Left Mediastinal Shift Research Articles

Cardiac herniation post left upper lobectomy and thymectomy: a case report

BackgroundCardiac herniation occurs when there is a residual pericardial defect post thoracic surgery and is recognised as a rare but fatal complication. It confers a high mortality and requires immediate surgical correction upon recognition. We present a case of cardiac herniation occurring post thymectomy and left upper lobectomy.Case presentationInitial presentation: A 48-year-old male, hypertensive smoker presented with progressive breathlessness and was found to have a left upper zone mass confirmed on CT biopsy as carcinoid of unclear origin. PET-CT revealed avidity in a left anterior mediastinal area, left upper lobe (LUL) lung mass, mediastinal lymph nodes, and a right thymic satellite nodule. Intraoperatively: Access via left thoracotomy and sternotomy. The LUL tumour involved the left thymic lobe (LTL), left superior pulmonary vein (LSPV), left phrenic nerve and intervening mediastinal fat and pericardium, which were resected en-masse. The satellite nodule in the right thymic lobe (RTL) was adjacent to the junction between the left innominate vein and superior vena cava (SVC). The pericardium was resected from the SVC to the left atrial appendage. Clinical deterioration: Initially the patient was doing well clinically on day 1, however there was sudden bradycardia, hypotension, clamminess, and oligoanuria, with raised central venous pressures and troponins. ECG: no capture in leads V1-2, but positive deflections seen on posterior leads. Echo: no acoustic windows, but good windows seen posteriorly. CXR: left mediastinal shift. Redo operation: After initial resuscitation and stabilisation on the intensive care unit, on day 2 a redo-sternotomy revealed cardiac herniation into the left thoracic cavity with the left ventricular apex pointing towards the spine, and inferior caval kinking. After reduction and repair of the pericardial defect with a fenestrated GoreTex patch, the patient recovered well with complete resolution of the ECG and CXR.ConclusionCardiac herniation can even occur following sub-pneumonectomy lung resections and should be considered as a differential when faced with a sudden clinical deterioration, warranting early surgical correction.

Management of massive bilothorax post-percutaneous trans-hepatic biliary drainage

BackgroundIatrogenic bilothorax is an infrequent major complication of percutaneous trans-hepatic biliary drainage (PTBD) and optimal treatment remains under-reported. The authors herein describe a case of PTBD complicated by a massive bilous effusion.Case presentationAn 80-year-old male underwent PTBD due to malignant obstructive jaundice (total bilirubin 20.0 mg/dL). Following discharge, the patient was readmitted with severe dyspnea and recurrence of jaundice (total bilirubin 15.0 mg/dL). CT depicted the drainage catheter traversing the right costophrenic sulcus, complete obliteration of the right pleural space, no aerated right lung parenchyma and left mediastinal shift. The pleural effusion was successfully drained, and the biliary drainage catheter tract was sealed with Gelfoam pledgets and coils, to prevent bilopleural fistula formation and recurrence of the effusion.ConclusionsIn this case, a successful totally percutaneous management of iatrogenic bilothorax following PTBD is described. Due to the potential of rapid clinical deterioration and empyema formation, immediate evaluation and treatment are warranted. Prompt pleural drainage with antibiotic therapy and bile flow diversion from the pleural cavity are required.

