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BACKGROUND: Pneumothorax is a common issue in the intensive care unit and emergency department, often diagnosed using lung ultrasound. The absence of lung sliding and the presence of the lung point sign are characteristic findings for pneumothorax. We describe a case of left pneumothorax diagnosed incidentally while performing a cardiac ultrasound through a new variant of the lung point sign. CASE REPORT: A 60-year-old patient with a medical history of diabetes, stroke, and right colon cancer underwent urgent surgical treatment for intestinal sub-occlusion. In the intensive care unit, the patient required mechanical ventilation due to shock unresponsive to fluid administration, and hemodynamic monitoring was performed using echocardiography. During systole in an apical four-chamber view, the abrupt vanishing of the heart was observed. When evaluating the tricuspid annular plane systolic excursion (TAPSE) using M-mode, the interposition of the stratosphere sign during mid-systole prevented the visualization of the TAPSE peak. Lung ultrasound revealed the absence of lung sliding and the presence of the lung point sign on the left side of the thorax, confirming the diagnosis of pneumothorax. A chest x-ray study further confirmed the diagnosis, and urgent drainage was performed. The patient showed improvement in hemodynamic and respiratory conditions and was successfully weaned from mechanical ventilation, and eventually discharged home. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: By incorporating the lung ultrasound findings, including this new variant of the lung point sign, into their diagnostic approach to pneumothorax, emergency physicians can promptly initiate appropriate intervention, such as chest tube insertion, leading to improved patient outcomes.

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El neumotórax espontáneo es una patología extremadamente rara durante la gestación. Se define como la presencia de aire dentro de la cavidad pleural que puede generar principalmente dolor torácico y disnea. Esta patología tiene unas bajas incidencia y prevalencia en el embarazo, pero es relevante por una alta tasa de recurrencia, con un buen pronóstico para la madre y el feto si es tempranamente diagnosticada y oportunamente manejada. Se relaciona con factores de riesgo como las maniobras de Valsalva efectuadas durante el trabajo de parto, además de con comorbilidad como el tabaquismo, y con el biotipo longilíneo, entre otros, por lo que son muy importantes una adecuada anamnesis y la evaluación de la exploración física. El obstetra debe sospecharlo ante la clínica de dolor torácico asociado a disnea en gestantes en el trabajo de parto y el parto, y tenerlo en cuenta como diagnóstico diferencial. Es de vital importancia tener un manejo multidisciplinario compuesto por ginecoobstetra, internista, neumólogo y neonatólogo, incluido el apoyo por una unidad de cuidado intensivo para evitar complicaciones materno-perinatales que se puedan asociar al neumotórax espontáneo.

Spontaneous pneumothorax is an extremely rare pathology during pregnancy. It is defined as the presence of air inside the pleural cavity that can mainly generate chest pain and dyspnea. This pathology has a low incidence and prevalence in pregnancy, but a high rate of recurrence with a good prognosis for the mother and the fetus if it is diagnosed early and managed early. It is related to risk factors such as Valsalva maneuvers performed during labor, in addition to comorbidities such as smoking, longilinear biotype, among others, so it is very important to have an adequate history and evaluation of the physical examination. The obstetrician must be attentive to chest pain symptoms associated with dyspnea in pregnant women during labor and delivery, suspect this pathology and take it into account as a differential diagnosis. It is vitally important to have a multidisciplinary management composed of the gynecologist-obstetrician, internist, pulmonologist, neonatologist, including the support of an intensive care unit to avoid maternal-perinatal complications that may be associated with spontaneous pneumothorax.

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Thoracic endometriosis syndrome (TES) is a rare disorder characterized by the presence of ectopic endometrial tissue in the chest cavity. The typical clinical manifestation is a spontaneous pneumothorax, which usually presents with chest pain, dyspnea, and/or cough. The diagnosis requires a high level of clinical suspicion and a complete gynecological history. Imaging studies can help with the diagnosis, although the gold standard is video-assisted thoracoscopic surgery (VATS). Surgical treatment in combination with at least 6 months of hormonal medical treatment has been shown to improve the prognosis and reduce the recurrence of this entity. We present the case of a 40-year-old patient with a history of pelvic endometriosis and multiple episodes of pneumothorax, who consulted at our institution for a new episode of spontaneous pneumothorax. A VATS was performed where nodules in the parietal pleura and diaphragmatic orifices were identified. In the postoperative period, she continued with hormonal treatment. At 6 months of follow-up, she reported improvement in pain and did not present new episodes of pneumothorax.

