When air's not in the right place

A pat on the back for everyone in this blogging group!

It has been a Pneumothorax week for me! So how I can not reflect on it? Haha… I did, and realize I thought I knew things which I don’t really know! *bad*

The 3 cases I saw really served as a very good source of revision for me on what are the different causes of pneumothorax. Things are falling into place and I am really beginning to appreciate clinical experience more than before! Hope this entry will help you guys gain some insight as well!

Pneumothorax (PTx) = air into the pleural space. The 3 different clinical presentations I encountered:
1. Bilateral PTx post MVA
2. (R) PTx post assault
3. (R) PTx post CABG

I have always thought that PTx is caused by something penetrating, resulting in a hole and hence air entry. So initially I thought the first two scenarios must have involved some broken ribs, glasses, knives etc. But nope, none of these. That’s when I searched for more information and found 3 possible mechanisms: spontaneous, penetrating injury and blunt blows/non-penetrating injuries. (1 ‘?’ solved!)

I must digress slightly and share with you it was not easy seeing a patient who has been assaulted… I had my qualms before I went in and my heart just sank when I saw this patient. Young, bruises on face, arms and haemorrhage in the eyes. Yet the face behind those injuries is angelic. There are definitely many serious issues involved here (as we understand from the nurse and case-notes) which I won’t disclose but I sincerely hope everything will be alright as this patient is far too young… Nevertheless, I maintain the professionalism needed of us. I didn’t have a different look on my face or ask insensitive questions or provided the treatment differently. I think that this was the best approach. I was glad it went well according to my FCE who was with me.

Back to PTx. For the 3rd case, the ‘?’ in me was, is it common to have PTx after cardiac surgery? Got my answer that it is often a consequence of opening the chest wall and particularly after harvesting IMA. I think that another reason will be the insertion of lines such as the CVP line as well as drain.

For this case, I had another query. This patient was in the ICU with post-op course complicated by PTx. Was also hard to wean off ventilator. PT’s treatment and mobilization were delayed due to these reasons. Although the PTx was detected early post-op, I could not understand the delay in inserting the ICC. I guessed it could be because the doctors were waiting to see if it would resolve spontaneously? And also, since it was not a tension PTx, there was no medical emergency. I guessed the wait is worthwhile if it can spare the patient from something invasive? But at the expense of other possible post-op complications eg: atelectasis, consolidation (her x-ray didn’t look too good, very much reduced lung volume)…??? Any thoughts on this guys? Cya on Monday!

Cheers, Peiying ~