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When Imaging Is Not Enough: Pneumothorax, Back to Basics FREE TO VIEW

David Shiu, DO; Nadeem Ali, MD; Killol Patel, MD; Sharad Sharma, MD; Thiruvengadam Anandarangam, MD; Christina Migliore, MD
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Newark Beth Israel Medical Center, Newark, NJ

Chest. 2014;146(4_MeetingAbstracts):333A. doi:10.1378/chest.1993760
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SESSION TITLE: Miscellaneous Case Report Posters II

SESSION TYPE: Affiliate Case Report Poster

PRESENTED ON: Tuesday, October 28, 2014 at 01:30 PM - 02:30 PM

INTRODUCTION: Chest Ultrasounography (US) is gaining attention for the diagnosis of pneumothorax. With higher sensitivity and similar specificity compared with chest radiography (CXR), its use has been proven in patient care. However, US should not take precedence over clinical signs of pneumothorax. We report a case of the limitations of ultrasound for the diagnosis of pneumothorax.

CASE PRESENTATION: A 20 year-old male, presented following a suicide attempt from ingestion and aspiration of ammonia. He was subsequently placed on veno-venous extracorporeal membrane oxygenation (VV-ECMO). Patient’s ECMO course was complicated by pneumothorax with chest tube placement. A chest computed tomography (CT) scan noted loculated pneumothorax on the left chest wall with an aforementioned chest tube. Ten days later, he was hemodynamically unstable with elevation of peak and plateau airway pressures. Auscultation noted bilateral air entry at the anterior and posterior chest wall. Bedside US at the upper and lower regions of the anterior, axillary and posterior chest wall was consistent with lung sliding, lung pulse and B-lines at each site and confirmed by two ultrasound trained physicians. CXR showed no expansion of the previously noted pneumothorax. Despite this an additional chest tube was placed to the left chest wall with immediate air decompression, decrease in airway pressures and return of hemodynamic stability.

DISCUSSION: Delay in the diagnosis of pneumothorax in a mechanically ventilated patient can be detrimental. The presence of lung sliding, lung pulse and B-lines at six chest wall locations is efficacious with high specificity and sensitivity in ruling out pneumothoraces. US is promising but it has limitations in patients with complex pathologies. Thus, hemodynamics and elevated airway pressures should never be substituted but rather play an equal role in the management.

CONCLUSIONS: Our patient was complicated by multiple invasive thoracic procedures, which raises a question as to the limitation of US in a complicated thoracic cavity. Clinical assessment proved superior in this case and that one must not rule out or rule in a disease process based on imaging alone but rather on a clinicians experience and findings.

Reference #1: Ding W, Shen Y, Yang J, He X, Zhang M. Diagnosis of pneumothorax by radiography and ultrasonography--a meta-analysis. Chest. May 5 2011

Reference #2: Lichtenstein DA, Menu Y: A bedside ultrasound sign ruling out pneumothorax in the critically ill. Lung Sliding Chest 1995, 108:1345-1348

DISCLOSURE: The following authors have nothing to disclose: David Shiu, Nadeem Ali, Killol Patel, Sharad Sharma, Thiruvengadam Anandarangam, Christina Migliore

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