Case Study
The bedside nurse activated a rapid response code for a patient who appeared to be in acute respiratory distress and had new right-sided chest pain. On arrival of the rapid response team (RRT), the patient was found to be a 62-year-old male with a history of chronic obstructive pulmonary disease (COPD) who was admitted one day ago for COPD exacerbation. Overnight, the patient was placed on bilevel positive airway pressure (BiPAP) therapy for respiratory acidosis. In the 10 min before the RRT event, the patient became acutely dyspneic with increasing lethargy and right-sided chest pain.
Vital Signs
Temperature: 37.4 °F, axillary
Blood Pressure: 90/50 mmHg
Heart Rate: 122 beats per min (bpm)
Respiratory Rate: 30 breaths per min
Oxygen Saturation: 70% on room air, 90% on 15 L/min (LPM) non-rebreather
Focused Physical Examination
A quick exam revealed a middle-aged male lying in bed in obvious distress. The patient appeared drowsy and tachypneic, using accessory muscles of respiration. There was reduced air entry on the right lung field, and the left lung was clear to auscultation. His cardiac examination revealed tachycardia with normal heart sounds. His abdomen was non-tender and non-distended. The remaining examination was unremarkable.
Working diagnosis
Acute respiratory failure because of COPD exacerbation vs. acute respiratory distress syndrome vs. pneumothorax
Interventions
A cardiac monitor and pads were attached to the patient. The patient was continued on 15 LPM via a non-rebreather mask, and a stat chest X-ray was ordered. Arterial blood gas (ABG), troponin, and electrocardiogram (EKG) were obtained. ABG showed reduced oxygen saturation with respiratory acidosis (pH 7.2/pCO 2 80 mmHg/pO 2 60 mmHg/SpO 2 91%). EKG was unremarkable for an acute ischemic event. Chest X-ray was significant for right-sided pneumothorax, which was not present on admission imaging ( Fig. 26.1 ). Thoracic surgery was paged emergently for the need of a chest tube for pneumothorax. The chest tube was placed at the bedside by thoracic surgery with rapid improvement of symptoms. The patient was transferred to the intensive care unit for closer monitoring.
Final Diagnosis
Secondary pneumothorax in the setting of COPD with possible bullae rupture because of BiPAP.
Pneumothorax
Pneumothorax is a collection of air in the pleural space separating the thoracic wall and lung. Air can enter the intra-pleural space through communication from the chest wall (e.g., after trauma) or through lung parenchyma across the visceral pleura (e.g., after rupture of an emphysematous bulla). Most pneumothoraces are simple, but tension pneumothorax is occasionally seen, which is a life-threatening emergency. Simple pneumothorax does not cause a mediastinal shift or hemodynamic instability. The different types of pneumothoraces are:
- 1.
Primary Spontaneous Pneumothorax
- a.
These occur spontaneously without a known lung pathologic condition.
- b.
These are most common in young, thin male adults.
- a.
- 2.
Secondary Spontaneous Pneumothorax
- a.
These occur in the setting of known pulmonary abnormality/pathologic condition.
- b.
These are more common in older patients.
- c.
Risk factors include COPD, cystic fibrosis, interstitial lung disease, and connective tissue disorders.
- d.
Carry higher morbidity and mortality than primary pneumothoraces and have recurrence rates up to 43% in five years.
- a.
- 3.
Traumatic Pneumothorax
- a.
These occur secondary to traumatic injury or iatrogenic causes.
- b.
The most common iatrogenic causes are transthoracic needle aspiration, subclavian needle stick, thoracentesis, transbronchial biopsy, and pleural biopsy.
- c.
Pneumothoraces are the second most common complication after chest trauma; rib fractures are the most common complication.
- a.
- 4.
Tension Pneumothorax
- a.
A life-threatening complication of traumatic pneumothorax in which air accumulates and becomes trapped by a one-way valve that can compress the lung, displace mediastinal structures leading to hemodynamic instability ( Fig. 26.2 ).
Fig. 26.2
Chest X-ray showing left tension pneumothorax pushing mediastinal structures to the right.
- b.
In the combat setting, like warzones, tension pneumothorax is the second most common cause of death
- a.
Pneumothorax can also be classified as closed pneumothorax or open pneumothorax; see Table 26.1 for the difference between closed and open pneumothoraces.
