Bilateral Pneumothorax Research Articles

Air under pressure: a case report on tension pneumomediastinum arising from traumatic injury

Abstract Background Tension pneumomediastinum (TPM) is a rare but critical condition characterized by the accumulation of air in the mediastinum, leading to increased intrathoracic pressure and cardiovascular compromise. This case report is novel due to the rarity of TPM arising from blunt chest trauma and the necessity for emergent surgical intervention after initial conservative management failed. Case presentation A 63-year-old male presented with severe chest pain and dyspnea following a high-impact motor vehicle collision. Initial assessment revealed tachypnea, tachycardia, and hypotension, along with extensive subcutaneous emphysema over the chest and neck. Imaging confirmed pneumomediastinum and bilateral pneumothoraxes, consistent with TPM. Despite initial management with high-flow oxygen and bilateral chest tube insertion, the patient’s condition deteriorated, necessitating emergent mediastinal decompression via an anterior subxiphoid incision. This intervention resulted in immediate hemodynamic improvement. Conclusions This case underscores the importance of recognizing TPM in patients with chest trauma and highlights the need for prompt surgical intervention in cases of hemodynamic instability. Early and accurate diagnosis and timely surgical management are crucial for improving patient outcomes in TPM.

A rare case of respiratory syncytial virus bronchiolitis with spontaneous L pneumothorax in an infant

Abstract: The most common self-limiting viral infection of the lower respiratory tract in the pediatric population is bronchiolitis, which most commonly affects infants. In most cases, respiratory syncytial virus (RSV) is the causative agent. In general, the recovery occurs within 5–7 days without any complications. Spontaneous pneumothorax is one of the rare and less-reported complications of bronchiolitis. We report a case of a male child aged 5 months with bilateral spontaneous pneumothorax (PNO) with subcutaneous emphysema following bronchiolitis. The nasopharyngeal swab was positive for RSV, and all other investigations ruled out any underlying illness causing spontaneous PNO. Although it is a rare complication of bronchiolitis, it may occur late during the disease course. Pediatricians must be aware of this life-threatening complication, which may develop during the disease course despite an early clinical improvement.

Combined antegrade and retrograde dilation (CARD) for management of complete esophageal obstruction: Multicenter case series.

Background and study aims Complete esophageal obstruction (CEO) is a rare complication of radiation therapy for esophageal or head and neck cancers and can be challenging to manage endoscopically. A rendezvous approach by combined anterograde and retrograde endoscopic dilation (CARD) can be used to re-establish luminal integrity in such cases. Our study aimed to review our experience with patients with CEOs managed by CARD. Patients and methods Six patients who had CARD for CEO were reviewed. The primary outcomes were immediate technical and clinical success of CARD. Secondary outcomes were adverse events (AEs) associated with the procedure and continued dependency on the percutaneous endoscopic gastrostomy (PEG)-or jejunostomy tube. Results The mean age was 59 years (range 38-83). Five patients had CEO secondary to neoadjuvant chemoradiotherapy for esophageal cancer, and one patient had complete obstruction secondary to neck trauma. CARD was technically successful in five patients (86%). Two patients had AEs. One had pneumomediastinum requiring no intervention, while the other had bilateral pneumothorax requiring chest tube placement. The median follow-up duration of repeated dilations to maintain liminal patency was 20 months. Four patients had improvement in dysphagia, tolerating oral intake, and mouth secretions after the procedure, with a mean functional oral intake scale (FOIS) score > 3 and an overall success rate of 83%. Conclusions The CARD approach to re-establish esophageal luminal patency in CEO is a safer alternative to high-risk blind antegrade dilation or an invasive surgical approach. It is usually technically feasible with improved swallowing ability in most patients.