RARE CASE OF PAZOPANIB-ASSOCIATED BILATERAL PNEUMOTHORACES IN A PATIENT WITH METASTATIC SYNOVIAL SARCOMA

TOPIC: Lung Cancer TYPE: Medical Student/Resident Case Reports INTRODUCTION: Bilateral pneumothoraces are a rare occurrence, comprising 1.4% to 7.6% of cases [1]. Secondary causes of pneumothorax include bullous emphysema, cystic parenchymal lung disease and tuberculous lung disease [2]. Malignancy is a rare cause of pneumothorax, yet sarcomas have been associated with pneumothorax in 2% of patients [3]. Pazopanib, a tyrosine kinase inhibitor used in the treatment of metastasized sarcoma, has been shown to have a 3.3% risk of developing pneumothorax [4]. CASE PRESENTATION: A 24-year-old previously healthy Yemeni female initially presented with left-sided groin pain and swelling. Computed tomography of the pelvis showed a large heterogeneous mass in the proximal left thigh. Biopsy was consistent with synovial sarcoma. Staging via chest computed tomography showed multiple pulmonary nodules concerning for metastasis. Over the course of two years, she failed multiple lines of chemotherapy and had progression of disease with new and enlarging bilateral pulmonary nodules. She was started on fourth-line chemotherapy with pazopanib (Votrient) 400 mg daily. Two months later, she presented with shortness of breath, found to be tachypneic, tachycardic and hypoxemic. Chest x-ray revealed bilateral pneumothoraces with left mediastinal shift concerning for tension pneumothorax. Two tube thoracostomies were placed; however, course was complicated by persistent air leak bilaterally, requiring video-assisted thoracoscopic surgery with bullectomy and surgical talc pleurodesis. Patient had a slow resolution of pneumothorax and subsequently discharged home without recurrence. DISCUSSION: Bilateral pneumothoraces can be life-threatening and are associated with poor long term prognosis, especially in patients with poor underlying lung function [5]. Pneumothorax is seen in approximately 2% of sarcoma patients with pulmonary metastases. In patients with sarcoma and pulmonary metastases, 41.6% of pneumothoraces were bilateral, and typically associated with multiple lung nodules, cystic or cavitary lesions, or presence of pleural nodules or thickening [3]. Additionally, cytotoxic agents have been shown to induce cavitation in pulmonary lesions and increase the risk of pneumothorax development [6]. Per the PALETTE trial which led to the approval of pazopanib for use in sarcoma, there was a 3.3% risk for pneumothorax development [4], comparable to the baseline rate of pneumothorax development in patients with sarcoma. Nevertheless, bilateral pneumothoraces carry potentially fatal consequences. CONCLUSIONS: In patients with sarcoma undergoing treatment with pazopanib, a bilateral pneumothorax, though rare, may be life threatening and should be acutely suspected. REFERENCE #1: TG Rim, JS Bae, YS Yuk. Life-Threatening Simulatenous Bilateral Spontaneous Tension Pneumothorax - A case report. Korean J Thorac Cardiovasc Surg. 2011 Jun; 44(3): 253-256.2. Mason RJ, Braoddus VC, Murray JF, Nadel JA. Murray and Nadel's Textbook of Respiratory Medicine. 4th ed. Elsevier Saunders (2005); Vol 2, Chapter 81. Philadelphia, PA. REFERENCE #2: Hoag JB, Sherman M, Fasihuddin Q, Lund ME. A comprehensive review of spontaneous pneumothorax complicating sarcoma. CHEST. 2010 Sep; 138(3);510-8.4. Van der Graaf WT, Blay JY, Chawla SP, Kim DW, et al. Pazopanib for metastatic soft-tissue sarcoma (PALETTE): a randomised, double-blind, placebo-controlled phase 3 trial. Lancet. 2012 May 19; 379(9829):1879-86. REFERENCE #3: Graf-Deuel E, Knoblauch, A. Simultaneous bilateral spontaneous pneumothorax. CHEST. 1994 Apr; 105(4):1142-6.6. Interiano RB, McCarville MB, Wu J, Davidoff AM, Sandoval J, Navid F. Pneumothorax as a complication of combination antiangiogenic therapy in children and young adults with refractory/recurrent solid tumors. J Pediatr Surg. 2015 Sep; 50(9):1484-9. DISCLOSURES: No relevant relationships by Sally Askar, source=Web Response No relevant relationships by Owais Nadeem, source=Web Response

Visual Diagnosis: Rapid Deterioration of Respiratory Status and Lower Limb Hypotonia in a 6-month-old Infant.

