CHEST Guidelines-An-87-Year-Old-Man-With-Progressive-Breathlessness

An-87-Year-Old-Man-With-Progressive-Breathlessness

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An 87-year-old man with a history of slow atrial fibrillation and urinary bladder carcinoma was admitted to the hospital after a fall. An initial chest X-ray revealed a large hiatus hernia, fractured ribs, and a left pleural effusion. A subsequent CT scan confirmed these findings. Five months later, the patient returned with worsening dysphagia and dyspnea, and tests showed reduced breath sounds and elevated creatinine and urea levels, which stabilized with hydration.<br /><br />A follow-up chest CT showed an increase in the left pleural effusion, which was challenging to assess due to the proximity of the hernia. A thoracic ultrasound (TUS) clearly distinguished between pleural fluid and the contents of the hernia. Thoracentesis, guided by ultrasound to avoid damaging the hernial sac, revealed exudative pleural fluid, and further cytological analysis suggested metastatic urothelial carcinoma.<br /><br />TUS proved invaluable in differentiating complex CT images and safely guiding interventions, such as real-time thoracentesis, by providing clear information on the echogenicity of pleural fluid and identifying potential septations. The case illustrates the significance of TUS in safely performing pleural space interventions and ensuring patient safety during procedures where there is a risk of injury to adjacent structures. <br /><br />In conclusion, TUS is a crucial tool for characterizing pleural effusions and guiding interventions, emphasizing its role in clinical practice. For this patient, TUS enabled precise distinction between pleural and hernia fluids and facilitated the safe insertion of an indwelling pleural catheter upon recurrence of the pleural effusion.

Keywords

hiatus hernia

pleural effusion

thoracic ultrasound

thoracentesis

metastatic urothelial carcinoma

dysphagia

dyspnea

indwelling pleural catheter

echogenicity

patient safety