Extrapulmonary Air Research Articles

Electrocardiographic changes in a right-sided pneumothorax.

A pneumothorax is an extrapulmonary air accumulation within the pleural space between the lung and the chest wall. Symptoms usually reported include dyspnoea and chest pain. However, there are many life-threatening conditions with the same symptomology making early pneumothorax diagnosis challenging, such as acute coronary syndrome. Electrocardiogram (ECG) changes caused by left and right sided pneumathoraces have been reported, but awareness remains poor. This case describes a 51-year old male who presented with a right-sided pneumothorax, new ECG changes and elevated troponin. The case highlights the importance of recognising right-sided pneumothorax-associated ECG manifestations in patients presenting with acute chest symptoms.

1009 Severe Thoracic and Abdominal Surgical Emphysema in a Patient with COVID-19 Pneumonia

Abstract Introduction Surgical emphysema is a relatively common occurrence in intensive care unit but its degree of spread in our patient is unusual. We present a case of a young adult with rapid widespread crepitus and worsening respiratory dynamics. Case description 35-year-old male with hypertension, type 2 diabetes and obesity was invasively ventilated for severe COVID-19 pneumonia. He developed reduced chest compliance, required high driving pressures, and had persistent hypoxia despite a high fraction of inspired oxygen. He was ventilated using protocolised ARDSNet lung protective ventilation (LPV) including periods of ventilation in the prone position. After 19 days of ventilation, worsening surgical emphysema was noted following a tracheostomy. Chest radiography demonstrated extensive extra-pulmonary air. Subsequent computed tomography confirmed widespread surgical emphysema from the face to the scrotum, bilateral pneumothoraces and pneumoperitoneum. Bilateral intercostal drains were inserted and LPV was continued. The pneumoperitoneum resolved with conservative management. The patient was mechanically ventilated for 59 days and was discharged home on day 104. Discussion Pneumothorax, pneumomediastinum and surgical emphysema can occur following high-pressure ventilation and surgical tracheostomy. However, pneumoperitoneum with extra-alveolar air collections communicating via potential fascial planes, perivascular sheaths or trans-diaphragmatic extension is rare. The cytokine storm postulated to occur in COVID-19 infection may cause alveolar destruction, leading to Macklin's phenomenon whereby air tracks along peri-bronchial vascular sheaths towards the mediastinum following alveolar rupture. In this patient, prolonged ventilation and high airway pressures probably compounded this effect and led to the complications described.

Finding the bubble: atypical and unusual extrapulmonary air in the chest

ObjectiveTo describe the radiologic findings of extrapulmonary air in the chest and to review atypical and unusual causes of extrapulmonary air, emphasizing the importance of the diagnosis in managing these patients. ConclusionIn this article, we review a series of cases collected at our center that manifest with extrapulmonary air in the thorax, paying special attention to atypical and uncommon causes. We discuss the causes of extrapulmonary according to its location: mediastinum (spontaneous pneumomediastinum with pneumorrhachis, tracheal rupture, dehiscence of the bronchial anastomosis after lung transplantation, intramucosal esophageal dissection, Boerhaave syndrome, tracheoesophageal fistula in patients with esophageal tumors, bronchial perforation and esophagorespiratory fistula due to lymph-node rupture, and acute mediastinitis), pericardium (pneumopericardium in patients with lung tumors), cardiovascular (venous air embolism), pleura (bronchopleural fistulas, spontaneous pneumothorax in patients with malignant pleural mesotheliomas and primary lung tumors, and bilateral pneumothorax after unilateral lung biopsy), and thoracic wall (infections, transdiaphragmatic intercostal hernia, and subcutaneous emphysema after lung biopsy).