1. Guillaume J. LimFat, BMSc* 2. Vinay Kukreti, MD†,‡ 1. *Undergraduate Medicine, Queen’s University School of Medicine, Kingston, ON, Canada 2. †Department of Pediatrics, Queen’s University School of Medicine, Kingston General Hospital, Kingston, ON, Canada 3. ‡Department of Pediatrics, Lakeridge Health Oshawa, Oshawa, ON, Canada A 6-month-old previously healthy boy presents to the local emergency department with a 1-week history of progressive lethargy, irritability, and anorexia. Two days before presentation he developed an unusual breathing pattern and worsening respiratory distress, and he had a fever of 101.3°F (38.5°C). There was no rhinorrhea, coryza, cough, vomiting, or diarrhea. He appears unwell, with respiratory distress, tachypnea, and grunting. His blood pressure is 80/45 mm Hg, heart rate is 200 beats/min, respiratory rate is 60 breaths/min, and oxygen saturation is 77% in room air. He is afebrile. There is significantly decreased air entry bilaterally, most impressively over the right lung field. His neurologic examination reveals a mild right-sided ptosis. Although he moves both arms normally, there is a noticeable paucity of movements in his lower limbs, with decreased tone in both legs. The remainder of his examination findings are normal. On further questioning the parents clarify that for the past 2 months there has been a relative decrease in leg movements, and he had stopped attempting to bear weight when made to stand with support. His respiratory status does not improve, and he requires supplemental oxygen to maintain appropriate oxygen saturation. Clinical laboratory tests reveal a white blood cell count of 18,800/ μ L (18.8×109/L) (neutrophil count, 6,200/ μ L [6.2×109/L]; lymphocyte count, 11,100/ μ L [11.1×109/L]; and monocyte count, 1,100/ μ L [1.1×109/L]) and normal electrolyte levels. A chest radiograph reveals a large right paravertebral mass with significant left mediastinal shift associated with rib and vertebral destruction and moderate right-sided pleural effusion (Fig 1). Given these findings and worsening …

CATAMENIAL PNEUMOTHORAX: A MANAGEMENT CHALLENGE

SESSION TITLE: Medical Student/Resident Pulmonary Manifestations of Systemic Disease 3 SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/09/2018 01:15 PM - 02:15 PM INTRODUCTION: Catamenial pneumothorax (CP) is a rare clinical entity presenting with recurrent pneumothorax in women of reproductive age (1). Presence of ectopic endometrial tissue in thorax leads to their activation with each menstrual cycle. We report a unique case of a young female who presented with recurrent spontaneous pneumothorax despite video assisted thoracoscopic surgery (VATS). CASE PRESENTATION: A 36-year-old female with history of endometriosis, CP status post VATS about 4 months prior to this presentation, DVT, was referred to our ER for admission after she was found to have large right pneumothorax on a CT chest done as outpatient for chest discomfort. She was hemodynamically stable with SpO2 97% on room air. CT chest revealed a very large loculated right pneumothorax with left mediastinal shift and extensive pleural thickening. Initially she underwent a pigtail catheter placement in the largest pocket. Despite the pigtail drainage, patient continued to have air leak and mediastinal shift. Thus, a decision was made to perform VATS again. Pleural biopsy and VATS pleurodesis were performed with placement of 12F, 19F, 28F chest tubes. Mediastinal shift resolved but she continued to have small pneumothorax. On day 16, she was discharged with a chest tube and outpatient follow-up. Chest tube was removed on one week follow up in the clinic. She continued to have small loculated right sided pneumothorax. Pleural biopsy obtained during VATS, showed positive paired-box gene8 (PAX8) in epithelial lining compatible with presence of endometrial tissue in pleura. She is currently on progesterone only mini pill and is closely followed up in clinic. DISCUSSION: Thoracic endometriosis is the most common site for extra pelvic endometriosis with CP being a common presentation. It mostly affects right side (85-90%) like in our case. Characteristic findings associated with CP include defects of diaphragm like perforation, stomata, pores and fenestrations, which can vary in size, shape and numbers (2). With this case, we emphasize that the physicians should be aware of this relatively uncommon clinical entity when encountering young female with recurrent pneumothorax. Even after confirmed diagnosis, CP poses a treatment challenge as it can continue to cause recurrent large pneumothoraces despite VATS and hormonal therapy. Patients can develop pleural thickening and loculations which makes management of future pneumothoarcses even more difficult. No clear guidelines exist on management of CP. With the disease affecting young population and having a significant effect on lifestyle, it is prudent that more research should be done for CP management. CONCLUSIONS: CP is an uncommon cause of recurrent pneumothorax. Histologic finding of endometrial tissue on pleural biopsy is often required to confirm the diagnosis. CP is usually managed with hormonal therapy and VATS but needs further investigation. Reference #1: Bagan P, et al. Catamenial pneumothorax: retrospective study of surgical treatment. Ann Thorac Surg 2003;75:378-81. Reference #2: Visouli AN, et al. Catamenial pneumothorax: a rare entity? Report of 5 cases and review of the literature. J Thorac Dis. 2012 Nov;4(Suppl 1):17–31. DISCLOSURES: No relevant relationships by Nidhi Aggarwal, source=Web Response No relevant relationships by Vivek Kumar, source=Web Response No relevant relationships by Yizhak Kupfer, source=Web Response No relevant relationships by Jignesh Patel, source=Web Response No relevant relationships by Anand Rai, source=Web Response No relevant relationships by Arjun Saradna, source=Web Response No relevant relationships by Ankur Sinha, source=Web Response No relevant relationships by Parita Soni, source=Web Response

