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?

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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.