Acute and Critical Care

Case Reports

Pulmonary
Digital tomography in the diagnosis of a posterior pneumothorax in the intensive care unit: Shauni Wellekens, Nico Buls, Johan De Mey, Vincent Van Nieuwenhove, Jeroen Cant, Joop Jonckheer; Acute Crit Care. 2024;39(2):323-326. Published online June 10, 2022; DOI: https://doi.org/10.4266/acc.2021.01802

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Abstract PDF: Portable chest radiography is a valuable tool in the intensive care unit. However, the supine position causes superposition of anatomical structures resulting in less reliable detection of certain abnormalities. Recently, a portable digital tomosynthesis (pDTS) prototype with a modified motorized x-ray device was developed. We aimed to compare the diagnostic value of pDTS to standard bedside chest radiography in the diagnosis of a posterior pneumothorax. A modified motorized x-ray device was developed to perform 15 radiographic projections while translating the x-ray tube 25 cm (10 cm ramp up and 15 cm during x-ray exposure) with a total radiation dose of 0.54 mSv. This new technique of pDTS was performed in addition to standard bedside chest x-ray in a patient with a confirmed posterior hydropneumothorax. The images were compared with the standard bedside chest x-ray and computed tomography (CT) images by two experienced radiologists. The posterior hydropneumothorax previously identified with CT was visible on tomosynthesis images but not with standard bedside imaging. Combining the digital tomosynthesis technique with the portable x-ray machine could increase the diagnostic value of bedside chest radiography for the diagnosis of posterior pneumothoraces while avoiding intrahospital transport and limiting radiation exposure compared to CT.

Gastroenterology
Circumferential esophageal perforation resulting in tension hydropneumothorax in a patient with septic shock: Saad Saffo, James Farrell, Anil Nagar; Acute Crit Care. 2021;36(3):264-268. Published online March 11, 2021; DOI: https://doi.org/10.4266/acc.2020.01067

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Esophageal perforations occur traumatically or spontaneously and are typically associated with high mortality rates. Early recognition and prompt management are essential. We present the case of a 76-year-old man who was admitted to the medical intensive care unit with fulminant Clostridium difficile colitis, shock, and multi-organ failure. After an initial period of improvement, his condition rapidly deteriorated despite aggressive medical management, and he required mechanical ventilation. Radiography after endotracheal intubation showed interval development of pneumomediastinum and bilateral hydropneumothorax with tension physiology. Chest tube placement resulted in the drainage of multiple liters of dark fluid, and pleural fluid analysis was notable for polymicrobial empyemas. Despite the unusual presentation, esophageal perforation was suspected. Endoscopy ultimately confirmed circumferential separation of the distal esophagus from the stomach, and bedside endoscopic stenting was performed with transient improvement. Two weeks after admission, he developed mediastinitis complicated by recurrent respiratory failure and passed away. This report further characterizes our patient’s unique presentation and briefly highlights the clinical manifestations, management options, and outcomes of esophageal perforations.

Citations

Citations to this article as recorded by

Current approach for Boerhaaves syndrome: A systematic review of case reports
Ippei Yamana, Takahisa Fujikawa, Yuichiro Kawamura, Suguru Hasegawa
World Journal of Meta-Analysis.2023; 11(4): 112. CrossRef

CPR/Resuscitation
Fatal airway obstruction due to a ball-valve clot with identical signs of tension pneumothorax: Hisaaki Munakata, Michiko Higashi, Takahiro Tamura, Yushi Ueda Adachi; Acute Crit Care. 2020;35(4):298-301. Published online April 20, 2020; DOI: https://doi.org/10.4266/acc.2019.00570

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Abstract PDF

Endo-tracheal tube obstruction due to an extensive blood clot is a recognized but very rare complication. A ball-valve obstruction in the airway could function as a check valve for the lung and thorax, resulting in tension pneumothorax-like abnormalities. A 47-year-old female patient had undergone implantation of a left ventricular assist device 3 weeks prior. On post-operative day 17, planned thoracentesis was performed for drainage of a pleural effusion. Despite the drainage, the patient’s oxygenation did not improve, and emergency tracheal intubation was conducted. Subsequent computed tomography revealed bilateral pneumothorax. Two days later, the patient’s trachea was extubated without complication, and a mini-tracheostomy tube was placed. Three hours later, reintubation was conducted due to progressive tachypnea. Although successful intubation was confirmed, ventilation became increasingly difficult and finally impossible. Marked increase in pulmonary artery and central venous pressures suggested progression of the previous tension pneumothorax. After emergency extracorporeal membrane oxygenation was initiated, fiberoptic bronchoscopy revealed the presence of a massive clot and ball-valve obstruction of the endotracheal tube. Two weeks later, the patient died due to severe hypoxic brain damage. Diagnosis of ball valve clot is not simple, but intensivists should consider this rare complication.

