Case 38: Sudden chest pain in a COPD patient
Tuesday, December 20th, 2011Author: Dr Ian Stell
This 70 year old female was woken in the early hours of the morning by sharp pain across the chest. This continued over the following hours and was exacerbated by inspiration. She had a history of moderately severe COPD.
Examination was unremarkable, she had features of stable COPD. Her oxygen saturation was 90% on room air.
This is her CXR:
This is a closer view of the mediastinum:
1. Suggest a diagnosis?
Click to see the answerPneumomediastinum. This arises from the rupture of an alveolus, with air tracking back along the fascial planes associated with the bronchi and pulmonary vessels to reach the mediastinum. It has similar causes as pneumothoraces, and it is associated with coughing, asthma and COPD. It is also associated with cocaine sniffing because of the alveolar damage which can result. The average age at presentation is about 30, but some cases occur in COPD at an older age.
Most present with pleuritic-type chest pain which can radiate to the back. Surgical emphysema in the neck can be present. An interesting sign (Hamman’s crunch) of crepitus on auscultation during systole, is sometimes heard.
2. What is the prognosis?
Click to see the answerThis is generally a benign condition, but tension in the air filled planes compressing the trachea has been reported. Spontaneous resolution is to be expected.
3. What is the explanation of the ‘step’ link appearance of the diaphragm on the CXR?
Click to see the answerThis is due to the extreme flattening of the diaphragm in COPD. This causes the ‘slips’ of diaphragm muscle passing to the ribs and costal cartilages to become higher than the dome of the diaphragm and to become silhouetted against pulmonary air.