CHEST Guidelines-An-87-Year-Old-Man-With-Progressive-Breathlessness (1)

An-87-Year-Old-Man-With-Progressive-Breathlessness (1)

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An 87-year-old man with a history of slow atrial fibrillation, managed with a pacemaker, and urinary bladder carcinoma was admitted to the hospital after a fall. Initial chest X-rays indicated a large hiatal hernia, fractured ribs, and a left pleural effusion. A subsequent chest CT confirmed these findings and showed no pneumothorax. The hernia was deemed long-standing and non-traumatic, as confirmed by previous radiology.<br /><br />Five months later, the patient returned with worsening dysphagia and shortness of breath. Examination revealed reduced breath sounds and raised creatinine and urea levels, which normalized with hydration. A chest CT and ultrasound identified increased left pleural effusion, complicated by the proximity to the hiatal hernia contents.<br /><br />Thoracic ultrasound (TUS) distinguished between pleural fluid and hernial sac contents, aiding in safe thoracentesis under real-time ultrasound guidance, which avoided injury to the closely situated hernial sac. The pleural fluid collected was an exudate, and subsequent cytological analysis indicated metastatic urothelial carcinoma.<br /><br />The case highlights TUS's utility in pleural effusion examination, offering advantages over CT in delineating pleural fluid characteristics and septations. TUS enables safer interventions in complex cases, particularly when small effusions increase the risk of injury to vital structures. This patient required an indwelling pleural catheter due to rapid pleural effusion recurrence, again guided by TUS.<br /><br />Overall, TUS is emphasized as essential in ensuring safe pleural procedures and is particularly beneficial for characterizing pleural effusion properties, thus informing treatment strategies and interventions.

Keywords

atrial fibrillation

pacemaker

hiatal hernia

pleural effusion

thoracic ultrasound

thoracentesis

metastatic urothelial carcinoma

indwelling pleural catheter

dysphagia

pleural fluid