Citations

Citations to this article as recorded by

Extracorporeal membrane oxygenation in critical airway interventional therapy: A review
Hongxia Wu, Kaiquan Zhuo, Deyun Cheng
Frontiers in Oncology.2023;[Epub] CrossRef
Endobronchial hydatid cyst causing variable intrathoracic airflow limitation selectively during expiration acting as a ball valve
Pavan Kumar Dammalapati, Sandeep Kumar Kar, Chaitali Sen Dasgupta
Indian Journal of Thoracic and Cardiovascular Surgery.2023; 39(4): 438. CrossRef
In reply: Non-ventilated lung airway occlusion during one-lung ventilation: a need for further research?
Jacques Somma, Edouard Marques, Jean S. Bussières
Canadian Journal of Anesthesia/Journal canadien d'anesthésie.2021; 68(9): 1458. CrossRef
A case of haemoptysis and bilateral areas of lung consolidation sparing the right lower lobe
Nadia Corcione, Antonio Ponticiello, Severo Campione, Alfonso Pecoraro, Livio Moccia, Giuseppe Failla
Breathe.2021; 17(4): 210072. CrossRef

Review

Pulmonary
Lung Ultrasound (in the Critically Ill) Superior to CT: the Example of Lung Sliding: Daniel A. Lichtenstein; Korean J Crit Care Med. 2017;32(1):1-8. Published online February 14, 2017; DOI: https://doi.org/10.4266/kjccm.2016.00955

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13 Web of Science
15 Crossref

Abstract PDF

This review article shows the potential of lung ultrasound in the critically ill (LUCI) to study lung sliding and describes the optimal equipment for its assessment. Then, it analyses the integration of lung sliding within lung ultrasound then whole body critical ultrasound. It describes the place of lung sliding in the BLUE-protocol (bedside lung ultrasound in emergency) (lung and venous ultrasound for diagnosing acute respiratory failure), the FALLS-protocol (fluid administration limited by lung sonography) (the role of lung sliding in circulatory failure), and the SESAME-protocol (sequential assessment of sonography assessing mechanism or origin of severe shock of indistinct cause) (whole body ultrasound in cardiac arrest). In the LUCIFLR project (LUCI favoring limitation of radiations), the consideration of lung sliding allows drastic reduction in irradiation and costs. In conclusion, lung sliding is proposed as a gold standard for indicating the presence of the lung at the chest wall and its correct expansion.

