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 Table of Contents  
POSTGRADUATE FORUM
Year : 2022  |  Volume : 2  |  Issue : 1  |  Page : 39-42

Nonexpanding pneumothorax despite double intercostal drainage tubes


Department of Pulmonary Medicine, Rajagiri Hospital, Kochi, Kerala, India

Date of Submission10-Jun-2021
Date of Decision18-Jul-2021
Date of Acceptance22-Jul-2021
Date of Web Publication17-Jan-2022

Correspondence Address:
Dr. Rajesh Venkitakrishnan
Rajagiri Hospital, Kochi, Kerala
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jalh.jalh_13_21

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  Abstract 


Pneumothorax is one of the most common emergencies encountered in day-to-day pulmonary practice. Early diagnosis and prompt intervention will reduce morbidity as well as mortality. The mainstay of treatment involves tube thoracostomy and drainage of pneumothorax in all except the mild cases. Proper technique and ascertaining correct tube position with follow-up imaging ensure successful lung expansion. We share the case of a gentleman who presented with nonexpansion of lung despite inserting 2 intercostal drainage tubes for the management of pneumothorax. Imaging with computed tomography thorax revealed both tubes to be coiled within the chest wall without entry into pleural space, thereby accounting for failed reexpansion. This case stresses the importance of following a structured evaluation in cases of nonexpanding lung after tube thoracostomy for pneumothorax.

Keywords: Complicated pneumothorax, intercostal tube insertion, persistent air leak, pneumothorax


How to cite this article:
Vijay A, Nirmal AS, Cleetus M, Augustine J, Venkitakrishnan R, Ramachandran D. Nonexpanding pneumothorax despite double intercostal drainage tubes. J Adv Lung Health 2022;2:39-42

How to cite this URL:
Vijay A, Nirmal AS, Cleetus M, Augustine J, Venkitakrishnan R, Ramachandran D. Nonexpanding pneumothorax despite double intercostal drainage tubes. J Adv Lung Health [serial online] 2022 [cited 2022 May 16];2:39-42. Available from: http://www.jalh.com/text.asp?2022/2/1/39/335918




  Introduction Top


Pneumothorax is defined as the presence of air in the pleural cavity. Spontaneous pneumothorax can be primary or secondary. A primary spontaneous pneumothorax occurs in the absence of any identifiable preexisting lung disease. Secondary pneumothorax occurs in an already diseased lung.[1] Chronic obstructive pulmonary disease (COPD) is the most common cause of secondary spontaneous pneumothorax. Management varies from simple observation to emergency pleural drainage depending on the volume of pneumothorax, underlying cardiorespiratory reserve and clinical status of the patient. The presence of respiratory distress alerts the clinician to look for the tension pneumothorax and calls for immediate intervention. In the majority of the cases, the average time taken for lung expansion is about 5 days following Intercostal drainage (ICD). Complications such as infections, persistent air leak (PAL), inadequate expansion due to trapped lung can punctate the course in 20% of patients.

Inadequate lung expansion after tube thoracostomy poses a clinical challenge and warrants a focused evaluation to identify the cause, which is crucial to plan further treatment. Incorrect tube position, blocked tube, inadequate water level in the underwater seal bottle, and failure to keep the suction bottle open to the atmosphere are common but easily correctable causes of failed lung expansion. Identification of easily correctable causes is vital as persistent pneumothorax causes increased length of hospital stay with attendant complications. We share a case of a 60-year-old gentleman with a background of COPD who presented to our emergency department with a nonexpanding pneumothorax of 7-day duration even after insertion of two intercostal drains. Physical evaluation evokes the suspicion that both intercostal tubes were coiled and remained in the chest wall itself without entry into the pleural space, which was confirmed by computed tomography (CT) imaging of thorax. Insertion of a third intercostal drain into the pleural cavity ensured prompt expansion of the lung allowing us to remove both the tubes which remained kinked in incorrect locations. The case highlights the importance of systematic assessment of all cases of nonexpanding pneumothoraces and appropriate intervention based on the cause. We present this case as a learning point for the general practitioners and budding pulmonologists to follow a structured check list in their clinical practice.


