This is a 15-year old male with a history of severe chronic lung disease and bronchopulmonary dysplasia since birth. He was premature, and since then has required multiple hospitalizations for acute exacerbations of his chronic lung disease. He is well known to the children’s hospital staff, but in the past few years, he has done well and has not required hospitalization.
He now presents to the emergency department in severe respiratory distress.
T38.4 (oral), P110, R40, BP 120/70. Oxygen saturation 75% in room air. On oxygen by mask, his oxygen saturation increases to 90%. He is in severe respiratory distress.
His color is pale and cyanotic. Heart regular. Lungs rhonchi, wheezing, and diminished aeration throughout. Moderately severe retractions. Perfusion good. Capillary refill time 2 seconds.
Bronchodilator therapy is administered and a portable chest radiograph is obtained.
[DDET Read radiology comments]
There are extensive infiltrates in both lungs. However, the left upper lung and both lower lungs show hyperlucent areas.
This film image was difficult to accurately capture with the scanner since the important findings are not easy to see.
Thus, the findings described here could only be appreciated on the original film.
Upon closer inspection of the original film, lung markings are faintly visible in the left upper and left lower hyperlucent regions. However, no lung markings are visible in the right lower hyperlucent region. A pneumothorax is suspected. [/DDET]
Previous radiographs show large blebs in the hyperlucent regions.
Questions: Is this a pneumothorax? If you aren’t sure, should you put a chest tube in?
There is some concern that this air collection may be a loculated pneumothorax. The density of the right upper lung may be due to acute infiltrates or compression of lung tissue from the pneumothorax.
Evacuating the pneumothorax may result in better expansion of the right lung and improvement in the patient’s condition. However, if this is just a hyperexpanded intrapulmonary bleb, inserting a chest tube into the pleural space would not be beneficial and may also worsen the patient’s condition by inducing a pneumothorax.
When such a patient is critically ill, this decision is extremely difficult. It is difficult to distinguish an intrapulmonary bleb from a loculated pneumothorax. However, in our patient with a preexisting bleb in that location, the former is more likely.
It is crucial to compare the patient’s current films with previous films to assist in this determination. There should be no doubt that this radiograph does NOT demonstrate a TENSION pneumothorax.
Although a tension pneumothorax requires immediate intervention, the therapy for an intrapulmonary bleb versus a loculated pneumothorax can usually wait for more decision making before rushing into an invasive procedure. A tension pneumothorax is associated with a mediastinal shift to the opposite side and compression of the contralateral lung. Clinically, a tension pneumothorax is usually associated with cardiovascular compromise (hypotension and/or bradycardia) in addition to respiratory deterioration. Since our patient does NOT have cardiovascular compromise, despite the severe degree of respiratory distress, a tension pneumothorax is unlikely.
If the patient’s clinical condition is not deteriorating, it may be best to delay an evacuation procedure until consideration of all clinical factors can be carefully assessed. A second opinion with an intensivist, a surgeon, or another emergency physician would be helpful. Although such a bleb may appear to be fragile, it is often surrounded by fibrous tissue.
This patient went on to require positive pressure ventilation for many days and the bleb did not rupture. Placing a tube thoracostomy prophylactically anticipating a pneumothorax in such a patient with a large pneumatocele undergoing positive pressure ventilation may seem to be reasonably justified. However, the tube thoracostomy itself may result in significant deterioration in such as patient as well.
Templeton JM. Thoracic Emergencies. In: Fleisher GR, Ludwig S (eds). Textbook of Pediatric Emergency Medicine, third edition. Baltimore, MD, Williams and Wilkins, 1993, pp. 1348-1349