How to discipline a Tension-seeking Lung

Case 9: How to discipline a Tension-seeking Lung. Awan. Z. 9:17-7-26

A male in his 30s developed sudden central chest pain after exercising at the gym. He sought medical advise and was given a diagnosis of gastritis with respective medication.

Just over two hours later, his severe chest pain recurred accompanied by difficultly in breathing. He self presented to ED and was noted to be pale, sweaty and clammy with BP 93/53 mmHg in triage. ECGs showed sinus rhythm with early repolarisation and no convincing dynamic ischaemic changes. His other vitals: RR34, 88 SATs RA, 120HR, 93/53 BP, GCS 15, 36.2T. He was transferred to Resus.

Immediate examination revealed markedly reduced right-sided air entry with hyper-resonance, prompting bedside lung ultrasound whilst an urgent portable chest xray was awaited.

This image was taken using a linear probe in a longlitudinal plane in the mid clavicular line on the right hemithorax. On the left one can see 2 ribs and the pleural space inbetween being interrogted by the M-mode vertical line. The M-mode tracing on the right shows a clear Barcode or Stratosphere Sign - parralel hozirzontal straight lines. In a pneumothorax, air separates the visceral and parietal pleura. The pleural surfaces are no longer apposed at the scanned point, so normal lung sliding is lost. On M-mode, parallel horizontal lines continue above and below the pleural line.

Pneumothorax → No pleural apposition → No lung sliding → Barcode / Stratosphere Sign

The findings were confirmed on the portable chest xray. A massive right sided pneumothorax with evidence of contralateral mediastinal shift. In the context of hypotension and acute respiratory distress, this was consistent with a diagnosis of a developing tension pneumothorax.

An immediate chest drain was inserted, with rapid improvement in chest pain, haemodynamics and overall clinical condition. The post-drain chest xray confirms adequate drain placement and lung re-expansion.

The diagrams below summarise the method used to scan the thorax for a pneumothorax and the difference between a normal ventilated lung (Seashore sign) and a Pneumothorax (Barcode Sign).

Learning Points:

· Chest pain is not always cardiac — examine the chest and consider alternative life-threatening diagnoses.

· POCUS can rapidly identify sonographic features of pneumothorax at the bedside.

· Lung sliding / Seashore Sign makes pneumothorax at that scanned location very unlikely.

· Absent lung sliding + Barcode Sign should raise suspicion for pneumothorax in the appropriate clinical context.

· Look for a Lung Point to increase diagnostic specificity.

· Integrate ultrasound findings with the patient’s clinical picture and haemodynamic status.

Lead Editor: Dr Zoya Awan, ED Registrar

Checked: Dr Ahmed Abdul-Ghani, Lead Project Consultant

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