Rapid Onset Delayed Pneumothorax

Clinical History

This is a 53 year old woman who was previously treated for a right upper lobe adenocarcinoma with chemotherapy and stereotactic radiation.  She was found to have recurrence on routine surveillance imaging, and biopsy was requested.


Procedural Imaging

Scout from a CT guided lung biopsy

© Jhimmelvir - Scout from a CT guided lung biopsy


Image 1.1

Scout from the planning CT shows vague right upper lobe lung nodule, port, and no pneumothorax


CT lung biopsy

© Jhimmelvir - CT lung biopsy


Image 1.2

CT image showing needle in position for biopsy. There is no pneumothorax.






Discussion

An autologous blood patch was administered during removal of the needle guide.  The patient tolerated the biopsy well, with no pneumothorax on immediate post procedural scans.  She was pain free and hemodynamically stable when transferred to the recovery area for observation.  Two hours later the patient remained pain free and hemodynamically stable.  A chest X-ray was obtain two hours later in anticipation of discharge.


Post Recovery Imaging

Expiration chest x-ray

© Jhimmelvir - Expiration chest x-ray


Image 2.1

2 hour post biopsy radiograph in expiration shows no pneumothorax







Discussion

Based on the clear chest x-ray and clinical status of the patient she was cleared for discharge and given discharge instructions.  10 minutes later a Rapid Response was called overhead to the recovery area.  Upon dressing to leave, the patient had become rapidly diaphoretic, hypotension and hypoxic, and was complaining of intense pleuritic chest pain.  Her breathing was rapid and shallow which precluded meaningful auscultation.  Because of the normal chest x-ray 10 minutes prior, pulmonary embolism was suspected.  The patient was taken to CT.


Post Discharge Imaging

CT scout with pneumothorax

© Jhimmelvir - CT scout with pneumothorax


Image 3.1

Scout image from an emergent CT showing a large right pneumothorax







Discussion

Based solely upon the scout image a small core chest tube was placed immediately and the patient rapidly recovered. The full CT scan was aborted.  The chest tube was removed the following day and the patient was discharged the day after that in stable condition.


Case Discussion

This case is a nice reminder about the dangers of percutaneous lung biopsy, the seriousness of pneumothorax even in a controlled environment, the importance of post-operative monitoring and patient education, and the perils and pitfalls of relying on imaging as a surrogate for patient well-being.  Percutaneous lung biopsies are a fairly ubiquitous procedure and the risk of pneumothorax is well known. Post-operative care at our institution involves two to four hours of observation followed by chest x-ray.   Patients with a clear radiograph and a stable clinical picture can generally be safely discharge. Patients who demonstrate a small pneumothorax but remain hemodynamically stable will undergo serial radiographs to confirm stability of the pneumothorax prior to discharge.  If subsequently discharged, these patients are usually brought back the following day for follow up x-rays. Patients who have experienced Clinical deterioration during recovery, or who have large pneumothoraces are treated with chest tube placement and hospital admission to the pulmonolgy service.

Delayed pneumothoraces, though not unheard of, or extremely rare in our experience. When they do occur they are typically discovered several days following a biopsy, are more common in patients with underlying COPD, and present as insidious onset of shortness of breath and/or pleuritic chest pain. This case illustrates the only experience we have had with the alarmingly rapid onset of a tension pneumothorax following an uncomplicated standard postoperative observation period and post-recovery chest radiograph.


Case Credits

Images and content graciously provided by:

Jason E. Himmel, MD


 

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