Pediatric Foreign Body Aspiration

Author(s): Yan, Sha; Azubuine, Uchechi | Abstract: ABSTRACT: History of present illness: A 10-month-old male presented after choking on a carrot. Mom reported coughing with perioral cyanosis. On examination, the child had no retractions, but wheezing was heard in the right lung fields particularly when coughing. Significant findings: Chest radiograph showed increased radiolucency (red arrow) and flattening of the diaphragm on the right side (blue arrow) consistent with hyperinflation of the right lung, as well as left mediastinal shift (green arrow), indicating obstruction. Discussion: Foreign body aspiration is a common condition in pediatrics and can be life- threatening. It happens most commonly in children younger than 2 years due to a natural curiosity for putting objects in their mouth and an immature swallowing mechanism.1 Most foreign bodies are located in the right main bronchus due to its wider diameter and more direct extension of the trachea.2 Witnessed choking has the highest sensitivity and specificity for this pathology (sensitivity 75.4% and specificity 92.1%).3 These children will often present with coughing, wheezing, and/or decreased lung sounds that suggest an aspiration.4Chest radiographs are excellent in detecting radiopaque objects. However, most aspirations are from radiolucent organic matters such as nuts or seeds.3 Radiographs that show focal area of hyperinflation, mediastinal shift, and atelectasis are highly specific for aspiration. Pathological findings on chest radiography showed an 86.1% sensitivity and 63.2% specificity.3 However, it is possible that these finding may not be seen on initial imaging. It is important to keep a high index of suspicion as undiagnosed foreign body aspiration can lead to chronic pulmonary infections, bronchiectasis, pneumothorax, asphyxia, and death.3 This child had both physical and radiographic findings of a foreign body aspiration in addition to a witnessed choking episode. He was taken to the operation room by the pediatric surgery team for bronchoscopy and a piece of carrot was removed from the right mainstem bronchus. Topics: Foreign body aspiration, pediatric foreign body, pediatric pulmonology, respiratory.

Congenital Chylothorax: Management and Long-term Outcome A Case Report and Literature Review

Congenital chylothorax is the most common cause of pleural effusion in the neonatal period. We describe a 9 days old new born admitted for respiratory distress. The chest X-rays showed a white right lung with a left mediastinal shift. A pleural aspiration assessed the diagnosis of chylothorax. Lympho-scintigraphy detected rapid drainage of lymph into the right side of the chest. A conservative treatment was initiated with pleural aspirations and total parenteral nutrition followed by enteral feeding using semi elemental formula. This treatment was effective and the child was discharged from the hospital at the age of 40 days. A 6 years follow-up, revealed no recurrence of the chylothorax.

Outcomes of Liver Biopsy in Patients Stratified on Renal Function

Purpose: Liver biopsy remains the gold standard in diagnosing hepatic conditions. There is minimal existing evidence regarding the risk associated with liver biopsy in a patient with Chronic Kidney Disease (CKD). We aimed to study the liver biopsy outcomes in patients with CKD. Methods: Retrospective chart review of a total of 171 patients above the age of 18 years who underwent percutaneous and/or transjugular liver biopsy done by either gastroenterologists or radiologists at the MetroHealth Medical Center (MHMC) between 1/1/2000 to 12/31/2010 was conducted. Patients with incomplete documentation, primary liver malignancy or liver metastasis and patients who underwent laparoscopy guided liver biopsy were excluded. Patients were divided into three groups based on renal function as defined by CKD-EPI and KDOQI equation. Group I included normal kidney function or CKD Stage 1 and 2 (n= 33). Group II included patients with CKD Stage 3, 4 and 5 (n=13). Group III included end stage renal disease requiring hemodialysis (n=7). Demographics included age, gender and weight of the patients. Laboratory investigations including pre and post procedure hemoglobin and hematocrit, platelets, liver function testing with PT, INR, aPTT were collected. History of bleeding diathesis, administration of antiplatelet or anticoagulant medications prior to or after the procedure, occurrence of bleeding complication til 1 week post procedure, methods used to control bleeding and amount of blood transfusion were also recorded. Bleeding was defined as obvious localized bleeding during or post procedure or more than 2 gram or 6% drop in hemoglobin or hematocrit respectively or imaging study (CT/USG/MRI) confirming liver hematoma. Results: Demographic data is per table 1. Bleeding as an intra or post-procedure complication of liver biopsy was confirmed in 3 of the 33 (9%) patients in group I, 2 of 13 (15%) patients in group II and 3 of the 7 (43%) patients in group III. In group 1, none of the patients required blood transfusion. In group 2, 1 patient had large right hemothorax with left mediastinal shift and required 2 packed RBC and 4 Fresh Frozen Plasma (FFP). In the third group, 3 patients required blood transfusions ranging from 1-6 units of packed RBC and 2 patients required an average of four units of FFP. 1 of the 3 patients developed right portal vein pseudoaneurysm and needed embolization.Table: Demographic and clinical characteristics of patientsConclusion: Clear increase in intra and post-procedure bleeding complication is noted with worsening renal function. With ever increasing demand of outpatient liver biopsies, care must be taken in risk stratifying patients based on renal function to prevent intra and post-procedural bleeding complication.

