Summary

Pneumothorax Management

• Young patient presenting with chest pain and tachypnea requires consideration of pneumothorax, especially with diminished breath sounds on one side
• Differential diagnosis should include musculoskeletal causes, infection, cardiac causes, and pulmonary embolism
• Investigation: Chest X-ray, bloodwork, and ECG are essential to rule out different causes
• X-ray findings: Decreased peripheral lung markings indicate pneumothorax; visible edge of collapsed lung
• Management options:
  • Small pneumothorax (3-4cm): Observation and painkillers if patient is stable
  • Larger/symptomatic pneumothorax: Chest drain placement
  • Surgical option: VATS (video-assisted thoracoscopic surgery) with apical resection and pleural pleurodesis
• For tension pneumothorax (shifted mediastinum, pushed-down diaphragm, larger interspaces): Urgent intervention required
• Warning: Intubation and mechanical ventilation without addressing pneumothorax can worsen the condition by forcing air into the pleural space

Pleural Effusion and Empyema

• Typical presentation: Dyspnea, cough, fever, decreased breath sounds
• X-ray shows fluid layering in pleural space
• Differential for pleural effusion: Inflammatory causes, pneumonic effusion, empyema, malignancy
• Workup includes chest X-ray, CT, bloodwork, and thoracentesis for both therapeutic and diagnostic purposes
• Empyema management requires:
  • IV antibiotics and drainage of fluid (pus)
  • For loculated effusions: Alteplase through chest drain to break up fibrin
  • Surgical option: Decortication for trapped lung
  • Prolonged course of antibiotics
• For septic patients with pleural effusion (hypotensive, tachycardic): Chest drain placement with IV fluids and antibiotics is the critical first step

Lung Masses and Lung Cancer

• Consider lung cancer in patients with persistent cough, especially smokers
• Complete workup includes:
  • CT chest to better characterize the mass
  • PET scan to assess tumor activity and spread
  • Biopsy to confirm diagnosis
  • Functional assessment of patient's ability to tolerate treatment
• Surgical options based on extent of disease:
  • Wedge resection: Least invasive, removes part of lung
  • Segmentectomy: Removal of lung segment
  • Lobectomy: Removal of an entire lobe
  • Pneumonectomy: Complete removal of lung on one side
• Surgical approaches: Thoracotomy (open), VATS (minimally invasive), or robotic
• Other treatments: Radiation, chemotherapy, immunotherapy, targeted therapy
• Surgical candidacy depends on both disease extent and patient factors
• Metastatic disease typically not suitable for surgical resection

Hiatus Hernia and GERD

• Common presentation: Long-standing post-prandial substernal/epigastric burning pain
• Important to rule out serious conditions first: Coronary artery disease and biliary colic
• Diagnostic workup: Upper GI endoscopy, acid studies, manometry
• Treatment options:
  • Lifestyle modifications
  • Medications: PPIs, motility agents, H2 blockers
  • Surgical: Laparoscopic hiatus hernia repair with fundoplication for large symptomatic hernias
• Key point: For large symptomatic hiatus hernia with worsening symptoms, surgical repair is the most appropriate treatment, not just medication adjustments or observation

Esophageal Cancer

• Red flags: Progressive dysphagia, weight loss, long history of heartburn
• Differential diagnosis: Cancer, hiatus hernia, stricture, diverticulum
• Diagnostic workup:
  • Upper GI endoscopy to visualize the lesion
  • Endoscopic ultrasound to assess surrounding structures
  • PET scan to evaluate tumor activity and spread
  • Functional testing to determine fitness for treatment
• Treatment approach guided by TNM staging (Tumor, Nodes, Metastasis)
• Treatment options:
  • Localized disease: Neoadjuvant therapy followed by esophagectomy
  • Superficial lesions: Endoscopic mucosal resection or ablation
  • Advanced disease: Chemoradiation, immunotherapy, palliative care
• Different approaches for different types: Squamous cell carcinoma typically treated with chemoradiation before surgery; adenocarcinoma increasingly treated with chemotherapy and immunotherapy before surgery

Action Items

• [ ] Remember TNM (Tumor, Node, Metastasis) framework when approaching any solid tumor case
• [ ] For adenocarcinoma of esophagus with nodal involvement, remember treatment approach is neoadjuvant therapy followed by esophagectomy
• [ ] When considering pneumothorax, order chest x-ray, ECG and relevant bloodwork
• [ ] For tension pneumothorax with desaturation, prioritize chest drain placement over intubation

Notes

Transcript

This is playing fortnight. Past medical history is unremarkable. He's on no medication. He comes to the eMERGE. You're seeing... He is a PGY-1 resident assessing this patient. Heart rate 100, blood pressure okay. Sat is okay, temperature okay. He looks pretty good except that he is a little bit tachypneic and uses accessory muscle a bit.

