SESSION TITLE: Pleural Case Report Posters
SESSION TYPE: Affiliate Case Report Poster
PRESENTED ON: Tuesday, October 29, 2013 at 01:30 PM - 02:30 PM
INTRODUCTION: Tension pneumoperitoneum following tension pneumothorax can develop in patients with respiratory failure on mechanical ventilation secondary to ruptured blebs, or in those with high airway pressures and decreased compliance (1). We report a case of a 48 year old male patient with severe acute respiratory distress syndrome secondary to necrotizing staphylococcal pneumonia who developed tension pneumothorax and pneumoperitoneum secondary to a ruptured pneumatocele.
CASE PRESENTATION: A 48 year old male patient with past medical history of acquired immunodeficiency syndrome with an absolute cluster of differentiation type 4 (CD 4) cell count of 52 cells/mm3 (480-1135), was admitted to the hospital with progressive shortness of breath, cough, and generalized weakness. Chest radiograph showed bilateral interstitial infiltrates, and blood and bronchoalveolar lavage cultures grew methicillin sensitive staphylococcus aureus (MSSA).Patient developed acute respiratory failure and was intubated. Two days into mechanical ventilation, he developed acute cyanosis, tachypnea, tachycardia, and distended neck veins. A right sided tesnsion pneumothorax was diagnosed clinically, and an emergent 9 French thoracotomy tube was placed on the second intercostal space with relief of his symptoms. Six hours later, patient developed progressive distension of the abdomen, and a chest radiograph showed the presence of free air under diaphragm. Lactic acid level was 0.4 mmol/L (0.5-2.2). A chest and abdomen computerized tomography scans (fig 1 and 2) confirmed the presence of right sided pneumothorax, a large right lower lobe cavitary lesion (pneumatocele), and a large amount of free intraperitoneal, and retroperitoneal air without definite abnormality in the stomach, small bowel or colon. Patient had a diagnostic laparoscopy that showed no evidence of bowel perforation, but resulted in decompression of his distention.
DISCUSSION: Possible mechanisms for air entering the peritoneal space from the pleural space include: air may escape from ruptured alveoli to the mediastinum and by the diaphragmatic openings to the retroperitoneal space and peritoneum, or air can also move directly through diaphragmatic defects. Tube thoracostomy could resolve the problem by eliminating air leak to the peritoneum, but decompression of tension pneumoperitoneum can be required to facilitate ventilation most of the time (2)
CONCLUSIONS: Tension pneumoperitoneum following tension pneumothorax can present without hemodynamic instability, elevated lactic acid levels, or evidence of bowel perforation. Tube thoracostomy can resolve the problem but abdomen decompression may be warranted.
Reference #1: Burdett-Smith P, Jaffey L Tension pneumoperitoneum J Accid Emerg Med. 1996 May;13(3):220-1
Reference #2: Mularski RA, Sippel JM, Osborne ML Pneumoperitoneum: a review of nonsurgical causes. Crit Care Med. 2000 Jul;28(7):2638-44
DISCLOSURE: The following authors have nothing to disclose: Fadi Safi, Nauman Siddiqui, Shahul Valavoor, Mohammad Al-Natour, Ragheb Assaly
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