ACE-CAA Issue 2 Sample Question
What is the MOST appropriate intervention for a man with the following chest radiograph?
Answer: C. Place chest tube. Read the discussion below.
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PREORDER ACE-CAA ISSUE 2
The chest radiograph presented (Figure 1) shows an appropriately placed endotracheal tube with right-to-left shift of the trachea, main bronchi, and heart, with compression of the right lung. The radiograph also demonstrates displacement of a right internal jugular catheter to the left. Given the degree of shift from apparent tension, a chest tube should be placed urgently before hemodynamic embarrassment ensues.
Figure 1. Chest radiograph with an appropriately placed endotracheal tube with right-to-left shift of the trachea, main bronchi, and heart, with compression of the right lung and displacement of a right internal jugular catheter to the left. Image courtesy of Jeremy S. Dority, MD.
A chest tube can be placed at approximately T4 (roughly in the axilla at the point at which ribs can be clearly palpated) in the mid- or anterior-axillary line. If the patient acutely decompensates hemodynamically, it may be more appropriate to perform an emergent needle decompression thoracostomy by placing a large-bore catheter on the affected side at the second rib space in the midclavicular line, followed by placement of a chest tube for continued decompression and lung expansion.
Patients with pneumothorax frequently develop expiratory wheezes, but bronchodilator therapy is not the most effective intervention.
The endotracheal tube does not need to be retracted, and such intervention will not improve the clinical situation.
Any subtle pleural effusion is not clinically relevant in the image presented.
1. Roberts DJ, Leigh-Smith S, Faris PD, et al. Clinical presentation of patients with tension pneumothorax: a systematic review. Ann Surg. 2015;261(6):1068-1078.
2. Barash PG, Cullen BF, Stoelting RK, Cahalan MK, Stock MC, Ortega R, eds. Clinical Anesthesia. 7th ed. Philadelphia, PA: Wolters Kluwer/Lippincott Williams & Wilkins; 2013:1508-1510.