Usage of Foley’s catheter in pediatric lung isolation, whole lung lavage: A case report

This case report delves into pediatric lung isolation challenges and innovations in managing patients with pulmonary alveolar proteinosis undergoing whole lung lavage. The central focus is on a 5-year-old girl who initially encountered intraoperative complications, including bilateral pneumothorax and pulmonary edema. However, a subsequent attempt employing a Foley’s catheter for lung isolation proved successful, with the patient displaying marked postoperative improvements. The case offers valuable insights into the intricate balance of anesthesia, ventilatory parameters, and the novel use of common medical equipment, like the Foley’s catheter, for specialized procedures in pediatric pulmonology.

Spontaneous pneumothorax in children: a radiological perspective.

Spontaneous pneumothorax is a common clinical condition due to several etiologies. Appropriate radiologic assessment helps avoid re-imaging and guide individualized management. To describe the etiologic factors of spontaneous pneumothorax in children from a radiological perspective. Thirty-nine children with spontaneous pneumothorax were evaluated according to their demographic characteristics, the presence of underlying lung diseases, and imaging findings. Twenty-one patients without underlying lung disease were assessed as primary spontaneous pneumothorax; eight of these 21 patients (38.9%) had subpleural air cysts in the apices/upper lobes of the lung on chest computed tomography (CT). In the remaining 18 patients with secondary spontaneous pneumothorax, the most common causes were respiratory diseases (33.3%), infectious lung diseases (33.3%), interstitial lung diseases (27.7%), and connective tissue diseases (5.5%). The mean age of children with secondary spontaneous pneumothorax was lower than that of children with primary spontaneous pneumothorax (P = 0.002). Recurrences occurred in 11 patients (52.3%) with primary spontaneous pneumothorax and three patients (16.6%) with secondary spontaneous pneumothorax. Bilateral pneumothorax was observed in three of the 18 patients with secondary spontaneous pneumothorax. Identifying the etiologic factors of spontaneous pneumothorax may help clinicians plan how to reduce the risk of recurrence. Radiologists should keep in mind the possible underlying diseases and assess imaging methods in children with spontaneous pneumothorax for subpleural air cysts and be suspicious about an underlying disease in cases of bilateral pneumothorax and in younger patients.

Approach to primary spontaneous pneumothorax: Experiences of a new pediatric surgery clinic

BackgroundThe prevalence of spontaneous pneumothorax in children during adolescence is low, but not negligible. Treatment involves conservative management and surgery. The aim of this study was to review our patients treated with diagnoses of primary spontaneous pneumothorax and to describe our therapeutic approach, outcomes, and deficiencies. MethodsNinety (90) patients diagnosed with primary spontaneous pneumothorax and treated and followed-up in our clinic between June 2020 and December 2023 were included in the study. The research was performed as a retrospective file review. Trauma, secondary pneumothorax, and newborn pneumothorax were excluded. ResultsSeventy six (76) patients were boys and 14 were girls, with a mean age of 16,23 years. Right pneumothorax was present in 44 patients, left pneumothorax in 41, and bilateral pneumothorax in 5. The 90 patients’ initial treatment involved tube thoracostomy, and 36 individuals with prolonged and recurrent pneumothorax underwent video-assisted thoracoscopic surgery (VATS). ConclusionThe success rate of apical wedge resection and mechanical pleurodesis with direct VATS in the treatment of prolonged and recurrent primary spontaneous pneumothorax in children is greater than 90 %. We think that, VATS is a successful, effective and safe treatment for spontaneous pneumothorax due to a significantly lower recurrence rate compared to chest tube insertion.

A fatal complication of tracheostomy cannula exchange: Bilateral pneumothorax, pneumomediastinum, and subcutaneous emphysema

A fatal complication of tracheostomy cannula exchange: Bilateral pneumothorax, pneumomediastinum, and subcutaneous emphysema

Victorious VV-Extracorporeal Membrane Oxygenation in Post-cardiac Arrest Pediatric Patient with Bilateral Pneumothorax with Severe ARDS

Victorious VV-Extracorporeal Membrane Oxygenation in Post-cardiac Arrest Pediatric Patient with Bilateral Pneumothorax with Severe ARDS

Vigilance to Prevent Organ Wastage—Bilateral Pneumothorax: A Complication of Apnea Test