  Case Report Top


A 60-year-old gentleman, a known case of COPD, presented to our emergency medicine department with nonexpanding pneumothorax and respiratory failure. He had 2 intercostal drains inserted to his chest from an outside center, which were inserted in subsequent days due to lack of lung expansion. He had a history of pulmonary tuberculosis and completed antituberculosis treatment 5 years back. He was evaluated at 2 different centers for the same complaint before presenting to our center. At the time of presentation, he was tachypneic and dyspneic and was transported to our institution with noninvasive ventilator support in an equipped ambulance vehicle. Visual inspection revealed that both tubes were not having respiratory swings of the air column and chest wall palpation evoked the suspicion that both drains were coiled within the chest wall and subcutaneous plane. Chest radiograph and reinsertion of intercostal drain were proposed, but he was in severe respiratory distress. Arterial blood gas analysis showed severe respiratory acidosis (pH of 7.16 and PaCO2 of 110 mmHg). Considering the respiratory distress and severe hypercapnia, he was promptly intubated, mechanically ventilated and reassessed with chest radiograph. Chest radiograph showed right pneumothorax with both drains having kinked tips [Figure 1]. CT of the chest further confirmed this [Figure 2]a and [Figure 2]b. CT showed bilateral emphysematous changes and moderate right pneumothorax. Two ICD tubes were seen on the right side showing coiled and kinked tips, which were malpositioned and not draining the pneumothorax space. Fibrotic changes with traction bronchiectasis were noted in bilateral upper lobes along with bilateral multiple lung parenchymal nodular opacities with most of them showing calcification suggestive of sequelae of previous granulomatous infection. A new intercostal drain was inserted into right pleural cavity in the 5th intercostal space and the nonfunctioning tubes were removed. The whole process of assessment, ventilation, imaging, and reinsertion of chest tube was completed within 45 min of presentation to emergency room. Repeat radiograph showed good expansion of right lung [Figure 3].
Figure 1: Chest radiograph shows persisting pneumothorax despite two intercostal drains

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Figure 2: (a) Computed tomography thorax - representative cut (mediastinal window) showing misplaced intercostal drain. (b) Showing representative computed tomography (lung window) image with malpositioned intercostal drain

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Figure 3: Showing expanded lung after re-insertion of intercostal drain into correct site

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His baseline blood investigations showed total counts of 14,000/mm3 with neutrophilia and raised CRP values (70 mg/l). Renal and liver function tests were within normal limits. He was weaned off ventilator support and was extubated in 48 h. Serial radiograph showed complete expansion of right lung with resolution of pneumothorax. Air leak ceased by the 4th day and ICD was removed after attempting pleurodesis on 6th-day postadmission. He was discharged in a stable state and remains under follow-up. No recurrence of pneumothorax has been reported till date.


  Discussion Top


Pneumothorax is defined as the presence of gas within the pleural space. Pneumothoraces are usually classified into spontaneous, posttraumatic, or iatrogenic. The management of pneumothorax varies depending on the volume of air that has collected in the pleural space, the underlying cardiopulmonary status of the patient, and the severity of symptoms. Size of the pneumothorax may not correlate with severity. Patients presenting with secondary pneumothoraces are generally more symptomatic as their underlying lungs are usually abnormal. Although observation (with supplemental oxygen administration) and simple needle aspiration are acceptable modalities of treatment in primary spontaneous pneumothorax, such measures are rarely successful in secondary spontaneous pneumothorax and most cases require tube thoracostomy with an intercostal drain (ICD) insertion. It is usually inserted in triangle of safety bordered by the anterior border of the latissimus dorsi, the lateral border of the pectoralis major muscle, a line superior to the horizontal level of the nipple, and an apex below the axilla.[2]