El síndrome de endometriosis torácica (TES) es un trastorno poco común caracterizado por la presencia de tejido endometrial ectópico en la cavidad torácica. La manifestación clínica típica es un neumotórax espontáneo, que generalmente se presenta con dolor torácico, disnea y/o tos. El diagnóstico requiere un alto nivel de sospecha clínica junto con una historia ginecológica completa. Los estudios de imágenes pueden ayudar con el diagnóstico, pero el gold standard es la cirugía toracoscópica videoasistida (VATS). Se ha demostrado que el tratamiento quirúrgico en combinación con al menos 6 meses de tratamiento médico hormonal mejora el pronóstico y reduce la recurrencia de esta entidad. Presentamos el caso de una paciente de 40 años con antecedentes de endometriosis pélvica y múltiples episodios de neumotórax, que consultó en nuestra institución por un nuevo episodio de neumotórax espontáneo. Se realizó una VATS donde se identificaron nódulos en la pleura parietal y orificios diafragmáticos. En el postoperatorio continuó con tratamiento hormonal. A los 6 meses de seguimiento refirió mejoría del dolor y no presentó nuevos episodios de neumotórax.

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OBJECTIVES: The appearance of characteristic pulmonary lesions has been noted after COVID-19, being described as post-COVID-19 pneumo-hematocele. The aim of this study is to describe the clinical, histopathologic, and imaging features of pneumo-hematocele and to suggest a treatment algorithm for these patients. METHODS: A retrospective study was performed in patients admitted with a diagnosis of SARS-CoV2 infection from March 2020 to September 2021 who presented a pneumo-hematocele on imaging studies. Clinical and demographic variables were recorded, and CT scans were analyzed. A secondary analysis was performed to estimate the risk provided by the pneumo-hematocele diameter of developing pneumothorax. RESULTS: 37 patients were diagnosed with pneumo-hematoceles, 97.3% were males with a median age of 41 ± 13 years and 51% were smokers. The mean diameter of the pneumatocele was 6.3 ± 2.8 cm; they were more common on the subpleural surface and in the inferior lobe. Thirty patients had ruptured pneumo-hematoceles and developed pneumothorax (81.1%); a total of 26 patients required surgery (70.3%). Lesions measuring 5 cm had a high risk of rupture (OR 6.8, CI 95% 1.1-42); those measuring 3 cm were prone to this complication. For each centimeter that the pneumo-hematocele diameter increases, the OR for rupture increases 1.5. CONCLUSIONS: It appears that post-COVID-19 pneumo-hematocele occurs secondary to encapsulation of blood accumulation inside the lung, as a result of micro-capillary bleeding, with partial reabsorption of blood and subsequent air filling. We recommend surgery for patients with pneumo-hematoceles of 5 cm and those with persistent lesions of 3 cm. TRIAL REGISTRATION: Clinical Trial Registration: NCT05067881.

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PURPOSE: Tube thoracostomy (TT) is a simple and a life-saving procedure; nevertheless, it carries morbidity, even after its removal. Currently, TT is managed and removed by chest X-ray (CXR) evaluation. There are limitations and these are directly linked to complications. The use of thoracic ultrasound (US) has already been established in the diagnosis of pneumothorax (PTX) and hemothorax (HTX); its use, in substitution of CXR can lead to improvement in care. Our aim is to evaluate the efficiency and safety of US in the management of TT. METHODS: Prospective and randomized study with patients requiring TT. They were divided in groups according to their thoracic injuries (PTX and HTX) and randomized into two groups according to TT management: US and CXR. Data collected included gender, age, mechanism of injury, days to TT removal, complications after TT removal and presence of mechanical ventilation. RESULTS: Sixty-one patients were randomized, of which 68.8% were male. The most frequent diagnosis was PTX, present in 37 cases. Median time for TT removal was 2.5 days in the US group and 4.9 in the control group (p = 0.009). The complication rate was 6.6%, with no morbidity in the US group. TT removal in patients with mechanical ventilation did not increase the incidence of complications. CONCLUSIONS: The use of US in the management is efficient and safe. It allows early TT removal regardless the cause of the thoracic injury.