Vigilance to Prevent Organ Wastage—Bilateral Pneumothorax: A Complication of Apnea Test

Tele-ICU Management of a Trauma Patient at a Peripheral Center

Methods: A 23-year-old male was admitted to a peripheral center following a fall from a tractor. Examination at admission revealed a conscious, stable patient with significant chest pain. The tele-ICU (intensive care unit) was called, and when they received the patient, he was stabilized and managed immediately. The tele-ICU connection was provided through the Command Center in Apollo Hospitals, Jubilee Hills, Hyderabad, India, which is connected to multiple spoke locations at peripheral centers using audio-visual aids. An intensivist is available 24 h daily to provide critical care services to the peripheral centers through audio-visual aids. The tele-ICU connection is provided to the peripheral centers through commercial audio-visual and bedside data transfer devices. The tele-ICU team supervised the primary survey remotely via a central monitor, viewing the patient’s vitals along with the audio/video calling capabilities of the cameras as a part of the tele-ICU program. Results: Chest X-rays showed bilateral pneumothorax, lung compression, and multiple rib fractures. The team at the peripheral center was immediately advised to institute bilateral intercostal drainage (ICD). High-resolution CT chest (HRCT) reveals extensive right and minor left pneumothorax, bilateral lung contusions, a right clavicle medial end fracture, and multiple rib fractures. Ultrasonography of the abdomen showed altered splenic echo texture and moderate left pleural effusion. Flail chest and paradoxical breathing pattern warranted endotracheal intubation. The patient was ventilated for 4 days. On day 3, the patient experienced an air leak from the left ICD, increased drain output, and decreased hemoglobin. The tele-ICU team consulted the cardiothoracic surgeon regarding the air leak and followed their advice to attach a vacuum bottle to the ICD. The patient’s breathing improved gradually. Mechanical ventilator settings (i.e., tidal volume, respiratory rate, and peak airway pressures) were reviewed daily by the tele-ICU team during the regular morning and evening rounds. In addition, the ventilator and the bedside monitor were continuously monitored from the Command Center through video conferencing, which is integrated with electronic software and regularly captures the patient’s vitals. After 4 days of mechanical ventilation, the patient was extubated and started on oxygen therapy. Oxygen was gradually tapered and stopped. After 8 days of uneventful hospitalization, the patient was discharged. Conclusion: Studies show that telemedicine can provide expert-guided mentoring for life-saving procedures, including pre-hospital assessment and triage for polytrauma, tube thoracotomies, and extended focused assessment with sonography in trauma (eFAST). Technology may help resource-constrained places adopt telemedicine and its benefits.

Recurrent spontaneous pneumothorax in four surgically treated Japanese Spitz dogs

AbstractFour Japanese Spitz dogs between 5 and 11 months old were presented for acute dyspnoea. Thoracic radiographs and CT identified bilateral pneumothorax and pulmonary cavitary lesions. The median lesion size was 30 mm (range 7‒50 mm). After initial stabilisation, one dog underwent median sternotomy, while three dogs underwent intercostal thoracotomy. Surgical exploration found grossly haemorrhagic pulmonary bullous lesions in all cases. Histopathology revealed blood‐filled cavities with interstitial fibrosis and pneumocyte hyperplasia. Dyspnoea recurred in all dogs postoperatively, with recurrence of lesions confirmed either radiographically or via CT in three of four cases. The median time from surgery to recurrence of pneumothorax was 9 days (range 5‒15 days). The mortality rate was 100%, and the median postoperative survival time was 22 days (range 5‒558 days). This report aims to raise awareness of this group of dogs presenting with spontaneous pneumothorax at a young age and with high recurrence rates despite surgery, contrary to the literature.

