5. All of the above

The patient is clinically in respiratory failure and needs a secure airway. The patient was left on non-invasive ventilation until intubation could be performed using a rapid sequence intubation sequence. Only one attempt was required. A nasogastric tube was placed immediately after intubation and revealed greenish stomach contents and about 400 mL of contents which was rapidly removed.

A portable chest x-ray was performed about 5 minutes after intubation (Figure 2).

Figure 2. Portable chest x-ray t taken 5 minutes after intubation.

A bronchoscopy was performed which showed significant external compression of the left main stem and shift of the main carina to the patient’s right side. The compression of the left main stem was about 90% but it was possible to flush saline and pass the bronchoscope through into the left lung. All segments on left side were visualized but all segments showed distorted architecture and signs of external compression. Moderate secretions were aspirated from the left side after the bronchoscope was passed deeper, but there was no obvious mucous plugging anywhere in the left lung. The right lung showed some green tinged aspirate and had thicker secretions, again without mucous plugging.  This was most marked in the RUL. The patient tolerated the procedure well.

A portable chest x-ray was taken after the bronchoscopy (Figure 3).

Figure 3. Portable chest x-ray taken after bronchoscopy.

What is the most likely explanation for the air in the patient’s chest seen in Figures 1B and 2? (Click on the correct answer to proceed to the fourth of six pages)

  1. Diaphragmatic hernia
  2. Pneumothorax with movement of air into the peritoneal space
  3. Rapidly resolving pneumothorax
  4. Ruptured pneumatocele
  5. Skin fold with air trapping

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