Pneumothorax in the Setting of Pulmonary Fibrosis

Introduction/Deviation: Pneumothorax is a common emergency room diagnosis with readily available treatment strategies available to prevent life-threatening complications such as tension pneumothorax, acute hypoxic respiratory failure, and pneumonia. However, in this case, those strategies would be complicated by severe underlying lung pathology, requiring adaptation involving atypical strategy including bipap in setting of low compliant lungs and pneumothorax. Presentation: 73 Male with past medical history significant for Chronic Hypercapnic and Hypoxic Respiratory Failure secondary to Severe Pulmonary Fibrosis presents for acute on chronic shortness of breath. Found to be in respiratory distress, imaging demonstrated a significant right-sided pneumothorax without tension physiology. A chest tube was placed with some improvement, but subsequent imaging revealed persistent PTX which prompted a second procedure to exchange the pigtail catheter for a 28fr catheter. Despite this the patient continued to have symptomatic PTX. CT imaging revealed severe pulmonary fibrosis. The patient was transferred to MICU cardiothoracic surgery was consulted and patient was placed on bipap with improvement in his symptoms. Chest X rays over the next 3 days revealed slightly improved pneumothorax, but the patient was unable to tolerate bipap. He was offered lung surgery, pleurodesis, but declined. He elected to pursue hospice given his poor prognosis. Discussion: Positive pressure ventilation is typically contraindicated in the setting of pneumothorax. With PTX refractory to normal treatment strategy in the setting of poorly compliant lungs due to pulmonary fibrosis, and peri-stable clinical presentation with unresolving hypercapnea and hypoxia, the patient was placed on bipap to assist in lung re-expansion, which proved to be an effective strategy although not without great risk. ie: further barotrauma, tension physiology, cardiovascular collapse, obstructive heart failure and shock. Conclusion: Critical thinking in acute care setting is essential to effective treatment, not every case follows the book, and experiences like this help provide precedent when providers in the future encounter similar complex life threatening situations. Grants: none