How to Recognize a Pneumothorax in Your Patient

December 20, 20139 Comments

WE’VE GOT A SAYING
I remember when I was training in internal medicine at Good Samaritan Medical Center in Phoenix, AZ., The house staff had a saying:

“If you haven’t had a complication yet (from a procedure), it’s because you haven’t done enough of them.

Well said.

A COMMON AND TRAGIC ERROR

I also remember the head of the medical department at Five Branches University (TCM) saying that it’s impossible to give a patient a pneumothorax (PTX) with an acupuncture needle. Well, gentle reader, we both know that’s not true. One of the reasons why I decided to travel all over California and give seminars on Red Flags is because of an incident in Santa Cruz where a well-known lecturer gave a PTX to a volunteer patient who was needled for a demonstration. Everyone missed it. She later needed an ambulance in the middle of the night to take her to the hospital gasping for air as her pneumo expanded.

That’s one thing-to give your patient a PTX. It’s entirely something else to ignore the subsequent signs and symptoms (SSX), never check vitals, forget to document important items (for medical-legal reasons) and send the patient home without instructions or follow up. By doing that you expose yourself to litigation at the least and a possible patient death at the worst.

Here’s the problem as I see it and it’s a big one.
Should you give your patient a PTX you can end up in court trying to defend yourself. Miss any or all of the key features that I will outline for you here, you may indeed end up a cash cow for some trial lawyer and possibly lose your license. It all depends on several factors.
THE THREE STAGES OF A PNEUMOTHORAX

1. Minor PTX (less than 15% of lung volume)

2. Intermediate PTX (15%-25%)

3. Major PTX (over 25%)

4. Catastrophic tension PTX (RELATED BUT DIFFERENT)

Number 4 would be an exceedingly rare event which you would not be able to do much besides offer CPR and call 911. A major PTX will have SSX’s so obvious that you will not miss the fact that something terrible is happening. It’s really stages 1 and 2 that I want you to focus on because this is where you can make a difference IF you follow my suggestions.

WHAT THE HECK IS A PNEUMOTHORAX ANYWAY?

Very briefly a pneumothorax is an abnormal collection of air inside the chest cavity but outside the lung tissue proper. In other words it’s a pocket of air that has collected between the two pleura. The pleural cavity is the potential space between the two pleurae (visceral and parietal) of the lungs. The pleura is a serous membrane which folds back onto itself to form a two-layered membrane structure. The thin space between the two pleural layers is known as the pleural cavity and normally contains a small amount of pleural fluid. The outer pleura (parietal pleura) is attached to the chest wall. The inner pleura (visceral pleura) covers the lungs and adjoining structures, via blood vessels, bronchi and nerves. (from Wikipedia).

pleura Gray968 There is not supposed to be air between the pleura.

What happens in a PTX from an acupuncture needle is that you inserted the needle through the chest and into the visceral pleura. In other words you just put a hole in your patient’s lung tissue. Now when she breathes the normal negative pressure that develops within the intrapleural space (the pleural cavity) starts to suck air into the chest from the lung and causing the lung to subsequently partially collapse.

ALWAYS MAINTAIN A HIGH INDEX OF SUSPICION

Now with a small PTX ( stage 1 or 2) we need to be aware of how your patient is going to present. It can be subtle so you need to have a high index of suspicion in order to catch it. What determines a high index? If after you are finished treating your patient and she feels worse after needling-stop and think things over. What do I mean worse? Often times when a person develops a small PTX they will become anxious.

ANXIETY

That’s the operative word here. ANXIETY. There are several things to consider: Did you needle the thorax in any way? If not consider a different cause for anxiety-panic attack for example.   If you did needle anywhere over lung then you need to rule out PTX.

SHORTNESS OF BREATH & CHEST PAIN

She may also complain of shortness of breath (SOB) or possibly pleuritic type chest pain. That’s the type that hurts when you cough or breath deeply.

GET YOUR VITALS

Next step is to obtain a set of vitals. That includes heart rate (HR), blood pressure (BP), respiratory rate (RR), temp is optional. Make sure that you know the upper and lower limits of normal for your vitals. A RR greater than 20 is abnormal unless there is an underlying condition causing a faster RR (COPD for example). HR-anything over 100 is by definition tachycardia and sometimes abnormal. LOOK THEM OVER AND DETERMINE IF ANY ARE ABNORMAL.

AUSCULTATE THE CHEST

Along with your vitals listen to the chest and compare the exact same spot on the contralateral side for comparison. With a PTX you will hear decreased or no breath sounds on the affected side.

ASSESSMENT

Let’s say our patient felt “off,” uncomfortable and a little anxious. “Let me just sit here for a while I just don’t feel right.” she might say. You then remember that it’s not normal to feel worse after a treatment and you recall that she received numerous needles over several Back Shu points. That’s your high index of suspicion. You now obtain vitals: BP is OK, HR 95, RR 25. On auscultation you think you might have heard a decrease in BS over the top right posterior chest area and in the axillary area on the right side. I understand that many of you do not have a lot of experience with the stethoscope but do it anyway.

NOW WHAT DO I DO?

Putting it together there is enough evidence to suggest that there is a small PTX in the top right lung fields. You cannot prove anything more than this because you’ll need a chest X ray (CXR) for confirmation.

She will need to be seen by an MD either at an urgent care facility, ER, walk in clinic, etc. But it must be now, today. A family member could pick her up and drive her to the ER or to her doctor’s office.  If she were acutely SOB, in distress, had chest pain, or a systolic BP < 90  you’ll need to call 911. With her mild symptoms and mildly fast RR and HR you do not need to call an ambulance.

DOCUMENT EVERYTHING IN THE CHART CLEARLY, SIGN IT AND TIME IT.

Now I know that it can be as anxiety provoking in you the LAc as it is in the patient. Furthermore, you do not have much experience with sending people to the hospital. I am sure that many would just as well forget it and send the patient home and pretend it’s all fine and that it’s an over-reaction to do anything more than send her home. That might work for some but it’s legally indefensible and you could be setting your patient up for a disaster. It’s far better to be wrong and safe. Moreover, giving a patient a PTX, while not a wonderful thing to do, is accepted as part of a medical procedure and you cannot be faulted for it. On the other hand being negligent by not investigating your patients condition is painting a huge bull’s eye on your back, one that any trial lawyer would be happy to send a spear into.

 

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About the Author ()

Christopher Rasmussen MD, MS is Founder and Professor at AdaptiveTCM where helps Traditional Chinese Medicine Practitioners treat complex patients with confidence through providing online CEUs and research. Dr. Rasmussen is currently writing a comprehensive, preventive medicine book, with an emphasis on inflammatory components of disease prevalent in today's patients.

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