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INTRODUCTION: Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) affects mainly the lungs causing pneumonia and complications like acute respiratory distress syndrome. Pneumothorax is a rare manifestation of the disease. This report is a description of a series of patients with COVID-19 and spontaneous pneumothorax, some of them with associated pulmonary cysts. METHODOLOGY: Cases were collected retrospectively. We included clinical data from medical records and described radiologic findings. Patients that developed pneumothorax during mechanical ventilation were excluded. RESULTS: Ten cases were included in this report, nine of them were male. The median age of our series was 62 years (IQR = 57-68). The median days since the onset of symptoms until the development of pneumothorax was 27 (IQR = 17-31), most cases developed after the second week of the diagnosis of pneumonia. Two cases required invasive mechanical ventilation, but pneumothorax occurred after ventilator weaning. Three cases showed subpleural pulmonary cysts. CONCLUSIONS: Cysts and pneumothorax are rare manifestations of SARS-CoV-2 pneumonia with mechanisms not completely understood. This report highlights the role of CT scan in diagnosis of COVID-19 complications.

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Introducción: El neumotórax espontáneo es la causa más frecuente de ingreso urgente en los servicios de cirugía torácica. Objetivo: Caracterizar a pacientes ingresados con diagnóstico de neumotórax espontáneo. Métodos: Se realizó un estudio descriptivo de 93 pacientes con diagnóstico clínico y radiológico de neumotórax espontáneo, se establecieron las variables del estudio y se utilizaron frecuencias absolutas y porcentajes. Para la asociación de las variables se empleó el estadígrafo ji cuadrado con un nivel de confiabilidad del 95 por ciento. Resultados: Predominó el neumotórax espontáneo primario (65,5 por ciento), el sexo masculino fue el más afectado (80,6 por ciento), con mayor frecuencia en el hemitórax derecho (72,2 por ciento) y el tabaquismo como antecedente (83,9 por ciento). La pleurostomía mínima fue el tratamiento definitivo en el 72 por ciento de los pacientes. La complicación más frecuente después de la pleurostomía, fue la fuga persistente de aire. El tratamiento quirúrgico con pleurodesis mecánica, ofreció un 100 por ciento de efectividad. La mortalidad quirúrgica fue nula. Conclusiones: El neumotórax espontáneo predomina en el sexo masculino en una proporción de 4,2:1, en pacientes menores de 40 años de edad. El antecedente patológico personal que más se asocia es la enfermedad pulmonar obstructiva crónica. El síntoma predominante es el dolor torácico. El neumotórax espontáneo primario fue más frecuente y el hemitórax derecho el más afectado. El tabaquismo está presente como antecedente en ambos tipos de neumotórax espontáneo. La modalidad de tratamiento más utilizada es la pleurostomía mínima(AU)

Introduction: Spontaneous pneumothorax is the most frequent cause of urgent admission to thoracic surgery services. Objective: To characterize patients admitted with a diagnosis of spontaneous pneumothorax. Methods: A descriptive study of 93 patients with a clinical and radiological diagnosis of spontaneous pneumothorax was carried out, the study variables were established and absolute frequencies and percentages were used. For the association of the variables, the chi square statistic was used with a confidence level of 95 percent. Results: Primary spontaneous pneumothorax predominated (65.5 percent), the male sex was the most affected (80.6 percent), with greater frequency in the right hemithorax (72.2 percent) and smoking as the antecedent (83.9 percent). Minimal pleurostomy was the definitive treatment in 72 percent of the patients. The most frequent complication after pleurostomy was persistent air leak. Surgical treatment with mechanical pleurodesis offered 100 percent effectiveness. There was not surgical mortality. Conclusions: Spontaneous pneumothorax predominated in males in a ratio of 4.2: 1, in patients under 40 years of age. The most associated personal pathological history was chronic obstructive pulmonary disease. The predominant symptom was chest pain. Primary spontaneous pneumothorax was more frequent and the right hemithorax the most affected. Smoking was present as a history in both types of spontaneous pneumothorax. The most widely used treatment modality was minimal pleurostomy(AU)