Electrocardiographic manifestations in a large right-sided pneumothorax

BackgroundPneumothorax is an extrapulmonary air accumulation within the pleural space between the lung and chest wall. Once pneumothorax acquires tension physiology, it turns into a potentially lethal condition requiring prompt surgical intervention. Common symptoms are chest pain and dyspnea; hence an electrocardiogram (ECG) is often performed in emergent settings. However, early diagnosis of pneumothorax remains challenging since chest pain and dyspnea are common symptomatology in various life-threatening emergencies, often leading to overlooked or delayed diagnosis. While the majority of left-sided pneumothorax-related ECG abnormalities have been reported, right-sided pneumothorax-related ECG abnormalities remain elucidated.Case presentationA 51-year-old man presented to the emergency department with acute-onset chest pain and dyspnea. Upon initial examination, the patient had a blood pressure of 98/68 mmHg, tachycardia of 100 beats/min, tachypnea of 28 breaths/min, and oxygen saturation of 94% on ambient air. Chest auscultation revealed decreased breath sounds on the right side. ECG revealed sinus tachycardia, phasic voltage variation of QRS complexes in V4–6, P-pulmonale, and vertical P-wave axis. Chest radiographs and computed tomography (CT) scans confirmed a large right-sided pneumothorax. The patient’s symptoms, all the ECG abnormalities, and increased heart rate on the initial presentation resolved following an emergent tube thoracostomy. Moreover, we found that these ECG abnormalities consisted of two independent factors: respiratory components and the diaphragm level. Besides, CT scans demonstrated the large bullae with a maximum diameter of 46 × 49 mm in the right lung apex. Finally, the patient showed complete recovery with a thoracoscopic bullectomy.ConclusionsHerein, we describe a case of a large right-sided primary spontaneous pneumothorax with characteristic ECG findings that resolved following re-expansion of the lung. Our case may shed new light on the mechanisms underlying ECG abnormalities associated with a large right-sided pneumothorax. Moreover, ECG manifestations may provide useful information to suspect a large pneumothorax or tension pneumothorax in emergent settings where ECGs are performed on patients with acute chest pain and dyspnea.

Buscando la burbuja: aire torácico extrapulmonar atípico e inusual

ObjectiveTo describe the radiologic findings of extrapulmonary air in the chest and to review atypical and unusual causes of extrapulmonary air, emphasizing the importance of the diagnosis in managing these patients. ConclusionIn this article, we review a series of cases collected at our center that manifest with extrapulmonary air in the thorax, paying special attention to atypical and uncommon causes. We discuss the causes of extrapulmonary according to its location: mediastinum (spontaneous pneumomediastinum with pneumorrhachis, tracheal rupture, dehiscence of the bronchial anastomosis after lung transplantation, intramucosal esophageal dissection, Boerhaave syndrome, tracheoesophageal fistula in patients with esophageal tumors, bronchial perforation and esophagorespiratory fistula due to lymph-node rupture, and acute mediastinitis), pericardium (pneumopericardium in patients with lung tumors), cardiovascular (venous air embolism), pleura (bronchopleural fistulas, spontaneous pneumothorax in patients with malignant pleural mesotheliomas and primary lung tumors, and bilateral pneumothorax after unilateral lung biopsy), and thoracic wall (infections, transdiaphragmatic intercostal hernia, and subcutaneous emphysema after lung biopsy).

Getting the Wind Knocked out of Your Chest: A Case of Endobronchial Valve Placement for Bronchocutaneous Fistula Following Thoracoplasty for Pulmonary Tuberculosis and Aspergillosis

