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Detection of Hemopneumothorax Using Ultrasound - Clinical Case Report of a 58 Year Old Female with a Lung Mass and Shortness of Breath

Detection of Hemopneumothorax Using Ultrasound - Clinical Case Report of a 58 Year Old Female with a Lung Mass and Shortness of Breath


Anjail Bharati D.O., Anita Singla M.D., Penelope Chun M.D., RDMS

Background:
Hemopneumothorax is a medical term describing the simultaneous presence of air and blood in the pleural space. The pleural space is a potential space located between the visceral pleura (attached to the lungs) and the parietal pleura (attached to the chest wall).  Pleural fluid (normally present in the pleural space), holds the two surfaces together by surface tension.  The principle of surface tension is illustrated in the same way when two sheets of glass are held together by a few drops of water.  The pleural space is therefore maintained in a constant state of negative pressure.  If the chest wall (and therefore the pleural space) is punctured, blood and air rush to enter the area of negative pressure in an effort to equalize the pressure to atmospheric pressure.  This creates a unique environment in vivo, where surface tension and negative pleural pressure are required to maintain optimal oxygenation and ventilation by spontaneous respiration.  Fluid and/or air present in the pleural space disrupts the relationship between the visceral and parietal pleura and the membranes no longer adhere to each other.  Hemopneumothorax can be a life-threatening condition.  Optimal treatment requires time-sensitive assessment and rapid diagnosis and treatment to improve outcome.  Bedside emergency ultrasound an be a useful tool in the diagnosis and management of hemopneumothorax.  It provides portable imaging in the case of the unstable patient, real time image acquisition and can be used to guide treatment (for example to confirm placement of the chest tube). 

Learning Objectives:
1.  To understand basic physiology of development of hemopneumothorax
2.  To illustrate findings of hemopneumothorax using bedside emergency ultrasound

Case Presentatio:
58 y.o. female with a history of diabetes mellitus, recently diagnosed with a right sided lung mass presented to the emergency department with a complaint of shortness of breath for 5 days.  She was examined by her primary care physician who noticed diminished breath sounds on the right side and sent her to the emergency department for evaluation.  On arrival her vital signs were T 9 HR 90  RR 26  BP 126/83  Osat96% Physical examination revealed a female who appeared in mild distress due to shortness of breath, heart exam with regular rate, lungs with diminished breath sounds right side. Chest x-ray revealed large layering effusion on the right side.  Bedside ultrasound showed presence of heterogeneous appearing fluid with hyperechogenic reflectors in the fluid.  Lung tissue appeared to be “floating” in the presence of fluid and the hyperechogenic reflectors (“bubbles”).  A diagnosis of hemopneumothorax was made and chest tube placed with significant improvement in symptoms.

Discussion:
Hemopneumothorax is a diagnosis, which can be made rapidly and reliably with the use of bedside ultrasound.  Presence of air can be determined through the presence of “bubbles” which appear as hyperechogenic reflectors in blood or fluid (both appear anechoic) which has accumulated in the pleural space.  Early recognition using bedside emergency ultrasound may expedite early treatment of this life-threatening condition.  Future case reports may enable more detailed description of ultrasound characteristics of this condition.

 
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