In the absence of a persisting air leak, unapposable pleural surfaces or an endobronchial obstruction, the pneumothorax resolves promptly after an ICD insertion. However, the pneumothorax can persist despite ICD insertion. There may be many causes for persistent pneumothorax. The most common cause of nonexpansion is a PAL. When there is lack of apposition between the parietal and visceral pleura as in the case of trapped lung or endobronchial tumor, reexpansion does not occur despite ICD drainage.[3] It can be due to pleural disease, endobronchial obstruction resulting in lobar collapse, or chronic atelectasis. Unexpandable lung may be categorized into two different clinical entities such as trapped lung and lung entrapment. Trapped lung is due to the formation of a fibrous visceral pleural peel creating a mechanical effect, without any active pleural inflammation or malignant involvement. Lung entrapment is usually secondary to active pleural inflammation, infection, or malignancy causing thick visceral pleural peel. Identifying this helps in effectively managing pneumothorax.[4] [Table 1] summarizes the common causes of nonexpanded lung after ICD insertion in pneumothorax.
Table 1: Causes of nonexpanded lung after intercostal drainage insertion for pneumothorax

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If there is air leak more than 5–7 days, it is called a PAL. A PAL is commonly caused by a secondary spontaneous pneumothorax due to an alveolar-pleural fistula; also noted after thoracic surgeries or with invasive mechanical ventilation. Due to alveolar pleural fistula, there will be flow of air from the lung parenchyma to the pleural space and worsening of the pneumothorax. Air bubbling into the chest drainage system is seen in such cases of air leak, either during spontaneous breathing or on coughing.[5]

Technical causes of unexpanded lung after tube thoracostomy include wrong positioning of tube, blockage of the drain, chest tube dislodgment, position of side holes of ICD being outside the chest wall, inadvertent closure of the port of the underwater seal system which lets the collected air escape into atmosphere, etc., In the first two cases, the fluid column within the tube fails to move (oscillate) with respiration or coughing.[2] Simple inspection of the chest wall and ICD site (after removal of adhesive materials) will reveal tube dislodgment or the presence of side holes exposed to atmosphere. On occasions like our case, a repeat chest radiograph or CT scan of the chest may be needed to confirm tube malposition. CT chest also helps to differentiate a pneumothorax from a parenchymal air space (bulla, healed fibrocavitory disease) or a nonpulmonary air collection in the thorax (diaphragmatic hernia, achalasia, subcutaneous air, etc.). A proposed check list and algorithm for approaching nonexpanded lung after tube thoracostomy are given [Figure 4].[6]
Figure 4: A proposed algorithm for the evaluation of nonexpanding lung after intercostal drain insertion

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  Conclusion Top


Our case stresses the importance of considering technical reasons for ICD failure and nonexpansion of lung after pneumothorax. Adherence to the systematic algorithm would help to identify these causes reliably and help in prompt institution of corrective steps.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient (s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Zarogoulidis P, Kioumis I, Pitsiou G, Porpodis K, Lampaki S, Papaiwannou A, et al. Pneumothorax: From definition to diagnosis and treatment. J Thorac Dis 2014;6:S372-6.  Back to cited text no. 1
    
2.
Kesieme EB, Dongo A, Ezemba N, Irekpita E, Jebbin N, Kesieme C. Tube thoracostomy: Complications and its management. Pulm Med 2012;2012:256878.  Back to cited text no. 2
    
3.
Huggins JT, Doelken P, Sahn SA. The unexpandable lung. F1000 Med Rep 2010;2:77.  Back to cited text no. 3
    
4.
Pereyra MF, Ferreiro L, Valdés L. Unexpandable lung. Arch Bronconeumol 2013;49:63-9.  Back to cited text no. 4
    
5.
Dugan KC, Laxmanan B, Murgu S, Hogarth DK. Management of persistent air leaks. Chest 2017;152:417-23.  Back to cited text no. 5
    
6.
MacDuff A, Arnold A, Harvey J; BTS Pleural Disease Guideline Group. Management of spontaneous pneumothorax: British Thoracic Society Pleural Disease Guideline 2010. Thorax 2010;65 Suppl 2:i18-31.  Back to cited text no. 6
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]
 
 
    Tables

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