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ABSTRACT: The border wall between the United States and Mexico consists of stretches of metal fencing of varying heights alternating and overlapping with areas of electronic surveillance. Despite national conversations centered around the social, environmental, economic, and political implications of this wall, there is a paucity of studies on deaths occurring in this region. Herein are described 2 cases of fatal injuries sustained from scaling the fence and accidentally falling onto the United States' side in New Mexico. These injuries are compared with those typically incurred in falls from lower and higher heights, and implications of both lateral and vertical expansion of the wall are discussed.

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BACKGROUND: Image-guided percutaneous transthoracic lung biopsy has become a widely used and less invasive diagnostic method. Pneumothorax is the most frequent complication after lung biopsy. The aim of the present study is to describe the experience with expectant management of asymptomatic small post-biopsy pneumothorax in order to reduce unnecessary hospital admissions. METHODS: A retrospective review was performed analyzing the results of subjects who underwent expectant and conservative treatment after presenting pneumothorax following  percutaneous lung biopsy, in a period of 6 years (January 2013 - December 2019) RESULTS: 160 subjects who underwent diagnostic percutaneous lung biopsy of lung nodules were evaluated. Of these, 46 subjects (29%) presented pneumothorax, of which 36 were small. This group of subjects was managed expectantly, with a therapeutic success of 81% (7 subjects had to undergo percutaneous pleural drainage). CONCLUSIONS: Expectant management in subjects with pneumothorax following percutaneous lung biopsy is a useful tool and should be applied by surgeons in order to avoid hospitalizations and / or unnecessary  and expensive procedures.

INTRODUCCIÓN: La punción biopsia percutánea transtorácica se ha convertido con el devenir del tiempo en un método diagnóstico de uso ubicuo y poco invasivo. Su principal complicación continúa siendo el neumotórax. El presente estudio describe la experiencia de este grupo con el manejo expectante del neumotórax pequeño y asintomático post biopsia, con el fin de reducir ingresos hospitalarios innecesarios. MATERIALES Y MÉTODOS: Se realizó una revisión retrospectiva, analizando los resultados de aquellos pacientes sometidos a tratamiento conservador de neumotórax post punción percutánea transtorácica en un periodo de 6 años ( Enero 2013 a Diciembre 2019). RESULTADOS: Un total de 160 sujetos fueron sometidos a una punción percutánea diagnóstica de pulmón en el lapso de tiempo estudiado. De estos, 46 ( 29%) presentaron neumotórax, siendo 36 de estos neumotórax pequeños. Este grupo fue manejado de forma expectante, con una tasa de éxito terapéutico del 81 % ( 7 sujetos debieron ser sometidos a drenaje pleural percutáneo). CONCLUSIONES: El tratamiento conservador de pacientes con neumotórax secundario a biopsia percutánea transtorácica es seguro, efectivo y útil. Debería ser utilizado por cirujanos como herramienta para evitar internaciones y/o procedimientos innecesarios y costosos.

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Resumen Objetivo: Comunicar el caso de una paciente de 77 años tratada de un angiosarcoma de cuero cabelludo, que evoluciona con neumotórax bilateral, cuyo estudio histopatológico informa enfermedad metastásica. Materiales y Método: Revisión de ficha clínica electrónica, registro informático de imagenología e informes de biopsias. Seguimiento ambulatorio en policlínico de cirugía. Resultados: Se realiza manejo por videotoracoscopía bilateral, con bulectomía más pleurodesis. Discusión: El neumotórax secundario por enfermedad metastásica es poco frecuente, aproximadamente 1% a 2% de los casos. De los tumores que más frecuentemente metastizan al pulmón se encuentran los sarcomas. Conclusión: El neumotórax metastásico es poco frecuente y requiere un alto índice de sospecha. Su manejo va a depender del pronóstico y de las condiciones generales del paciente.

