Endgames Picture Quiz

A dangerous complication of thoracocentesis

BMJ 2013; 346 doi: https://doi.org/10.1136/bmj.f1048 (Published 05 March 2013) Cite this as: BMJ 2013;346:f1048
  1. Sinan Robert Eccles, specialist trainee year 4, respiratory medicine
  1. 1Department of Respiratory Medicine, Wrexham Maelor Hospital, Wrexham LL13 7TD, UK
  1. sinaneccles{at}gmail.com

A 19 year old man with no previous medical problems presented with a six day history of breathlessness and left sided chest pain that had started acutely. His respiratory rate was 22 breaths/min, with oxygen saturations of 95% in room air. A chest radiograph showed a large left pneumothorax with slight mediastinal shift (fig 1).

Fig 1 Chest radiograph taken at presentation

A chest drain that was inserted initially improved his symptoms, but he rapidly deteriorated in the first hour after drain insertion. His breathlessness and pain worsened. He coughed up a large volume of frothy clear yellow sputum. His respiratory rate increased to 35 breaths/min and oxygen saturations fell to 85% on high flow oxygen. Chest radiography was repeated (fig 2).

Fig 2 Chest radiograph taken one hour after insertion of a chest drain

Questions

  • 1 After chest drain insertion for treatment of a pneumothorax, should the fluid at the underwater seal of the bottle oscillate, bubble, or both?

  • 2 Is the drain likely to be functioning correctly in this case?

  • 3 What complication of thoracocentesis has occurred?

  • 4 How is this condition managed?

  • 5 What advice should be given on discharge if the patient makes a full recovery?

Answers

1 After chest drain insertion for treatment of a pneumothorax, should the fluid at the underwater seal of the bottle oscillate, bubble, or both?

Short answer

The fluid at the underwater seal should oscillate and bubble.

Long answer

After insertion of an intercostal chest drain, the drain should be connected to a drainage system containing a valve mechanism.1 In most cases this will be a bottle with an underwater seal that allows fluid or air to escape, but not enter, the pleural cavity. During inspiration the pressure in the pleural cavity falls, causing an upward movement of fluid (towards the pleural cavity) at the underwater seal. During expiration, the pressure in the pleural cavity rises, which causes downward movement of the fluid. This up …

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