Bilateral Pneumothorax (chest xray picture): The Pressure Is On!

The pressure of the rising hospitalist census is  nothing compared to the pressure of a bilateral pneumothorax. Read on for a medical school friends example of an uncommon example of complications from  advanced COPD on chronic home oxygen use and steroids.  The female  was accepted on transfer from another hospital for increasing  dyspnea on exertion and shortness of breath.   She was a frequent flier to the medical system due to the very poor underlying lung function from a self reported greater than 100 pack year history of smoking.

The patient told the nurse practitioner at the community emergency department that the last time she felt like this she ended up on a breathing machine,  and she wanted to be transferred to a larger hospital with ICU cares.  At the time, she was  alkalotic by pH. and only on 2 or 3 liters of oxygen. She had no infiltrate on chest xray.

The patient was accepted to a general care floor for close monitoring.  Unfortunately, during the patient's ambulance transfer,  she was intubated and placed on ventilator support. For people with respiratory support, intubation is in many ways the most stable way to protect an airway for transfer.   Except when it isn't.

The squad had just rolled in and the patient was very tachycardic.  And suddenly out of no where,  bradycardia into asystole.  Code blue was called.  ACLS was started immediately.  Epinephrine, CPR,  check pulse, check rhythm and on and on.  The real deal. The patient just went form stable to critically unstable in the course of an hour.

In this clinical example, it is readily apparent that something catastrophic was occurring.   She  had very distended neck veins.  Her neck was turning purple, like a blueberry. Her compressions were becoming stiffer and stiffer and her abdomen was becoming stiff as well.  This wasn't working.  ACLS resuscitation  wasn't doing a thing to bring back a stable heart rhythm.  Could this be a bilateral pneumothorax?

Nothing seemed to work.  Was this a bilateral pneumothorax?  After several more doses of epinephrine through an urgently placed central line,  the patient's chest wall was needled with an 18 gauge needle through the second intercostal rib space through a left left anterior approach.  There it was, the hissing sound of survival.  Then the other side.  Hiss.  Diagnosis?  Tension pneumothorax.  Bilateral tension pneumothorax. 

Almost immediately, stable pulse, rhythm and blood pressure returned.   Next step:  bilateral chest tubes.  Of course, that's a job left for the intensivist.  This chest xray here  is an example of a COPD patient with bilateral 18 gauge needles jutting out of her 2nd intercostal spaces.  Look closely and you'll see them.  That's the bilateral pneumothorax sign.