Aim: To report the case of a 77-year-old patient treated for angiosarcoma of the scalp, who evolves with bilateral pneumothorax, whose histopathological study reports metastatic disease. Materials and Method: Review of electronic clinical record, computerized imaging record and biopsy reports. Outpatient follow-up at the polyclinic of surgery. Results: Management was performed by bilateral videothoracoscopy, with bulectomy plus pleurodesis. Discussion: Secondary pneumothorax due to metastatic disease is rare, approximately 1 to 2% of cases. Sarcomas are among the tumors that most frequently metastasize to the lung. Conclusion: Metastatic pneumothorax is infrequent and requires a high index of suspicion. Its management will depend on the prognosis and the general conditions of the patient.

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BACKGROUND The prevalence of chronic medical conditions continues to rise, as does the number of patients seeking alternative treatments for them. Chronic pain is a prevalent medical complaint and acupuncture often is used to treat it. The Chinese literature documents several adverse events (AEs) associated with acupuncture, including cardiac tamponade, pneumothorax, infection, and nerve injuries. These complications are rare and may be associated with anatomical characteristics of the patients and deep insertion of the acupuncture needles. Differences in body type, weight, height, sex, and muscle mass contribute to anatomical differences and the depth at which vital organs lie. Having a better understanding of these anatomical differences may alter the occurrence of such AEs. CASE REPORT A slim 58-year-old man who was treated for neck pain with acupuncture presented with 2-day history of moderate-severity pleuritic and sharp pain radiating from the left scapula to the midaxillary and retrosternal area. A left-sided pneumothorax was diagnosed on chest X-ray and the patient was treated with a chest tube. CONCLUSIONS This case underscores that acupuncture can result in complications such as a pneumothorax from puncture of the pleura. These types of AEs from acupuncture can be avoided with a better understanding of anatomical differences, including body mass index and variations in depth associated with body size, musculature, or skeletal structure. When placing the needles, it is crucial for practitioners to know that the depth at which vital organs lie may differ between patients.

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It has been described that patients with coronavirus disease 2019 (COVID-19) may present pneumothorax, either spontaneously, primarily due to constant cough, secondary to pneumonia caused by said disease, or iatrogenic due to mechanical ventilation that require high pressures, or traumatic due to urgent approaches, in a difficult airway such as that of these patients. The use of bedside ultrasonography has been gaining great relevance to complement clinical diagnosis, which has become a useful and reliable tool for personnel treating critically ill patients.

Se ha descrito que los pacientes con la enfermedad por coronavirus 2019 (COVID-19), pueden presentar neumotórax, ya sea de forma espontánea, primaria por la tos constante, secundaria a la neumonía causada por dicha enfermedad, o ya sea iatrogénica por la ventilación mecánica que requieren con altas presiones, o traumática por los abordajes urgentes, en una vía aérea difícil como la de estos pacientes. El uso de la ultrasonografía a la cabecera del paciente ha venido cobrando gran relevancia para complementar el diagnóstico clínico, la cual se ha convertido en una herramienta útil y fiable para el personal que atiende pacientes críticamente enfermos.

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Coronavirus Disease 2019 (COVID-19) has rapidly spread worldwide. Numerous studies have shown its typical and atypical CT findings. We report one COVID-19 patient who presented with a transient pneumothorax, spontaneous pneumomediastinum (SP), as well as subcutaneous emphysema during hospitalization. Chest CT andclinical findings were discussed, and a literature review is presented. The probable cause of SP in COVID-19 was alveolar damage. Once pneumothorax and SP were present, the patient should be carefully monitored to prevent respiratory deterioration, especially when lung lesions are severe.

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A 36-year-old-woman, smoker, without other relevant medical history, presented with symptoms of dyspnea, right localized chest pain, and non-productive cough. On the emergency department, the chest X-ray was interpreted as a giant right pneumothorax and a chest drain was inserted. Thoracic computed tomography demonstrated a giant emphysematous bulla with 23 cm on her right upper lobe. We report the first uniportal video-assisted thoracic surgery bullectomy for a bulla greater than 20 cm, in a patient with vanishing lung syndrome.

