A 70- year-old gentleman is known to have the following conditions:
- systemic hypertension
- type 2 diabetic mellitus
- coronary artery disease
- history of pulmonary TB – completed 2 years back
- h/o ca stomach – underwent surgical intervention (2014)
The patient was apparently normal 10 days back, following which he started developing shortness of breath grade 2 (NYHA) initially, which gradually progressed to grade iv one day before we saw him (19-5-2021).
The patient was rushed into our ER on 20-5-2021 without a prior history or a routinely done screening to avoid contact with suspected covid pneumonia. He was brought in a peri-arrest state and was immediately received in bay 1,
His initial vitals were:
Spo2 not recordable
Airway – threatened , cpine was clinically cleared
B/l air entry was equal, with fine basal crepts
Bp- 110/60 mmhg, p/a soft, bs +
B/l pupils reacting to light 2mm
Primarily suspecting it to be a respiratory compromise, we had connected an NRBM with 15l o2 and had primed the attendees for intubation. Subsequently, the patient regained consciousness only with oxygen administration and obeyed our commands, so we preferred to continue nrbm.
We, as emergency physicians, have seen a varied presentation of covid cases during this last 480 days since its first appearance in Kerala last year on 27-1-2021. We had moved the patient to an isolation ER assuming it must be another covid case who was received in near hypoxic cardiac arrest. Once brought to the isolation, we had carried out an abg/ chem 8(rft+electrolytes) point of care/ECG..
The blood gas picture was a severe type ii respiratory failure with the following:
Hence, we decided to escalate him to non-invasive ventilation – BIPAP with ippv-12, peep-6, respiratory rate of 24 to treat the acute severe type ii respiratory failure with co2 narcosis.
He was also initiated with the first doses of steroids/ anticoagulants (keeping the covid protocol in mind)
Chest CXR was preferred initially due to hemodynamic instability. Since he responded well to the above treatment, we moved him for a CT chest, which revealed the following:
1) right moderate to massive pneumothorax and passive atelectasis of right upper/ middle part lower lobe (? Ruptured bullae)
2) right upper lobe apical segment large multi-septae bullae
So the patient was dianosed with secondary penumothorax due to tuberculsosis.
An ICD was planned, but due to the presence of multiple unruptured bullae, CTVS opinion was sought, and with the help of Dr. Manikandan, an ICD was placed using 28 French trochanter in the right pleural cavity. An ICD tube was connected to the underwater seal drain. And the pneumothorax drainage was confirmed with air bubbling in the under-water seal.
ECG – normal sinus rhythm
rate 125 bts / min
no acute st-t changes
RFT – bun 36
Serial CXRs taken over the week are as follows:
The patient is doing hemodynamically stable now and is being planned for vats- bullectomy + pleurodesis
Challenges faced in these cases:
1) As the patient was rushed into the ER in a peri-arrest state, we had bypassed the ‘history taking ‘and started arriving at the diagnosis. We had to act quickly as stabilisation of the patient mattered more important.
2) Even though we initially made a provisional diagnosis of covid, the above patient never had symptoms like fever, cough, cold, tiredness prior to the spo2 drop. This made us rethink our approach.
3) The initiation of anticoagulants was a double-edged weapon as it may have helped with covid but could have complicated when procedures like ICD were to be planned or sit and pray for a prompt and skilled hand doing the procedure.
4) When the WHO has listed social distancing and suggested to avoid CPR in suspected patients during this pandemic, had this patient been taken elsewhere, I wouldn’t think they would have proceeded for further evaluation and resuscitation. On the other hand, i would thank and salute our emergency team who was on floor, ready to go till maximum extent to treat him regardless of the CT findings which were taken later.
5) Being biased was a big lesson learnt from this case as the primary referring physician was of the opinion that the patient had a congestive cardiac failure and we thought it to be of covid. This last odd 500 days has taught us that shortness of breath, which is under evaluation, is covid-related until or unless proven because of its varied presentation.
6) The decision of upscaling from NRBM to NIV could have been detrimental to this patient with an underlying pneumothorax. But the clinical picture didn’t fit in, and gut feeling said we were missing a piece of the puzzle. In spite of a type 2 respiratory failure, we still took the risk of de-escalating him back to NRBM which proved beneficial.
7) There are two types of pneumothorax primary spontaneous pneumothorax and secondary spontaneous pneumothrax. Secondary pneomothorax occurs in pre- existing COPD and TB.
This patient had ruptured bullae causing pneumothorax and which was above the size of 2cm. Hence, we had to do an intercostal drainage. Below is the algorithm to be followed for pneumothorax.
Covid has become a part of our lives over this one year and if not mistaken soon would be among ranks of diseases like sHTN, T2Dm, COPD, CKD, which we routinely collect during history from patient. So, I would like to say that all breathing difficulties are not related to covid…!!
Oxford Book of Emergency / Chapter 3/ Spontaneos Pnemothorax
Dr Nadhim Rizvi
2nd Year MRCEM Resident
Kauvery Hospital, Chennai