Story 19 Small pneumothorax, severe SOB and our thinking processes

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At Storifield Royal, Wednesday 21:35

The pre-alert phone rings..

” Hi Resus. We are bringing a 69 year old female who developed severe shortness of breath this evening . She had an operation done on her left lung 2 weeks ago but we are unable to get much history due to her respiratory distress . She was discharged on Monday( 2 days ago). I have her discharge letter which says a lung nodule was removed from her left lung along with partial lobectomy. Her Hospital no. is DIB-123-SOB & obs are

P= 119/min      RR 40/min       BP 106/66 

Temp 36.2       SpO2 85% on 15 L NRB mask

ETA is 4 min. “

4 minutes of pre-alert were used to do the following:

Review of discharge letter – patient had a solitary lesion on left lower lobe . A lobectomy was performed to remove this lesion. Pt had developed pneumothorax on left side post procedure which was drained . Her chest tube was removed 1 day prior to her discharge.No other significant Past medical history.

Preparation for ABCs

Team briefing – SHO tasked  to perform ABG . Nurse to cannulate and take blood samples. ITU on stand by.

The patient arrives. At a glance,

A:Patent and clear. Trying to speak but unable to say anything due to severe shortness of breath

B: Normal sounds on rt side. Unable to auscultate on left side due to sub cutaneous emphysema.

SpO2 89% on 21 L( 15L/min NRB + 6L/min nasal cannulae)

RR 44/min

Chest expansion bilaterally symmetrical. Trachea central.

C: Pulse 122/min BP 110/71 Abdomen soft

ECG showed sinus tachycardia and incomplete RBBB

D: GCS 15/15. Neurologically intact

ABG( on 21L/min)

pH 7.29 pCo2 3.9 pO2 9.9 HCO3 21 Lactate 3 BE -4

Furthermore, a bed side echo was attempted but due to the presence of sub-cut emphysema and respiratory distress, optimal cardiac window couldn’t be obtained.

By this stage, I have formed the diagnosis using my type 1 thinking (types of thinking explained below)

It has to be a Pneumothorax.  Subcutaneous emphysema, history of operation on that side, post op insertion of chest drain for pneumothorax , what else could it be?

Even though patient was severely hypoxic, a blood pressure was stable. A quick portable chest x-ray was performed.


CXR showing small left apical pneumothorax


I was not amused!!!angry-funny-face-of-baby-boy

As per my type 1 thinking, x-ray would have revealed a big pneumothorax. Findings were not adding up. Small pneumothorax couldn’t explain patient’s condition. A look back at her x-ray on discharge showed apical pneumothorax on left side was old and was persistent post chest drain.  It was a time to put a different thinking cap on (type 2)

Before we move on, let us just watch a short clip to help us understand types of thinking processes. No animals were hurt in the making of this video!!

This is what is going through goat’s mind

 I ve been put down. I have seen it in the past what happens next. Oh there comes the  knife over my throat. Oh dear….

Goat’s fast, intuitive reaction and instantaneous decisions with TYPE 1 THINKING tells her that she must be dead.She stays still.

After few seconds, she realises something is different. She doesn’t feel dead. When made to stand up, using her focussed decision making & reasoning with TYPE 2 THINKING PROCESS, goat decides to walk away. Sheeww!! What a relief.

In our patient, old persistent pneumothorax is not the reason for the new SOB that she developed 2 hours earlier. With relatively normal looking chest x-ray , a decision to perform CTPA was taken. Patient was given sub-cut low molecular weight heparin while awaiting CT. A scan was performed with the support of ITU colleagues.

Arrows showing bilateral emboli almost completely obstructing the pulmonary blood flow.

On return from scanner, pt’s blood pressure had dropped to 89/60. Patient was thrombolysed using IV alteplase resulting in immediate improvement of her symptoms. Oxygen requirement reduced drastically to mere 6 litres/min over next 45 minutes while alteplase was being infused . Patient was admitted under thoracic medicine for further care. She made a complete recovery and was discharged home 2 days lateron long term anti-coagulants.



Inspired by

2014 ESC Guidelines on the diagnosis and management of acute pulmonary embolism

LITFL Thrombolysis for sub massive PE

LITFL ECG in pulmonary embolism


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