Vancomycin-resistant Enterococcus faecium: A Sinister Cause of Necrotizing Pneumonia in Post-COVID-19 Patient

Post-COVID-19 necrotizing pneumonia has been rarely reported. We report of case of a 55-year-old male with underlying comorbidities of diabetes and hypertension and a history of severe COVID-19 illness managed with mechanical ventilation. A few days after recovery, he developed bilateral pneumothorax and empyema with lung collapse and multiple patchy air opacities. Pus discharge from both intercostal tubes grew Enterococcus faecium resistant to vancomycin and sensitive to linezolid. The patient was successfully treated with linezolid and showed complete recovery.

Buffalo chest in a not so high fall: a case report

Bufallo chest refers to an anatomical variation characterized by an ongoing connection between the two pleural spaces, a unique feature found in these animals, since they possess a single pleural space due to an incomplete mediastinum. When this condition is found in humans, a unilateral chest trauma can cause bilateral pneumothorax. We reported a case of a 91 year old male who, after a fall resulting in right ribs fractures, presented at the emergency department with an extensive bilateral pneumothorax. We described clinical and imagiological features and our approach. This case demonstrates an unusual presentation of a rare anatomical anomaly.

Characteristics of anesthetic and surgical tactics in treatment of a patient with a giant thyroid mass in a cancer center (clinical case)

This paper describes an example of radical surgical treatment of a patient with a giant retrosternal goiter complicated by compression of the organs of the neck and mediastinum. Considering all the risks and possible complications, we should take into account the fact that enlarged thyroid (T) body with retrosternal location can cause displacement and stenosis of the trachea and esophagus, and dislocation of large vessels and nerves of the mediastinum. This anatomical specificity is an imminent threat to successful treatment, and it also carries a certain risk of asphyxia and sudden death of the patient. In this clinical case, radical surgical treatment in this patient included sequential mobilization in two pleural cavities, and then the total removal of T through the traditional surgical access. The anesthetic complexity to support the surgical intervention involved both difficult intubation due to tracheal stenosis, and also the required separate ventilation of the lungs to visualize anatomical structures and mobilize a multinodular formation in two pleural cavities. Standard methods of artificial lung ventilation could be ineffective and even dangerous in this case due to the location and size of the tumor. We focused our attention on high-frequency ventilation (HFV), the best method of respiratory support during surgeries for tracheal and bronchial pathologies. The main task of the anesthetic team in this clinical case was to prevent the development of hypercapnia and hypoxia during intubation of the stenotic tracheal segment, and then adequate ventilation of the lungs with reduced area of proper gas exchange due to bilateral surgical pneumothorax. Thus, the full treatment was carried out due to the only safe method of compensating lung ventilation with anesthesia by HFV. The applied HFV method creates an adequate gas exchange in the lungs due to the small ventilation volume and high frequency of respiratory cycles per minute. HFV both prevented the development of threatening complications during intubation of the stenotic tracheal area and ensured an adequate gas exchange during successive thoracoscopic stages of thyroid tumor mobilization.

Emergent Bedside Cesarean Section for COVID-19 Patient on Veno-venous Extracorporeal Membrane Oxygenation: A Case Report

