), blood pressure is 122/74 mm Hg, pulse is 110/min, and respirations are 32/min; pulse oximetry is 93% on 4 L oxygen by nasal cannula.  A presumptive diagnosis of COPD exacerbation is made.  His trachea is intubated and he is placed on mechanical ventilation.  A central venous catheter is placed in the right subclavian vein.  Intravenous antibiotics, glucocorticoids, and inhaled bronchodilators are administered.  Despite these measures, the patient continues to desaturate over the next 20 minutes with a pulse oximetry reading of 83% despite breathing 100% inspired oxygen.  His inspiratory pressures are elevated.  Repeat vital signs show blood pressure of 80/50 mm Hg and pulse of 120/min.  The trachea is deviated to the left.  Breath sounds are absent on the right side and wheezes are heard on the left side.  Neck veins are distended.  Which of the following is the best next step in management of this patient?

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Explanation:

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Pneumothorax

Spontaneous pneumothorax

Tension pneumothorax

Associated features

  • Primary: no preceding event or lung disease; often thin, young men
  • Secondary: underlying lung disease (eg, COPD, CF)
  • Life-threatening
  • Often due to trauma or mechanical ventilation

Signs & symptoms

  • Chest pain, dyspnea
  • ↓Breath sounds, ↓chest movement
  • Hyperresonant to percussion

Same as spontaneous plus:

  • Hemodynamic instability
  • Tracheal deviation away from affected side

Imaging

  • Visceral pleural line
  • Absent lung markings beyond pleural edge

Same as spontaneous plus:

  • Contralateral mediastinal shift
  • Ipsilateral hemidiaphragm flattening

Management

  • Small (≤2 cm): observation & oxygen administration
  • Large & stable: needle aspiration or chest tube
  • Urgent needle decompression or chest tube placement

CF = cystic fibrosis; COPD = chronic obstructive pulmonary disease.

This patient has likely developed a tension pneumothorax (TP) as a complication of subclavian central venous catheter placement.  TP is a life-threatening condition caused by air within the pleural space that displaces mediastinal structures and compromises cardiopulmonary function.  It develops when injured tissue forms a one-way valve allowing air to enter the pleural space but preventing it from escaping naturally.  TP is characterized by rapid-onset severe shortness of breath, tachycardia, tachypnea, hypotension, and distension of the neck veins due to superior vena cava compression.  Positive-pressure ventilation can worsen TP by increasing intrathoracic pressures and intensifying the one-way valve effect.  As the pleural cavity fills with air, increased pressure is required to initiate inspiratory flow.

TP is a clinical diagnosis, and decompression should be initiated immediately with needle thoracostomy (or, if available, direct emergency tube thoracostomy) in hemodynamically unstable patients.  Classically, the second intercostal space in the midclavicular line has been used, but this fails in up to 50% of patients due to chest wall anatomy.  Consequently, the fifth intercostal space in the midaxillary line is an excellent alternate site.  Needle thoracostomy should be followed by an emergency tube thoracostomy.

(Choice A)  Although an arterial blood gas would provide information about the severity of respiratory compromise, waiting for such a result is inappropriate.

(Choices B and E)  Intubation of the left mainstem bronchus would result in hypoxia and absent right-sided breath sounds, and cardiac tamponade would result in hypotension, tachycardia, and distended neck veins.  However, neither condition alone would account for all of this patient's findings or for the tracheal deviation.

(Choice C)  Fluid resuscitation and vasopressors are appropriate treatments for shock.  Although shock may cause sudden clinical deterioration, it would not explain the lack of breath sounds or tracheal deviation.

(Choice F)  In TP, an x-ray will show deviation of the trachea and mediastinum away from the affected side and increased lucency on the affected side of the chest.  If there is diagnostic uncertainty or the patient is hemodynamically stable, radiographic confirmation should be considered.  Otherwise, treatment of this emergent condition should not be delayed by waiting for radiographic studies.

Educational objective:
Tension pneumothorax is a life-threatening condition caused by air within the pleural space that displaces mediastinal structures and compromises cardiopulmonary function.  It is characterized by rapid-onset dyspnea, tachycardia, tachypnea, hypotension, and distension of the neck veins.  Treatment should be initiated immediately with needle thoracostomy.