SESSION TITLE: Procedures Case Report Posters SESSION TYPE: Affiliate Case Report Poster PRESENTED ON: Tuesday, October 27, 2015 at 01:30 PM - 02:30 PM INTRODUCTION: Bronchopleural fistula (BPF) is cause for significant morbidity and mortality following pulmonary resection, complicated pleural infection or pneumothorax. Several methods exist for the treatment of BPF ranging from conservative methods to more invasive surgical correction. Endobronchial valve (EBV) placement is a promising minimally invasive technique for poor surgical candidates. CASE PRESENTATION: A 61-year-old male was diagnosed with pulmonary tuberculosis following a trip to Mexico in 2013 and initiated on RIPE therapy, later converted to Rifampin and Isoniazid after sputum clearance. His course was complicated by pulmonary aspergillosis and empyema with significant left upper lobe (LUL) destruction requiring thoracoplasty with Eloesser flap. Several months later he was hospitalized for sepsis and found to have a BPF for which he underwent muscle flap closure. Upon follow-up, he was noted to have a large extrapulmonary air pocket that varied with inspiration. A large BPF between the LUL and lingula was confirmed by bronchoscopy. He was deemed to be a poor repeat surgical candidate due to suboptimal nutritional status and debility so a less invasive intervention was favored. In December 2014 the patient underwent bronchoscopic placement of a removable 7.0mm Spiration® IBV valve. At one month follow up there was significant reduction in the extrapulmonic air accumulation (shown). DISCUSSION: Endobronchial valves were first designed for bronchoscopic lung volume reduction in patients with severe emphysema and air trapping. More recently they were approved by the FDA under the Humanitarian Device Exemption for use in persistent air leaks (PAL) following lung resection. Off-label use for BPF or PAL secondary to suppurative lung infection or spontaneous pneumothorax have become increasingly popular owing to the minimally invasive technique. One-way EBV's work by blocking airflow distal to the valve promoting atelectasis and healing of the BPF while permitting clearance of airway secretions without affecting valve migration. CONCLUSIONS: This is a novel report of the successful use of one-way EBV for a large proximally located BPF after definitive closure was attempted with a muscle flap. Further trials are needed to establish guidelines regarding indications for use, optimal duration and prognosis after placement in such situations. Reference #1: Giddings, O. et al. Endobronchial valve placement for the treatment of bronchopleural fistual: a reivew of the current literature. Curr Opin Pulm Med. 2014. 20:347-51. DISCLOSURE: The following authors have nothing to disclose: Amber Oberle, Khalil Diab, Lorenzo Zaffiri, Aliya Noor Endobronchial valve (EBV) placement for bronchopleural fistulas or persistent air leaks after spontaneous pneumothorax, suppurative chest infection and failure of conventional therapy is currently regarded as off-label and not approved by the FDA. EBV's were originally designed for bronchoscopic lung volume reduction in patients with severe heterogeneous emphysema but have not been FDA approved for this indication. In 2006, The FDA did approved the use of EBV's under the Humanitarian Device Exemption program for patients with persistent air leaks after lung parenchymal resection.

ACR Appropriateness Criteria Routine Chest Radiographs in Intensive Care Unit Patients

Daily routine chest radiographs in the intensive care unit (ICU) have been a tradition for many years. Anecdotal reports of misplacement of life support items, acute lung processes, and extra pulmonary air collections in a small number of patients served as a justification for routine chest radiographs in the ICU. Having analyzed this practice, the ACR Appropriateness Criteria Expert Panel on Thoracic Imaging has made the following recommendations: • When monitoring a stable patient or a patient on mechanical ventilation in the ICU, a portable chest radiograph is appropriate for clinical indications only. • It is appropriate to obtain a chest radiograph after placement of an endotracheal tube, central venous line, Swan-Ganz catheter, nasogastric tube, feeding tube, or chest tube. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed every 2 years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer-reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances where evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment. The strongest data contributing to these recommendations were derived from a meta-analysis of 8 trials comprising 7,078 ICU patients by Oba and Zaza [1].

Pneumomediastinum in the neonatal and paediatric intensive care unit

The incidence, aetiology and pathophysiology of pneumomediastinum (PM), an uncommon and potentially serious disease in neonates and children, were evaluated. A retrospective chart review of all patients diagnosed with PM who were hospitalised in the intensive care unit of the University Children’s Hospital Zürich, Switzerland, from 2000 to 2006, was preformed. We analysed the incidence, severity and causes of PM and investigated the possible differences between neonatal and non-neonatal cases. Seven children and nine neonates were identified with PM. All patients had a good outcome. Six cases of PM in the group of children older than 4 weeks were deemed to be caused by trauma, infection and sports, whereas one case was idiopathic. All nine neonatal cases presented with symptoms of respiratory distress. We were able to attribute four cases of neonatal PM to pulmonary infection, immature lungs and ventilatory support. Five neonatal cases remained unexplained after careful review of the hospital records. In conclusion, PM in children and neonates has a good prognosis. Mostly, it is associated with extrapulmonary air at other sites. It is diagnosed by chest X-ray alone. We identified mechanical events leading to the airway rupture in most children >4 weeks of life, whereas we were unable to identify a cause in half of the neonates studied (idiopathic PM).

