A previously fit 45 year old man was noted to be in respiratory distress 24 hours following maxillofacial surgery.
Clinical examination revealed the following:
• Respiratory rate of 22/min
• Decreased air entry left side
• Crackles left base
• HR-104/min, regular. JVP not raised. Apical impulse 5th left intercostal space anterior axillary line.
Investigations:
• ECG – normal
• Chest X-Ray – complete whiteout on the left side.
(a) What is the likely cause of his respiratory distress?
College Answer
- Left lung collapse from
- Perioperative blood aspiration
- Aspiration of gastric contents
- Sputum
Discussion
From the examination findings, it seems his patient in respiratory distress has some sort of left-sided lung pathology and a completely normal cardiovascular examination. The JVP is not raised , so probably this is not a heart-related thing. The usual apex beat is in the mid-clavicular line, so the apex beat is actually displaced - it has moved in the direction of the quiet lung. If the lung was quiet because of some sort of space-occupying process, the mediastinum would have shifted away from the quiet lung (eg. if there was massive haemothorax or pleural effusion).
The maxillofacial surgery is a clue. They either inhaled some blood post-operatively, have a sputum plug, have aspirated, or are suffering post-operative atelectasis.