Background & Case: A 38-year-old Spanish-speaking, pregnant woman at 26.1 weeks’ gestation with two previous Cesarean sections (C-section) presented with acute respiratory distress syndrome secondary to COVID-19 pneumonia. She was intubated and ventilated, complicated by bilateral pneumothoraces and emphysema requiring bilateral chest tubes and blow holes. She had worsening hypoxic respiratory failure ultimately requiring cannulation for venovenous extracorporeal membrane oxygenation (VV-ECMO). She was started on cefazolin for Methicillin-susceptible Staphylococcus aureus bacteremia. On day three of VV-ECMO, there was non-reassuring fetal heart tone necessitating emergent bedside non-sterile Cesarean section at 27.2 weeks’ gestational age in the surgical intensive care unit. Post-Cesarean section, her respiratory failure improved, and she was decannulated from VV-ECMO 13 days later. This case report highlights that VV-ECMO can be a life-saving treatment option for pregnant women with cardiopulmonary failure who are unresponsive to conventional therapy. Literature describing Caesarean section on VV-ECMO is limited. Specifically, there have been only a handful of case reports of C-sections on patients put on VV-ECMO due to respiratory failure. Results: The obvious benefit of proceeding with this emergent bedside C-section was to save the fetus. However, this had to be weighed against the risks of hemorrhage in this high-risk patient since she had two previous C-sections and was on a therapeutic heparin drip while on VV-ECMO. Additionally, there is the risk of infection due to having the C-section done in a non-sterile manner, especially in a patient who is bacteremic. This was mitigated by using additional prophylactic antibiotics post-operatively. The patient’s respiratory status improved significantly after the fetus was delivered, likely due to improvements in respiratory mechanics post-partum. The successful outcome of this patient and her baby required the timely coordination of a multidisciplinary team. Conclusions: Emergent C-section on a pregnant woman with respiratory failure on VV-ECMO can be life-saving for the fetus and the mother. However, the inherent risks associated with it requires close monitoring of the patient and the fetus in order to determine when this is truly necessary. Keywords: Acute respiratory distress syndrome, Cesarean-section, COVID-19, Pregnancy, Veno-venous extracorporeal membrane oxygenation

Clinical features of pneumothorax associated with COVID-19: A retrospective analysis of two centres

BackgroundPneumothorax is a known sequela of coronavirus disease 2019 (COVID-19). However, the clinical features of pneumothorax associated with COVID-19 have not been fully elucidated. MethodsPatients who developed pneumothorax within 6 months of being diagnosed with COVID-19 were retrospectively analysed at two institutions. We investigated the background factors, COVID-19 severity and treatment, timing of pneumothorax onset, treatment modalities, treatment duration, and prognosis of these patients. ResultsA total of 21 patients were diagnosed with pneumothorax within 6 months of COVID-19 diagnosis. The combined incidence rate of pneumothorax at two institutions was 0.89 %. The mean age of these patients was 72.5 years, and they were predominantly male (90.5 %), with a history of smoking (76.1 %). The most frequent comorbidity was hypertension, followed by type 2 diabetes mellitus, COPD, and malignancy. Approximately 76 % of the patients had moderate or severe disease requiring oxygenation. Moreover, 90.5 % of these patients were taking antiviral drugs; 52.4 %, immunosuppressant agents (baricitinib/tocilizumab); and 66.7 % were on dexamethasone. The median time to the onset of pneumothorax was 15.0 days, and 86 % of cases occurred within 1 month of COVID-19 diagnosis. Bilateral pneumothorax and pneumomediastinum were noted in one patient each. Chest drainage was performed in 71.4 % of the patients. The mean treatment duration for pneumothorax was 14.1 days, and the 30-day mortality rate was 28.6 %. ConclusionPneumothorax associated with COVID-19 was more common in patients with moderate or severe disease requiring oxygenation, and occurred within 1 month of COVID-19 diagnosis. Pneumothorax associated with COVID-19 is a serious complication with a high mortality rate and clinicians should pay attention to it.

Successful Medical Management of Bilateral Pneumothorax Due to Nasogastric Tube Misplacement in a Cat.

A 7 yr old female spayed domestic shorthair was evaluated for suspected lily ingestion and acute vomiting. The cat had vomited suspected lily plant material before presentation, and a nasogastric tube (NGT) was placed to continue to administer activated charcoal. The NGT was passed with sedation and limited restraint. To confirm placement, a single lateral radiograph was taken, which showed that the tube was in the trachea, bronchus, through the pulmonary parenchyma, and extending into the region of the craniodorsal retroperitoneal space. The tube was subsequently removed, resulting in a tension pneumothorax. Bilateral thoracostomy tubes were placed and attached to continuous suction. The pneumothorax resolved after 2 days, the thoracostomy tubes were removed, and the cat was discharged on day 3 after admission. To the authors' knowledge, this is the first described pneumothorax complication with successful medical management secondary to routine nasogastric tube placement in a cat. This case report underscores the importance of preparedness for thoracostomy tube placement before removal of any NGT that has been confirmed to be placed through the pulmonary parenchyma.

