Opacified Hemithorax With Ipsilateral Mediastinal Shift After Transthoracic Needle Biopsy

Abstract

A 75-year-old woman underwent transthoracic CT-guided cutting-needle biopsy of a 5 5-cm mass of the superior segment of the left lower lobe and had an episode of recent hemoptysis. She had been ill for 3 months with dyspnea, cough, and intermittent sputum production. Chest radiographs revealed a persistent left lower lobe alveolar opacification believed to be pneumonia; however, the patient had no improvement with two courses of oral antibiotics. She had severe COPD and was receiving home oxygen at 2 L/min, with baseline dyspnea with minimal exertion. Immediately following the CT-guided biopsy of the lung mass, she expectorated a large volume (approximately 500 mL) of bright red blood, and CT imaging revealed a pneumothorax. The pneumothorax was evacuated with a 12F chest tube placed under CT guidance. The patient remained hypoxic with an oxygen saturation of 85% on partial nonrebreather oxygen mask, and so was then intubated, with improvement in her arterial oxygen saturation to 90% but on fraction of inspired oxygen of 1.0. Suctioning through the endotracheal tube returned scant amounts of bloody secretions over the next several hours. After stabilization, she was transferred to an ICU. In the midst of the transport, her arterial oxygen saturation declined to 65%, followed soon thereafter by cardiac arrest. She was pulseless and had absent breath sounds over her entire left hemithorax. Cardiopulmonary resuscitation was initiated. Cardiac monitoring revealed electromechanical dissociation. The patient was administered epinephrine, 1 mg IV, and a 32F left-sided chest tube was placed emergently. The chest tube immediately drained 50 mL of blood, but no rush of air or air leak in the chest tube was appreciated, and subsequently the tube showed no respiratory variation. She had a return of spontaneous circulation shortly thereafter, with a total arrest time of 4 min. She was neurologically intact and following commands 30 min later. A chest radiograph was obtained (Fig 1).