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Bilateral spontaneous pneumothorax
  1. S Hedges1,
  2. V Perkins1
  1. 1Department of Anaesthesia, Dumfries and Galloway Royal Infirmary, Bankend Street, Dumfries DG1 4AP, UK
    1. S C Wilkie2,
    2. L J Hislop2
    1. 2Accident and Emergency Department, Royal Alexandra Hospital, Paisley, UK

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      Wilkie et al describe a case of bilateral spontaneous pneumothorax in a 39 year old man.1 We are concerned that the conclusion drawn, namely the importance of urgent chest radiography for all patients in respiratory distress should not take precedence over the even more urgent need to ensure adequate oxygenation of the patient.

      It appears clear that the patient was at significant risk of cardiorespiratory arrest despite stating that “cardiac output was not impaired.”

      We are told that despite only having an arterial oxygen saturation of 60% on 15 litres of oxygen and despite signs of significant hypoxaemia on blood gas analysis, the decision was made to proceed to radiography before intubation.

      We would argue that prompt intubation should have preceded radiography, as delay in achieving oxygenation while awaiting the chest radiography could have had catastrophic consequences.

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      Authors' reply

      The point raised by Drs Hedges and Perkins is well taken and we would agree that chest radiography should not take precedence over the need to ensure adequate oxygenation of the patient. It did not take precedence in the illustrated case.

      The patient was found to be in respiratory distress and immediate preparations were made to intubate and ventilate him. During this time the radiological facilities in the resuscitation room and on-site radiographer enabled the chest radiograph to be taken without any delay in the time to intubation; indeed it is clear from the article that the patient was being ventilated before the return of the radiograph.

      The aim of this article was to illustrate that urgent chest radiography in patients with respiratory distress can be invaluable in establishing a definitive diagnosis and we agree that secondary investigations should never take precedence over adequate airway management.

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