On examination of a critically ill patient who was in respiratory distress, the following signs were noted:

  • Tachypnoea
  • SpO2 88%
  • Trachea shifted to the left
  • Reduced air entry and dullness to percussion in the infraclavicular and axillary areas on the left side.

a) What is the likely lung pathology?

b) List 3 causes of this pathology in critically ill patients.

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College Answer

a) What is the likely lung pathology?
Left lung collapse


b) List 3 causes of this pathology in critically ill patients.
Right bronchial intubation
Mucus plugging – left main bronchus
Obstructive lesions left main bronchus.

 

Discussion

This question interrogates one's knowledge of the highly regarded Talley and O'Connor manual of physical examination.

 

a) What is the likely lung pathology?
There can really be only one sort of pathology which causes a retraction of the mediastinum towards the silent lung. Atelectasis of the whole lung has somehow occurred.


b) List 3 causes of this pathology in critically ill patients.

The Required Reading chapter on the care for the post-pneumonectomy patient includes a brief section with this list of differentials. It was not the most appropriate place to put this list, but there was nowhere else to put it.

In brief, these are the causes of a silent hemithorax with mediastinal shift towards the quiet side, in a patient who is in respiratory distress:

  • Right bronchial intubation
  • Occlusion of a main bronchus:
    • Sputum plugging
    • Inhaled object
    • Migrated tracheal or bronchial stent
    • Large blood clot in massive haemoptysis
    • Tumour
  • Post pneumonectomy patient whose left chest drain has been left on suction.
  • Phrenic nerve injury with a paralysed hemidiaphragm
 

References

References

Clinical Examination of the Critically Ill Patient, 3rd edition by L.I.G. Worthley - which can be ordered from The Book Depository

Clinical Examination: whatever edition, by Talley and O'Connor.

Iyer, Anand, and Sumit Yadav. "Postoperative Care and Complications After Thoracic Surgery." (2013).