POSITIVE PRESSURE AND THE DEVELOPMENT OF EXTRAPULMONARY AIR LEAKS IN PEDIATRIC STATUS ASTHMATICUS

PURPOSE: Endotracheal intubation and mechanical ventilation are frequently undertaken in children with status asthmaticus and impending respiratory failure. However, the use of positive pressure for pediatric status asthmaticus is thought to be associated with the development of extrapulmonary air leaks. Non-invasive positive pressure ventilation (NPPV) has been used as an alternative intermediary therapy in some children. The purpose of this study was to determine if the mode of positive pressure delivery per se affects the likelihood of development of an extrapulmonary air leak.

Extensive pneumothorax, pneumomediastinum and surgical emphysema as a complication of bleomycin therapy

Bleomycin is a commonly used chemotherapeutic agent and one of the commonest cytotoxic drugs leading to pulmonary parenchymal damage. It generally leads to interstitial pneumonitis and fibrosis, hypersensitivity reactions and acute respiratory distress syndrome. We describe an 8-year-old boy who, following prolonged bleomycin therapy, demonstrated extensive air dissection and extrapulmonary air, an unusual and fatal complication.

Using CT to diagnose tracheal rupture.

A retrospective study was performed to assess CT sensitivity for diagnosing tracheal rupture. Intubated cadaver tracheas were examined to assess endotracheal tube balloon overdistention and deformity and to evaluate the relationship of balloon pressures to tracheal injury. Neck or chest CT scans of 14 patients with tracheal rupture and 41 control trauma patients with pneumomediastinum but without tracheal injury were reviewed and compared to assess the presence and location of extrapulmonary air, whether direct visualization of tracheal wall disruption was possible, the size and shape of endotracheal tube balloon, signs of transtracheal balloon herniation in intubated patients, and the location of the extratracheal endotracheal tube. Intact and experimentally injured cadaver tracheas were used to evaluate tube balloon pressure and configuration. All 14 patients with tracheal rupture had deep cervical air and pneumomediastinum. Overdistention of the tube balloon occurred in 71% (5/7) of the intubated patients, and balloon herniation occurred in 29% (2/7). Direct tracheal injury was seen in 71% (10/14) of the patients as a wall defect (n = 8) or deformity (n = 2). Overall, CT was 85% sensitive for detecting tracheal injury. Patients with tracheal injury had a significantly lower incidence of pneumothorax (p = 0.01) than did the control group. The CT appearance of balloon herniation through defects in the cadaver tracheas closely mimicked those of patients with tracheal injury. The amount of balloon pressure required to rupture the intubated trachea was extremely high and rupture was difficult to obtain. CT can reveal tracheal injury and can be used to select trauma patients with pneumomediastinum for bronchoscopy, leading to early confirmation and treatment.

Mediastinal and Subcutaneous Emphysema Complicating Bronchial Asthma I. Clinical Studies of 52 Cases

Fifty five episodes of mediastinal and subcutaneous emphysema in 52 asthmatic patients, 38 males and 17 females, were experienced at Doai Memorial Hospital during the past 16 years, 1964 to 1980. Age distribution ranged from 2 to 21 years of age, the highest incidence was observed at 12 years of age, especially in autumn (61.2%). The incidence of these complications in moderate to severe asthmatic attacks ranged from 0.305% in October to 0%in January with an average incidence of 0.16%. Extra-pulmonary air disappeared within 11 days after onset in all cases. The occurrence was associated with upper respiratory infection (85.5%) and also followed a severe attack of asthma. There was a significant correlation between the age of onset and the duration of asthma (r = 0.91, Y = 0.95X - 1.99, p<0.001), but no apparent relationship between the complication and corticosteroid dose. This complication did not occur following mechanical ventilation in all but two cases. Conservative and nonsurgical approach as well as careful observations were recommended.

Subvisceral pleural air in neonates with respiratory distress.

We reviewed our cases of persistent extrapulmonary air following chest tube placement and decided to test the hypothesis that this entity may represent collections of air beneath the visceral pleura. We describe ten patients who had this entity despite one or more chest tubes per pleural cavity, and described the creation of subvisceral pleural blebs in preterm lambs with respiratory distress requiring mechanical ventilation. We conclude that (1) subvisceral pleural air may occur in infants with respiratory distress and, thus, may be inaccessible to chest-tube drainage, and (2) centrifugal dissection of air, though poorly appreciated previously, may play an important role in the pathogenesis of extrapulmonary air.