There is a diminished sound on one side, otherwise he is fine. So in a situation like this, you want to think about... Pneumothorax in a patient who doesn't have any past medical history and just presents that with a perverted chest state. Obviously, your differential diagnosis is musculoskeletal.

You've got to think about infection, other less likely causes for priority chest pain, cardiac causes, PE, but you just need to think about it in the back of your head. In a situation like this, you may actually see this as a family doctor or if you work in a walking clinic.

Obviously emergency room. These are generally the three scenarios that we see patients like this. And so if you're thinking about this patient's having chest pain, you've got to think about chest x-ray for sure. If you're thinking about other causes, infection, PE, or even cardiac causes, you need to do some blood work.

and ECG to rule them out.

So here is the x-ray that you ordered, maybe this error, you look interested, what do you see? On the left side, it looks like there's decreased peripheral lung markings. That's what I noticed right away. That's right, yeah. So we've got a pneumothorax here. You see the edges of the lung that has collapsed here.

And so this is a spontaneous pneumothorax. So what do you do with it? If the patient comes in and it's like three, four centimeter pneumothorax, you know, when you watch the patient, you give him some painkillers and he looks okay, you can actually observe pneumothorax.

The other option is if the patient has chest pain, shortness of breath, the pneumothorax is quite big. alternative is to put a chest strain and just for you guys to know that there is actually a surgical treatment for this and this is something that sometimes the emergency physician or family doctor needs to discuss with the patient and that is the term is VATS, apical retrospection and pleural visas.

So you guys need to know the terms because it will come up during your residency and your practice. So, let's see. Naleka, what do you see?

I see on the left side basically no lung, other than like a small little lump.

So what is the diagnosis?

Attention Pneumothorax. So you see the mediastinum is shifted to the other side, the diaphragm is pushed down. The interspace is slightly larger than the other side, so there is pressure building up in the chest. That is a tension in the motoraxe and requires urgent attention.

All right. Bear with us. Why don't you read the question?

Sure, so question one. Following a placement of a left subclavian vein catheter, a 50-year-old man developed shortness of breath and chest pain. His breath sounds are diminished on the left side and percussion of the left chest reveals hyper-resonance. His oxygen saturation by pulse oximetry drops from 97% to 72%.

Which of the following is the best treatment? So what's our point for this patient?

Sorry, I'm just going to read it quickly.

So they put a catheter in his subclavian vein on the left side. So if they do that, they have to go below the clavicle. What can possibly happen if they put a catheter through below the clavicle? They might have punctured the lung. That's right. So the guy has an iatrogenic pneumothorax.

So this is a common complication, especially when they actually insert a pacemaker. So that's the path they take, so having a trajectory pneumothorax is a common thing. Okay, so Brenda, why don't you read the answers and we'll see which one is correct.

So option A is auctioneric, option B is like a bluff. Hold on, hold on. So it says, which of the following is the best treatment? So oxygen therapy, is that the best treatment? Oh sorry, I was just, I was reading all the answers.

I don't think so. Okay, so oxygen treatment is a supportive treatment, but it's not really a treatment, right? So you just support the patient. Okay, B. Placement of a left chest ring. How about this one?

I wouldn't go with it either. You will not go with it either. Okay, you can call a friend. Friend. Megan, you're next.

I will be your friend Brenda. I actually was thinking like maybe I would do the chest straight I think just because. His oxygen saturation is dropping so fast. That's correct. It's like a dramatic needle decrease. That's correct. That wasn't an option. That's correct. He is actually desaturating and you were thinking of pneumothorax. And you just mentioned that the treatment is to put a drain in.

Okay, Megan, why don't you just continue.

Pneumothorax

Pleural effusion

Lung Cancer

GERD/Hiatal Hernia

Dysphagia/Esophageal Cancer