Secondary Spontaneous Pneumothorax in Patients with Silicosis.

Background and aims: Patients with silicosis are at increased risk of pneumothorax. However, the true incidence of pneumothorax in these patients is yet unknown. Our objective was to study the proportion of secondary spontaneous pneumothorax (SSP) in patients with silicosis who present with acute respiratory deterioration. We also analyzed the risk factors, clinical course, actual management, and treatment outcomes of pneumothorax in patients with silicosis. Materials and methods: It was a hospital-based descriptive cross-sectional study. A total of hundred silicosis patients presenting with any acute worsening respiratory symptoms (dyspnea, cough, and chest pain) warranting admission were enrolled. A detailed history, clinical examination, and radiological investigations were done in all cases. Results: A total of 100 patients were included in this study. The mean age of subjects was 51.6 years. Breathlessness was the most common presenting symptom followed by chest pain. A total of 43 (43%) patients had pneumothorax at presentation. Right-sided pneumothorax was seen in 26 (26%) cases, left-sided in 11 (11%) cases, and six patients (6%) had bilateral pneumothorax. No significant correlation of smoking with pneumothorax was observed in the present study. Around 42% of patients had pulmonary tuberculosis which was microbiologically confirmed. Conclusion: The present study emphasizes that all patients of silicosis who present with acute worsening shortness of breath and or chest pain need to be evaluated for pneumothorax. How to cite this article: Bairwa M, Sharma A, Luniwal M. Secondary Spontaneous Pneumothorax in Patients with Silicosis. J Assoc Physicians India 2023;71(10):64-66.

A RARE CASE OF BILATERAL SPONTANEOUS TENSION PNEUMOTHORAX IN A PATIENT WITH MUCORMYCOSIS

Mucormycosis is an invasive fungal infection seen in immunocompromised hosts. Here a rare case of mucormycosis with pulmonary involvement followed by bilateral spontaneous tension pneumothorax is described. Bilateral spontaneous tension pneumothorax is a rare and fatal condition. We present a case of 3 years old child, diagnosed case of acute Leukemia. During the course of induction chemotherapy, he was hospitalized with fever and diarrhea. He was being managed on lines of neutropenic colitis. During the hospital stay, the child developed sudden respiratory distress and seizures. Chest X-ray showed bilateral spontaneous tension pneumothorax. Immediate bilateral chest tubes insertions were done. He was also electively intubated. After successful lung expansion, the trial of weaning off the ventilator was given and patient was successfully extubated. CT Thorax after lung re-expansion showed few pneumatoceles with no bronchopleural fistulous communication. CT Brain and para nasal sinuses showed fungal rhinosinusitis with intracranial extension. Nasal endoscopy and debridement of necrotic tissue was done. Tissue cultures showed the growth of mucor species. The patient was also started on amphotericin B that was later changed to Posaconazole. He responded well to anti-fungal treatment and there was no recurrence of pneumothorax. Keywords: Mucormycosis, Tension pneumothorax, Bronchopulmonary fistula

Deoxyguanosine kinase deficiency and recurrent spontaneous pneumothorax: a case report

BackgroundDeoxyguanosine kinase deficiency is mainly manifested by hepatic and neurological damage, hence it belongs to the hepatocerebral form of mitochondrial deoxyribonucleic acid depletion syndrome. The association between deoxyguanosine kinase deficiency and recurrent spontaneous pneumothorax has not currently been reported.Case presentationA 12-year-old Russian boy with deoxyguanosine kinase deficiency, a recipient of a liver transplant with amyotrophy secondary to his mitochondriopathy, presented with recurrent spontaneous bilateral pneumothorax refractory to drainage and surgery.ConclusionTo our knowledge, this is the first documented case of deoxyguanosine kinase deficiency associated with recurrent spontaneous pneumothorax, which could be considered a late complication of deoxyguanosine kinase deficiency. At this point, this is only an association and further studies and research need to be performed to help confirm the pathogenesis of this association.