Una mujer de 36 años de edad, fumadora, se presentó en la sala de emergencias por disnea, tos y dolor torácico derecho. La radiografía fue interpretada como neumotórax y se colocó un tubo de drenaje. La tomografía computarizada del tórax mostró una bulla enfisematosa gigante, de aproximadamente 23 cm. Reportamos el primer caso de bullectomía por uniportal VATS en una paciente con síndrome del pulmón evanescente que presentaba una bulla mayor de 20 cm.

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In late 2019, a novel coronavirus initially related to a cluster of severe pneumonia cases in China was identified. COVID-19 cases have rapidly spread to multiple countries worldwide. We present a typical laboratory confirmed case of COVID-19 pneumonia, that was hospitalized due to hypoxemia but did not require mechanical ventilation. Although initially the patient was evaluated with a favorable outcome, in the third week of the disease, the symptomatology deteriorated due to a massive hypertensive pneumothorax with no known previous risk factor. Since the first cases of COVID-19 have been described, pneumothorax was characterized as a potential, though uncommon, complication. It has been reported that diffuse alveolar injury caused by SARS-CoV-2 can cause alveolar rupture, produce air leakage and interstitial emphysema. Although uncommon, pneumothorax should be listed as a differential diagnosis for COVID-19 patients with sudden respiratory decompensation. As a life-threatening event, it requires prompt recognition and expeditious treatment.

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Diagnostic error and diagnostic delays in health care are widespread. This article outlines an improvement effort targeting weekday evening inpatient radiology delays through staffing changes replacing trainees with faculty-trainee team coverage, pushing faculty coverage from 4 pm to 8 pm. Order-report turnaround times (TATs), critical findings TATs for pneumothorax and intracranial hemorrhage (ICH), and percentage meeting target were compared pre and post implementation for the 4 to 8 pm time frame using the Mann-Whitney U and χ2 tests, respectively. Stakeholder surveys assessed patient safety, morale, education, and operational efficiency. Median TATs (minutes) improved: X-rays 906 to 112, computed tomography 994 to 84, magnetic resonance imaging 1172 to 233, and ultrasound 88 to 58. Median critical findings TATs (minutes) improved from 853 to 30 and 112 to 22 for pneumothorax and ICH, respectively, and the percentage meeting target improved from 45% to 65%. Survey results reported perceived improvement in patient safety, education, and operational efficiency and no impact on morale.

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El tratamiento de los lactantes con quistes pulmonares congénitos conlleva una resección quirúrgica. Las variaciones en la ubicación y el tamaño del quiste de aire en el pulmón afectado implican la selección de diferentes estrategias quirúrgicas. La presencia de quistes pulmonares congénitos gigantes que imitan un neumotórax a tensión no permitiría tomar una decisión precisa y realizar un tratamiento oportuno durante una emergencia respiratoria. Los escasos informes sobre este tipo de experiencia hacen referencia a quistes a tensión durante la niñez. En este artículo, presentamos el caso de un niño con un quiste pulmonar congénito gigante que imita neumotórax a tensión según las manifestaciones clínicas y las evaluaciones del diagnóstico por imágenes. La descompresión instantánea del neumotórax a tensión no logró aliviar la dificultad respiratoria del niño. En los niños que presentan evidencia clínica de neumotórax a tensión, se debe excluir la posibilidad de un quiste pulmonar congénito gigante.

Treats of symptomatic infants with congenital cystic lung lesions (CCLLs) need surgical resection. Variable location and size of the air cyst of involved lung mean that different surgical strategies must be selected. The presence of huge CCLLs mimicking tension pneumothorax would hamper accurate judgment and timely treatment in dealing with respiratory emergencies. Rare experience reports are coping with childhood tension cystic lung lesion. We present a case of childhood huge CCLLs which was similar to tension pneumothorax based on clinical manifestations and imaging evaluations. Implementation of instant decompression measure against tension pneumothorax failed to alleviate respiratory distress of child. We should exclude the possibility of huge lung cystic lesion in children when clinical evidence inclines to the diagnosis of tension pneumothorax.

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