Citations

Citations to this article as recorded by

Head-to-toe bedside ultrasound for adult patients on extracorporeal membrane oxygenation
Ghislaine Douflé, Laura Dragoi, Diana Morales Castro, Kei Sato, Dirk W. Donker, Nadia Aissaoui, Eddy Fan, Hannah Schaubroeck, Susanna Price, John F. Fraser, Alain Combes
Intensive Care Medicine.2024; 50(5): 632. CrossRef
Transthoracic needle biopsy for diagnosis of lung cancer
Dongil Park
Journal of the Korean Medical Association.2023; 66(3): 160. CrossRef
Determinants of point-of-care ultrasound lung sliding amplitude in mechanically ventilated patients
David N. Briganti, Christine E. Choi, Julien Nguyen, Charles W. Lanks
The Ultrasound Journal.2023;[Epub] CrossRef
Humán kadávermodell a légmell ágy melletti ultrahang-diagnosztikájához.
Noémi Ádám, Gábor Orosz, Máté Berczi, Tamás Ruttkay
Orvosi Hetilap.2023; 164(46): 1824. CrossRef
Ultrasonography in cardiopulmonary emergencies
Kiran Kumar Gudivada, Bhuvana Krishna, Shiva Kumar Narayan
Lung India.2023; 40(3): 260. CrossRef
Early detection of delayed pneumothorax using lung ultrasound after transthoracic needle lung biopsy: A prospective pilot study
Jeong Suk Koh, Chaeuk Chung, Ju Ock Kim, Sung Soo Jung, Hee Sun Park, Jeong Eun Lee, Da Hyun Kang, Yoonjoo Kim, Dongil Park
The Clinical Respiratory Journal.2022; 16(5): 413. CrossRef
Usefulness of Lung Ultrasound Follow‐up in Patients Who Have Recovered From Coronavirus Disease 2019
Yale Tung‐Chen, Milagros Martí de Gracia, Maria Luz Parra‐Gordo, Aurea Díez‐Tascón, Sergio Agudo‐Fernández, Silvia Ossaba‐Vélez
Journal of Ultrasound in Medicine.2021; 40(9): 1971. CrossRef
The role of lung ultrasound in COVID-19 disease
Dirk-André Clevert, Paul S. Sidhu, Adrian Lim, Caroline Ewertsen, Vladimir Mitkov, Maciej Piskunowicz, Paolo Ricci, Núria Bargallo, Adrian P. Brady
Insights into Imaging.2021;[Epub] CrossRef
Point-of-Care Ultrasound in Acute Care Nephrology
Nithin Karakala, Daniel Córdoba, Kiran Chandrashekar, Arnaldo Lopez-Ruiz, Luis A. Juncos
Advances in Chronic Kidney Disease.2021; 28(1): 83. CrossRef
YEARS Algorithm Versus Wells’ Score: Predictive Accuracies in Pulmonary Embolism Based on the Gold Standard CT Pulmonary Angiography*
Ahmed Abdelaal Ahmed Mahmoud M. Alkhatip, Maria Donnelly, Lindi Snyman, Patrick Conroy, Mohamed Khaled Hamza, Ian Murphy, Andrew Purcell, David McGuire
Critical Care Medicine.2020; 48(5): 704. CrossRef
Sonographische Bildgebung der Lunge bei COVID-19
M. Schmid, F. Escher, D.-A. Clevert
Der Radiologe.2020; 60(10): 919. CrossRef
Lung Ultrasound in Critical Care
Maddani Shanmukhappa Sagar, Souvik Chaudhuri, Vedaghosh Amara, Sirish Gauni, Tushar Mittal
Indian Journal of Respiratory Care.2020; 9(2): 141. CrossRef
Current Misconceptions in Lung Ultrasound
Daniel A. Lichtenstein
Chest.2019; 156(1): 21. CrossRef
Role of thoracic ultrasound in children with chronic kidney disease
SaneyaAbd El-Halim Fahmy, NaglaaAbd El-Moneam Abd Allah, AmiraI Al-Masry, Eman Sobh
The Scientific Journal of Al-Azhar Medical Faculty, Girls.2019; 3(3): 693. CrossRef
Novel approaches to ultrasonography of the lung and pleural space: where are we now?
Daniel Lichtenstein
Breathe.2017; 13(2): 100. CrossRef

Case Reports

Cardiology/Pulmonary
Successful Rescue Therapy with Pumpless Extracorporeal Carbon Dioxide Removal in a Patient with Persistent Air Leakage due to Empyema: Jaeyoung Cho, Yeon Joo Lee, Jae-Ho Lee, Choon-Taek Lee, Young-Jae Cho; Korean J Crit Care Med. 2017;32(3):284-290. Published online November 14, 2016; DOI: https://doi.org/10.4266/kjccm.2016.00185

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Abstract PDF: A young metastatic lung cancer patient developed empyema due to an infection with carbapenem-resistant Acinetobacter baumannii. Hydropneumothorax was detected and managed by a tube thoracotomy. However, persistent air leakage through the chest tube was observed due to the presence of a bronchopleural fistula (BPF). As hypercapnic respiratory failure had progressed and the large air leak did not diminish by conservative management, a pumpless extracorporeal lung assist (pECLA) device was inserted. The pECLA allowed the patient to be weaned from mechanical ventilation and the BPF to heal. The present case shows the effective application of pECLA in a patient with empyema complicated with BPF and severe hypercapnic respiratory failure. pECLA enabled us to minimize airway pressure to aid in the closure of the BPF in the mechanically ventilated patient.

Thoracic Surgery
Subclavian Artery Laceration Caused by Pigtail Catheter Removal in a Patient with Pneumothorax: Hyo Jin Kim, Yang Hyun Cho, Gee Young Suh, Jeong Hoon Yang, Kyeongman Jeon; Korean J Crit Care Med. 2015;30(2):119-122. Published online May 31, 2015; DOI: https://doi.org/10.4266/kjccm.2015.30.2.119

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3 Crossref

Abstract PDF

We report a case of subclavian artery laceration caused by the removal of a pigtail pleural drainage catheter in a patient with a pneumothorax. The patient was successfully resuscitated through diagnostic angiography with subsequent balloon occlusion and primary repair of the injured subclavian artery. Although pigtail drainage of a pneumothorax is known to be safe and effective, proper insertion and removal techniques should be emphasized to reduce the risk of complications.

