To drain or not to drain?

Case 6: To drain or not drain? Burd R, Bloomfield J. 6:13-2-26

A patient with clear signs of chest sepsis was brought to ED as a blue call. They had a 5 day history of a productive cough, fever and worsening shortness of breath. They did not have any comorbidites however did have a lifelong smoking history. On arrival the vital observations were:

RR40, SATs 72 RA -> 88 ON 15L NRM, HR 120, BP 110/40, 38.5T, GCS 14 - mild confusion

An A-to-E assessment was done. The patient had significant work of breathing and auscultation was obsurced by transmitted sounds from upper airway secretions and frequent coughing. A portable chest xray was carried out:

The working diagnosis was a Community Acquired Pneumonia with signs of sepsis. Sepsis six was administered and the patient was referred to the medical team with an ICU review.

Given the patient's severe hypoxia and Type 1 Respiratory failure on blood gas analysis despite being on 15L NRM, the question arose, "was there any pleural effusion component to the homogenous white out of the lower half of the right lung? Did this patient need a chest drain to improve respiratory function?" The patient was not stable for an urgent CT transfer, so a bedside ultrasound was carried out.

This scan was carried on with the curvilinear probe starting at the hepatorenal angle and scanning cephalically to examine the lung base. The red line represents the diaphragm and the striped area below it is the liver. Note the blue line that runs along the abdominal thoracic spine with the individual echogenic vertebra. Above the diaphram we have abnormal echodense shadowing in the region of the lower lobe of the right lung that looks like liver (green arrow). This is called Hepatisation and correlates with dense consolidation of the lung tissue.

In normal, healthy, ventilated lungs, the air in alveoli largely reflect and scatter ultrasound waves, preventing visualisation of deeper lung tissue. As a result the image appears dominated by artefacts - an obscured light fuzzy image - this is normal lung. In this patient, the lung has solid consolidation, so ultrasound waves are transmitted down to the thoracic verbrea and we can see the spine, running along the yellow line - this is called the Anterior Spine sign. In this image there is clear evidnece of pneumonia and no drainble pleural effusion.

The patient did not recieve a chest drain, was accepted by ITU and treated with Optiflow with improved oxygenation.

Learning Points:

In this case, POCUS provided the answer to a critical question - was there a large pleural effsuion that needed draining to help treat severe hypoxia in Type 1 Respiratory Failure. Hepatisation was diagnostic of dense pneumonic consolidation.

An Anteiror Spine sign is also visible in large pleural effusions due to the transmission of ultrasound waves in the thoracic cavity through the fluid. However it may also be visible with diffuse consolidation in a severe pneumonia, which also transmits ultrasound waves to the vertebra.

Trainee Lead Editor: Dr Amy Knowles, ST5

Checked: Dr Ahmed Abdul-Ghani, Lead Project Consultant

Page updated

Google Sites

Report abuse