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A 61 year old female smoker with a background of chronic obstructive airways disease (COPD, FEV1 1.2/FVC 1.85: predicted 2.42/2.86), pulmonary tuberculosis, carcinoma of the breast, and coeliac disease was admitted with a six day history of progressive breathlessness associated with a productive cough. Chest auscultation showed bilateral expiratory wheeze. Admission chest radiograph showed hyperinflated lungs. She was treated for an infective exacerbation of COPD.
Five days later she became acutely unwell. Auscultation of the chest showed severely reduced air entry on the right side; the trachea was central. Urgent portable erect and supine chest radiographs did not confirm a pneumothorax. Observations: sinus tachycardia at 140 beat/min with no acute changes on 12 lead electrocardiogram, respiratory rate of 40 breath/min, decrease in systolic blood pressure to 90 mm Hg, and oxygen saturation below 90%. An intercostal drain was inserted immediately because of the very …