Congenital diaphragmatic hernia: Deleterious effects of pulmonary interstitial emphysema and tension extrapulmonary air

Survival after repair of congenital diaphragmatic hernia (CDH) is limited by adequacy of prenatal pulmonary development. Ventilatory function may be compromised further by multiple adverse perinatal factors that necessitate intermittent pressure ventilation (IPPV). Barotrauma frequently complicates IPPV, and is observed in several forms. These complications lead to ventilatory and hemodynamic dysfunctions. Of 50 infants with CDH repaired in the first 24 hr of life, 36% survived. Infants operated in the first 8 hr had a lower survival rate (28%) than those operated between 8 and 24 hr (50%). Tension extrapulmonary air (TEPA) was observed in 30 infants (60%), was significantly higher in dying infants ( p p

A Modification of the Chest Transilluminator

We have found the Mini-Light Illuminator (Medgeneral, Minneapolis, Minnesota) extremely useful in our neonatal intensive care unit for the early detection of pneumothorax, pneumomediastinum, and developing hydrocephalus; for defining some abdominal masses; and for following the removal of extrapulmonary air. The initial article about the Mini-Light by Kuhns et al. (Pediatrics 56:355, September 1975) suggested the possibility of bacterial contamination. More recent correspondence (Pediatrics 57:975, June 1976) from them further noted a potential thermal hazard.

VARIATIONS IN FINDINGS FROM NEONATAL AUTOPSIES

Prominent lesions in 312 neonatal autopsies performed in our service between 1965 and 1970 inclusive were compared with those from 170 necropsies from the last 6 years. Autopsy rates were 90% and 83%. During these two periods 54.5% and 49.5% of deaths respectively occurred in infants less than 1000 gms. Incidence of babies of 500 gms. or less has remained over 10%. predominant lesions in both periods have been hyaline membrane disease (HMD), pneumonia and intracranial hemorrhage (ICH). HMD has not decreased lately, but there is a higher incidence of early lesions and 40% of the infants were under 1000 gms. Pneumonias have diminished (34% to 26%), as also have omphalitis, septicemia and meningitis. However, necrotizing enterocolitis and systemic candidiasis have only been observed in recent years. ICH has also decreased from 30% to 20%. There has been a higher proportion of congenital malformations (excluding patent ductus arteriosus) from 9% to 15.8%. The most striking changes have been related to certain pulmonary lesions. Bronchopulmonary dysplasia present in 10 autopsies in the last 4 years was not seen previously, and complications due to extrapulmonary air have risen from 2% to 12.5%. Pulmonary hemorrhage has increased slightly. Traumatic lesions have been infrequent throughout the period of observation.

Intrapulmonary CO 2 receptors in the duck:III. Functional localization

Single-unit activity in the right vagus nerve was recorded from 67 intrapulmonary CO 2 receptors in anesthetized ducks. The right caudal thoracic air sac was cannulated and the mesobronchus was blocked in the right lung between the origins of ventrobronchi and dorsobronchi. The lung could be unidirectionally ventilated in either direction. Two different tests were applied to each receptor in an attempt to determine its location within the lung. 1. (1) Gross localization of receptors in cranial or caudal parts of the lung was assessed on the basis of differences in discharge frequency when gas flow direction was air sac to trachea vs. trachea to air sac. More than 95% of the receptors were in caudal parts of the lung. 2. (2) For finer localization, pure CO 2 or O 2 was insufflated via catheters into the ventilatory gas stream either proximal or distal to the blocking balloon during gas flow in both directions. In this way, the location of 60 receptors (90%) could further be specified. Of these receptors 56% were found to be in the caudal ends of paleopulmonic parabronchi, 27% in neopulmonic parabronchi, and 12% in dorsobronchi or in parabronchial tissue near the dorsobronchi; only 5% were located in the cranial ends of paleopulmonic parabronchi; none were in the ventrobronchi or extrapulmonary air ways. Thus, CO 2 receptors are located in those parts of the lung that experience marked fluctuations in CO 2 concentration during the respiratory cycle. Differences in location permit satisfactory explanation of differences in discharge pattern of CO 2 receptors observed during spontaneous breathing.