Anesthetic experience in patient for single lung transplantation with previous contralateral pneumonectomy -A case report-

A 48-year-old woman with cystic fibrosis and a previous left pneumonectomy had surgery planned for single lung transplantation under general anesthesia. Due to progressive dyspnea and recurrent respiratory infection, she could not maintain her normal daily life without lung transplantation. The anesthetic management and surgical procedure was expected to be difficult because of the left mediastinal shift and an asymmetric thorax after the left pneumonectomy, but the single lung transplantation was successfully done under cardiopulmonary bypass.

Subclavian artery penetration involving central line access treated with a self-expanding stent

Fig. 2. (A) Angiogram shows the leakage of contrast media in the right subclavian artery (white arrow). (B) The angiogram following the insertion of the self-expanding stent shows no leakage of contrast media in the right subclavian artery (black arrow). Fig. 1. Chest computed tomography scan shows the central venous catheter penetrating the right subclavian artery and within the pleural space (white arrow). The large amount of pleural effusion with a passive atelectasis of the right lung, subsegmental atelectasis in the left lung, and a left mediastinal shift are shown. Left nephrectomy state and postoperative pneumoperitoneum can be seen.

Intrathoracic Caecal Perforation Presenting as Dyspnea

Introduction. Bochdalek hernia is a congenital defect of the diaphragm that is usually diagnosed in the neonatal period and incidentally in asymptomatic adults. Small bowel incarceration in a right-sided Bochdalek hernia is exceptional for an adult. Case Presentation. A 54-year-old woman was admitted for acute dyspnea, tachycardia, hypotension, and fever. Five days before, she had been experiencing an episode of diffuse abdominal pain. The admission chest X-ray was interpreted as right pleural effusion and pneumothorax with left mediastinal shift. Chest tube drainage was purulent. The thoracoabdominal CT examination suspected an intestinal incarceration through a right diaphragmatic defect. At laparotomy, a right-sided Bochdalek hernia was confirmed with a complete necrosis of the incarcerated caecum. Ileocaecal resection was performed, but the patient died from delayed septic complications. Conclusion. Intrathoracic perforation of the caecum is a rare occurrence; delayed diagnosis due to misleading initial symptoms may lead to severe complications and poor prognosis.

Recurrent Giant Hemangioma Causing Severe Respiratory Distress

Hemangioma is a common benign tumor of the liver that is usually asymptomatic. If >4 cm (giant hemangioma), it could present symptoms related to bleeding, thrombosis, consumptive coagulopathy, or adjacent abdominal organ compression. If symptomatic surgical treatment should be considered, liver resection as well as enucleation are considered. Recurrences after surgical resection are rare. We herein present a case of woman admitted to the emergency room for acute severe respiratory distress. She had undergone 2 surgical resections of liver hemangiomas. The respiratory syndrome, as showed by chest x-ray, computed tomography scan, and nuclear magnetic resonance imaging, was related to a recurrent giant multiple hemangioma, creating a prominent compression of right lung with left mediastinal shift and left heart dislocation. It resulted in pulmonary parenchymal compression associated with reduced chest wall compliance and increased pulmonary pressure. The patient was not eligible for surgical treatment because of the disease extension and her clinical conditions. She died 6 months later from respiratory insufficiency and hypercapnic coma.

