Jack Differential Diagnosis Of Chest Pain Pneumothorax Pneumothorax Guidelines V Q Mismatch Lung Compliance Mechanics Of Breathing Pneumothorax Chest Drain B T S Guidelines For Use Of Suction In Pneumothorax Safe Triangle Basic Questions About Jack Cardiovascular Respiratory

I could see he was in trouble immediately. I had just finished sorting out a young girl with diabetic crisis when Jack was brought into the resus area by the ambulance crew. He looked grey and sweaty and was gasping for breath, while clutching his left chest. There wasn’t really time to go through his whole history in detail, but I’d seen him in respiratory outpatients a few weeks ago and remembered he had chronic obstructive pulmonary disease (COPD).

He said he’d been well until that morning when he’d suddenly felt much more short of breath and an intense stabbing pain on the left side of his chest which caught him when he tried to breathe in. On examination he had reduced air entry and was hyper-resonant of the left side. ^{Differential Diagnosis Of Chest Pain}

I got him an x-ray urgently and wasn’t too surprised to see a large pneumothorax on the left. Many pneumothorax presentations are on background of asthma or COPD. ^Pneumothorax

No wonder he was so short of breath. His inflamed and congested airways were causing enough problems. A collapsed lung massively reduced his already compromised lung function with the additional insult of severe VQ mismatch. Blood going to the collapsed lung was returning to the heart without meeting and equilibrating with fresh alveolar ventilation. ^{V Q Mismatch}

I wasn’t sure about what to do straight away as I knew that there was difference about what the BTS guidelines said about dealing with primary and secondary pneumothorax. Once I’d bleeped for senior help, I had a quick look at the guidelines on my phone. ^{Pneumothorax Guidelines}

He was thin and it was actually pretty easy to insert a chest drain into the safe triangle once we’d got him in the right position. ^{Safe Triangle}

After we connected the drain to the bottle it started bubbling immediately. Within a couple of minutes Jack looked pinker and a whole lot more comfortable. The drain was swinging and bubbling nicely. ^{Mechanics Of Breathing ◦ Pneumothorax Chest Drain}

Jack was admitted to the respiratory ward. A few hours later when I dropped by to see him, the lung had expanded on the x-ray and the drain was swinging nicely without any bubbling. I was relieved but not surprised his lung had re-inflated so easily given the increased lung compliance that you see in COPD patients ^{Lung Compliance}

While chatting to the respiratory registrar later, he told me that it wasn’t uncommon to have an ongoing air leak; particularly with secondary pneumothorax and that sometimes surgery was needed to fix the problem. In a patient like Jack - who was pretty frail – the worry would be that he may not make it through surgery. If he hadn’t re-expanded his lung so easily, we might have tried suction on his drain. ^{BTS Guidelines For Use Of Suction In Pneumothorax}