Citations

Citations to this article as recorded by

A randomised controlled trial of intrapleural balloon intercostal chest drains to prevent drain displacement
Rachel M. Mercer, Eleanor Mishra, Radhika Banka, John P. Corcoran, Cyrus Daneshvar, Rakesh K. Panchal, Tarek Saba, Melanie Caswell, Sarah Johnstone, Daniel Menzies, Sana Ahmer, Mitra Shahidi, Amelia O. Clive, Manish Gautam, Giles Cox, Chris Orton, Judith
European Respiratory Journal.2022; 60(1): 2101753. CrossRef
AN UNUSUAL COMPLICATION OF PIGTAIL CATHETER: COLONIC PENETRATION
Yakup Ülger, Anıl Delik
Gastroenterology Nursing.2021; 44(6): 463. CrossRef
Median Sternotomy for the Management of Life-Threatening Bleeding Resulting from Proximal Upper Extremity Amputation
Hyunseong Kang, Gyu Bum Seo, Su Wan Kim
Journal of Acute Care Surgery.2020; 10(2): 58. CrossRef

Gastroenterology/Pulmonary
Respiratory Complications Associated with Insertion of Small-Bore Feeding Tube in Critically Ill Patients: Jeong Am Ryu, Joongbum Cho, Sung Bum Park, Daesang Lee, Chi Ryang Chung, Jeong Hoon Yang, Kyeongman Jeon, Gee Young Suh, Chi Min Park; Korean J Crit Care Med. 2014;29(2):131-136. Published online May 31, 2014; DOI: https://doi.org/10.4266/kjccm.2014.29.2.131

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Abstract PDF

Small-bore flexible feeding tubes decrease the risk of ulceration of the nose, pharynx, and stomach compared with large-bore and more rigid tubes. However, small-bore feeding tubes have more respiratory system complications, such as pneumothorax, hydropneumothorax, bronchopleural fistula, and pneumonia, which are associated with significant morbidity and mortality. Thus, it is important to confirm the correct position of feeding tubes. Chest X-ray is the gold standard to detect tracheal malpositioning of the feeding tube. We present three cases in which intubated patients exhibited an altered mental state. An assistant guide wire was used at the insertion of small-bore feeding tubes. These conditions are thought to be potential risk factors for tracheobronchial malpositioning of feeding tubes.

Citations

Citations to this article as recorded by

Clinical usefulness of capnographic monitoring when inserting a feeding tube in critically ill patients: retrospective cohort study
Jeong-Am Ryu, Kyoungjin Choi, Jeong Hoon Yang, Dae-Sang Lee, Gee Young Suh, Kyeongman Jeon, Joongbum Cho, Chi Ryang Chung, Insuk Sohn, Kiyoun Kim, Chi-Min Park
BMC Anesthesiology.2016;[Epub] CrossRef
Nutritional Assessment of ICU Inpatients with Tube Feeding
Yu-Jin Kim, Jung-Sook Seo
Journal of the Korean Dietetic Association.2015; 21(1): 11. CrossRef
Respiratory Complications of Small-Bore Feeding Tube Insertion in Critically Ill Patients
Kyoung-Jin Choi, Jeong-Am Ryu, Chi-Min Park
JOURNAL OF ACUTE CARE SURGERY.2015; 5(1): 28. CrossRef

Original Article

Thoracic Surgery
Clinical Characteristics of the Development of Pneumothorax in Mechanically Ventilated Patients in Intensive Care Units: Wan Chul Kim, Su Jin Lim, Kyong Young Kim, Seung Jun Lee, Yu Ji Cho, Yi Yeong Jeong, Mi Jung Park, Kyoung Nyeo Jeon, Jong Deog Lee, Young Sil Hwang, Ho Cheol Kim; Korean J Crit Care Med. 2014;29(1):13-18. Published online February 28, 2014; DOI: https://doi.org/10.4266/kjccm.2014.29.1.13