Pectus excavatum repair using a costal cartilage graft for patients with tracheobronchomalacia

Background: Pectus excavatum is sometimes associated with tracheobronchomalacia, which usually manifests left mediastinal shift, atelectasis of the left lung, and recurrent pulmonary infection. Standard repair of pectus excavatum alone usually failed to improve symptoms. Methods: Pexis of the great vessels and pericardium combined with the support of the lower sternum, using a contralateral costal cartilage graft following the standard Ravitch's repair of pectus excavatum, has been used in 6 children during the past 5 years. In addition to respiratory symptoms, diagnosis of tracheobronchomalacia was made by bronchoscopy using an ultrathin fiberscope. Results: Using the described operative technique, an excellent cosmetic and functional result was obtained in 5 of 6 children. However, atelectasis of the left lower lobe and the narrowing of the left mainstem bronchus continued postoperatively in one patient, which required the insertion of the Palmaz stent in the left mainstem bronchus. Conclusion: This technique may help improve tracheobronchomalacia in patients with pectus excavatum and should be tried before the insertion of an internal stent. J Pediatr Surg 36:1650-1652. Copyright © 2001 by W.B. Saunders Company.

Surgical intervention for emphysematous pulmonary regions in a postoperative infant with congenital diaphragmatic hernia

A postoperative infant with congenital diaphragmatic hernia (CDH) developed extrinsic obstruction of the trachea by the innominate artery that ensued from unequal expansion of the lungs followed by left mediastinal shift. Septation of the anterior mediastinum prevented unequal expansion of the lungs, and elongation of the innominate artery improved proximal airway obstruction. Prolonged artificial ventilation, however, resulted in the emphysematous bullae in the left lung. Lung volume reduction surgery (LVRS), at 3 years of age, ameliorated the respiratory distress and resulted in good weight gain. Surgical intervention, including LVRS, should be considered to improve respiratory disturbance caused by difference in compliance of the lungs in children. J Pediatr Surg 35:1820-1821. Copyright © 2000 by W.B. Saunders Company.

An Unexpected Complication During Laparoscopic Herniorrhaphy

An Unexpected Complication During Laparoscopic Herniorrhaphy

Index of Suspicion

Index of Suspicion

Index of Suspicion

1. Harminder S. Dhaliwal, MD 1. Columbia Medical Center, Lewisville, TX This section of Pediatrics in Review reminds clinicians of those conditions that can present in a misleading fashion and require suspicion for early diagnosis. Emphasis has been placed on conditions in which early diagnosis is important and that the general pediatrician might be expected to encounter, at least once in a while. The reader is encouraged to write possible diagnoses for each case before turning to the discussion, which is on the following page. We invite readers to contribute case presentations and discussions. A 5-year-old girl is seen because of 5 days of fever and worsening cough accompanied by nausea, poor appetite, and decreased fluid intake. She complains of right-sided back and shoulder pain and has difficulty walking. She has had no contact with ill persons. On physical examination, her rectal temperature is 38.9°C (102°F), pulse is 151 beats/min, respirations are 52 breaths/min, and oxygen saturation by pulse oximetry is 95% on room air. Her respirations are labored, rapid, and shallow, with nasal flaring, retractions, and occasional grunting. Inspiratory crackles are heard over the right lung base. Scattered palatal petechiae are present. Her abdomen is diffusely tender, without guarding or rebound tenderness. Her leukocyte count is 7,900/mm3, with 76% band forms, 5% metamyelocytes, and 2% myelocytes. Chest radiographs demonstrate complete opacification of the right middle lobe with a small right pleural effusion. The child is admitted for intravenous rehydration and broad-spectrum antibiotic therapy. Despite therapy, she develops moderate respiratory distress, vomiting, and oliguria. Computed tomography of the chest demonstrates a large right pleural effusion with early left mediastinal shift. A right thoracostomy tube is placed and 400 mL of fluid is evacuated. Despite these measures, the child’s condition continues to deteriorate. Her platelet count is 18,000/mm3; hematocrit, 15%; direct bilirubin level, 22 mg/dL; aspartate aminotransferase level, …

Management of Congenital Lobar Emphysema with Endobronchial Intubation and Controlled Ventilation

Management of Congenital Lobar Emphysema with Endobronchial Intubation and Controlled Ventilation