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Case 171

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Male patient, 63 years old, with squamous cell carcinoma at the base of the tongue that partially occludes the airway, is admitted for elective tracheostomy. During the procedure, the puncture of the right central vein was performed. The patient evolved with desaturation, breathlessness and chest pain on the right. On physical examination, he was normotensive, with labored breathing and decreased respiratory sounds in the right hemithorax. Chest radiograph (Figure 1) has been requested.

Analyzing the clinical history and the radiography, which is most likely diagnosis and the proper work up?

a) Simple pneumothorax, oxygen therapy and clinical observation

25%

b) Hypertensive pneumothorax, thoracic drainage

25%

c) Hypertensive pneumothorax, thoracentesis

25%

d) Simple pneumothorax, thoracic drainage

25%
   

Image analysis

Image 1: Simple radiography of the chest, anteroposterior view. Patient in supine position, presence of tracheostomy, showing a pneumothorax on the right lung, identified by the absence of pulmonary vessels (asterisks) laterally to a thin radiopaque line parallel to the chest wall, which corresponds to the visceral pleura (arrows). There is moderate contralateral deviation of mediastinal structures and signs of extension of the right to the left of the midline pleural gas accumulation through the retrosternal space; partial blurring of the left heart border.

 

Image 2: Chest radiography, anteropossterior view, after insertion of pigtail catheter to the right (arrows).

Highlights

- PTX is the presence of air in the pleural cavity and its main clinical manifestations are sudden chest pain and dyspnea.

- The imaging study of choice is a simple chest X-ray.

- The main aspect is the absence radiologic visualization of pulmonary vessels laterally `thin radiopaque line parallel to the chest wall (visceral pleura)

- The magnitude of PTX should be estimated by radiography and assists in the procedure definition.

- PTX is hypertensive emergency condition and should be addressed ASAP.

References

- Stark P. Imaging of pneumothorax. UpToDate 2014. [Accessed in May 2014]. Available at: http://www.uptodate.com/contents/imaging-of-pneumothorax.

- Light RW. Primary spontaneous pneumothorax in adults. UpToDate 2014. [Accessed in May, 2014]. Available at: http://www.uptodate.com/contents/primary-spontaneous-pneumothorax-in-adults.

- Light RW. Secondary spontaneous pneumothorax in adults. UpToDate 2014. [Accessed in May, 2014]. Available at: http://www.uptodate.com/contents/secondary-spontaneous-pneumothorax-in-adults.

- Sahn AS, Heffner JE. Spontaneous pneumothorax. The New England Journal. 2000; 342(1): 868-874.

- Hyzy RC. Overview of tracheostomy. UpToDate 2014. [Accessed in May, 2014]. Available at: http://www.uptodate.com/contents/overview-of-tracheostomy.

- Martins MA, Carrilho FJ, Alves VAF, Castilho EA, Cerri GG, Wen CL. Clínica médica FMUSP, volume 2: doenças cardiovasculares, doenças respiratórias, emergências e terapia intensiva. Barueri: Manole; 2009.

- Silva CIS, Muller NL. Colégio Brasileiro de Radiologia e Diagnóstico por Imagem: Tórax. Rio de Janeiro: Elsevier; 2010.

Author

Fábio Mitsuhiro Satake, 4th year medical student at UFMG

Email: fabiosatake[at]gmail.com

Supervisors

Dr. Eliane Viana Mancuzo, Pulmonologist in HC/UFMG

Email: elianevmancuzo[at]ig.com.br

 

José Nelson Mendes Vieira, Professor of the Anatomy and Image Department of the UFMG Medical School.

E-mail: zenelson.vieira(at)gmail.com

Reviewers

Thaís Salles Araujo, Renato Gomes Campanati, Júlia Alvarenga Petrocchi, Barbara Queiroz, Luanna Monteiro

Translated by

Bárbara de Queiroz e Bragaglia, 5th year medical student at UFMG. Email: barbara.bragaglia[at]gmail.com.br

 

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