February 2013 Critical Care Case of the Month: Thoracentesis Through the Looking Glass

Clement U. Singarajah MD

Jay E. Blum

Allen R. Thomas MD

Henry Luedy MD

Elijah Poulos MD

Tonya Whiting DO

Phoenix VA Medical Center

Phoenix, AZ

History of Present Illness

A 62 year old man was recently diagnosed with Stage 4 squamous cell left lung cancer with metastases to the pleura, brain and mediastinum. He also had known chronic obstructive pulmonary disease (COPD) with a FEV1 = 1.96 L and a known left side pleural effusion (see Figure 1).

Figure 1. Baseline chest radiograph showing left pleural effusion (red arrow).

He was seen as an outpatient for symptomatic shortness of breath and underwent real time ultrasound guided left sided thoracentesis removing 500 ml of straw-colored fluid. The procedure was uneventful except that near the end, the patient started to cough.  He denied any symptoms post procedure apart from some minor puncture site pain. A routine post procedure chest x-ray was performed (Figure 2).

Figure 2. Post-thoracentesis x-ray (Panel A) and its negative image (Panel B).

What new abnormality is identified on the post-procedure chest x-ray?

1. Left pneumothorax
2. Right pneumothorax
3. Lung “sliding” on the left
4. New pneumonia in the left upper lobe
5. Left hilar retraction

Reference as: Singarajah CU, Blum JE, Thomas AR, Luedy H, Poulos E, Whiting T. February 2013 critical care case of the month: thoracentesis through the looking glass. Southwest J Pulm Crit Care. 2013;6(2):63-74. PDF