대한흉부영상의학회 Korean Society of Thoracic Radiology

Discussion

Diagnosis With Brief Discussion

Diagnosis

Spontaneous Hemopneumothorax

Radiologic Findings

Chest radiograph shows hydropneumothorax in the left thorax. Noncontrast-chest CT shows subpleural high-attenuated areas suggesting hemothorax in dependent portion. Bloody fluid was aspirated via the chest tube. He was previously healthy. Anemia was developped after admission and might be due to the venous bleeding from the pleural surface. After observation for one day, the patient was stabilized and hemopnrumothorax was successfully treated.

Brief Review

Spontaneous hemopneumothorax (SHP) is a complication of primary or secondary pneumothorax and can lead to potentially life-threatening conditions. SHP is a rare disorder, complicating 0.5?2% of patients with spontaneous pneumothorax. It involves accumulation of air and blood within the pleural space in the absence of trauma or other obvious causes. The clinical picture can be dramatic due to the hypovolemic shock.

The mechanisms are bleeding either of a torn apical vascular adhesion between the parietal and visceral pleura or of torn congenital aberrant vessels between the parietal pleura and the bulla as the lung collapses or due to rupture of vascularized bullae.

A patient's age and history, clinical evaluation, radiological evaluation, air and blood aspiration, and hemoglobin determination in the aspirated blood can be very useful diagnostic tools in order to differentiate between SHP and a blood-stained effusion.

Therapeutic policy should be decided upon individually based on the patient's condition and clinical appearance of the disease. The goals of treatment include resuscitation, hemostasis, and re-expansion of the lung. Initial treatment consists of fluid resuscitation and drainage of the pleural space. Homologous blood transfusions may also be required, although most of our patients did not receive any since they were young and able to recover from the anemia postoperatively.

Indications for thoracotomy were hypovolemic shock, continuous bleeding (100 ml/h), persistent air leak, impaired lung expansion, pachypleuritis, or recurrent pneumothorax. Intraoperatively, the bleeding site was identified, the adhesion cauterized or ligated, and the air leak sealed by excising the apicolytic disease. Subsequently, pleural abrasion was performed and effective drainage was secured.

Video-assisted thoracoscopic surgery became the best approach for many thoracopulmonary problems, especially for spontaneous pneumothorax. It is considered an alternative method that reduces surgical trauma, causes less postoperative pain and results in shorter hospital stay. It can be used in elective surgery after initial resuscitation.

Doctor should pay attention to the tube drainage because bleeding could be aggravated by chest tube insertion due to decreased intrathoracic pressure.

References

Kakaris S, Athanassiadi K, Vassilikos K, Skottis I. Spontaneous hemopneumothorax: a rare but life-threatening entity. Eur J Cardiothorac Surg. 2004;25:856-858.

Keywords

Pleura, Idiopathic,