The Role of Serial Physical Examinations in Diagnosis of a Tension Pneumothorax Secondary to Alveolopleural Fistula

Abstract

Tension Pneumothorax (TNP) is a life-threatening condition that is shown to have the best outcomes on patient mortality when it is caught early and treated immediately. The diagnosis of a TNP is usually clinical as patients will present hemodynamically unstable and delaying treatment to obtain imaging can result in death. Occasionally, some patients with TNP can present with minimal symptoms. In such cases, physical exam findings are essential in establishing a diagnosis and initiating treatment before clinical deterioration occurs. Here, we present a case of a 53year old woman with a history of COPD and >20 pack year smoking history who came to the emergency department for 2 days of cough and dyspnea. Upon presentation the patient was hemodynamically stable and a chest x-ray showed a cavitary lung lesion in the right upper lung field. On day 2 of admission the physical exam rendered harsh bronchial breath sounds and hyperresonance to percussion in the right upper lung field where the cavitary lesion was that were not present on prior examinations. The change of physical exam findings prompted the care team to obtain a chest x-ray that showed a massive right sided TNP with right lung atelectasis and mediastinal shift to the left. After the chest x-ray was obtained and TNP confirmed the patient's oxygen saturation trended down. The patient immediately underwent chest tube placement and she remained clinically stable. In this case, the attention to changes on the physical exam led to a prompt diagnosis and the patient was able to be treated accordingly and remain stable. Typically, patients with a TNP present with signs of hemodynamic instability such as hypotension and tachycardia-but this patient had no change in her dyspnea or vitals when the physical exam was performed. As a result, the physical exam findings were the only indicator to get the repeat chest x-ray that led to the diagnosis of TNP. This case emphasises the importance of the physical exam in all patients but especially those with cavitary lung lesions as rapid clinical deterioration due to cavity rupture is possible.