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Abstract PDF: Background
Pneumothorax (PTX) can occur as a complication of positive pressure ventilation in mechanically ventilated patients.
Methods
We retrospectively reviewed the clinical characteristics of patients who developed PTX during mechanical ventilation (MV) in the intensive care unit (ICU).
Results
Of the 326 patients admitted (208 men and 118 women; mean age, 65.3 ± 8.74 years), 15 (4.7%) developed PTX, which was MV-associated in 11 (3.3%) cases (6 men and 5 women; mean age, 68.3 ± 9.12 years) and procedure-associated in 4. Among the patients with MV-associated PTX, the underlying lung diseases were acute respiratory distress syndrome in 7 patients, interstitial lung disease in 2 patients, and chronic obstructive pulmonary disease in 2 patients. PTX diagnosis was achieved by chest radiography alone in 9 patients and chest computed tomography alone in 2 patients. Nine patients were using assist-control mode MV with the mean applied positive end-expiratory pressure, 9 ± 4.6 cmH₂O and the mean tidal volume, 361 ± 63.7 ml at the diagnosis of PTX. Two patients died as a result of MV-associated PTX and their systolic pressure was below 80 mmHg and heart rates were less than 80/min. Ten patients were treated by chest tube insertion, and 1 patient was treated by percutaneous pigtail catheter insertion.
Conclusions
PTX can develop in patients undergoing MV, and may cause death. Early recognition and treatment are necessary to prevent hemodynamic compromise in patients who develop PTX.

Case Reports

Delayed Onset Contralateral Reexpansion Pulmonary Edema after Tension Pneumothorax: A Case Report: Dongseop Song, Jai Yun Jung; Korean J Crit Care Med. 2013;28(2):137-140.; DOI: https://doi.org/10.4266/kjccm.2013.28.2.137

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Abstract PDF: A 16-year-old male patient presented with left side chest pain. The initial chest radiograph showed tension pneumohtorax on the left side. Air was evacuated by closed thoracostomy. About 72 hours later, during administration of general anesthesia for thoracoscopic bullectomy, unilateral pulmonary edema affecting the contralateral lung developed without definite infiltration in the left lung. The operation was suspended and the patient was admitted to the intensive care unit. A close observation of the patient and conservative therapy were enough to manage this pulmonary edema. This is a very rare manifestation of reexpansion pulmonary edema that is unpredictable and could be fatal. The clinical course is described in this article.

Reexpansion Pulmonary Edema Following the Early Decompression of Pneumothorax Occurred after Anesthetic Induction in a Patient with Lung Bulla: A Case Report: Hye Jin Jeung, Hyun Jung Lee, Seok Jai Kim, Sang Hyun Kwak; Korean J Crit Care Med. 2010;25(3):159-162.; DOI: https://doi.org/10.4266/kjccm.2010.25.3.159

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Abstract PDF: When a rapidly re-expanding lung has been in a state of collapse for more than several days, pulmonary edema sometimes occurs. This is called reexpansion pulmonary edema. In general, it most commonly occurs in patients with a large pneumothorax of long duration. In this case, a 15 year old female patient with a 2.3 cm sized bulla in the right lung developed right pneumothorax after anesthetic induction. Although early drainage by closed thoracostomy was performed, right pulmonary edema eventually occurred. It is unusual that vigorous reexpansion pulmonary edema developed even though early decompression was performed within one hour after development of pneumothorax.

Subcutaneous Emphysema and Pneumothorax Occurred during Patient Transfer to Intensive Care Unit: A Case Report: Yoonki Lee, Won Young Kim; Korean J Crit Care Med. 2004;19(1):52-56.

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Abstract PDF: A 48 years old female patient was scheduled for emergency surgery due to bleeding after intracerebral aneurysmal clipping under general anesthesia. Previously checked chest X-ray taken just a few hours before surgery showed no abnormal finding and she didn't show any sign of pneumothorax or hemothorax including dyspnea, tachypnea or cyanosis. Surgery was uneventful. After the completion of surgery, patient was transferred to the neurosurgical intensive care unit with intubation. During transfer, patient showed bucking and signs of subcutaneous emphysema around chest, shoulder and face. Oxygen saturation was low when she admitted to the neurosurgical intensive care unit, so the ventilator care was started. The patient's oxygenation were getting worse progressively, so we checked chest AP several times and one of the chest X-ray taken at that time revealed no vascular and lung marking on the left lung field suggesting pneumothorax. Emergency chest tube drainage was performed. She recovered dramatically and three days later, ches X-ray showed the complete resorption of the pneumothorax.

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