A 65-year-old man with severe chronic obstructive pulmonary disease (COPD) was admitted with a four-day history of chest pain and worsening shortness of breath. He explained the chest pain started suddenly when he tried to reach out for something on his computer table. It was located on the right anterior chest, sharp in nature, 7/10 in intensity, pleuritic, and worse with coughing and deep breathing. He had a past medical history of severe COPD with frequent exacerbations recently necessitating multiple antibiotics and steroid courses, coronary artery disease, gastroesophageal reflux disease (GERD), and hypertension. He had a 30-pack per year smoking history and quit about 10 years ago. He was a retired fireman living with his family.\nVitals signs in the emergency department (ED) were stable; he was breathing on ambient air. The physical examination demonstrated decreased breath sounds bilaterally without any wheezing or Ronchi. Moderate tenderness was present in the mid-axillary line in the fifth intercostal space, but no other abnormalities were noticed. Laboratory investigations were negative for any leukocytosis, troponin, or any other abnormalities. The electrocardiogram (EKG) showed a normal sinus rhythm. Computed tomography (CT) angiography was done to rule out pulmonary embolism (PE). The CT was negative for PE but showed mild peribronchial infiltrate in the right middle lobe and posterolateral lung herniation between the seventh and eighth ribs, with minimal subcutaneous emphysema along the right chest wall (Figure ).\nThe patient was admitted to the hospital and managed conservatively on broad-spectrum antibiotics, including vancomycin, levofloxacin, and 40 mg per day of prednisone. Two days later, his face swelled up suddenly with a change in the quality of his voice while he was eating dinner. An examination showed a swelling in the neck, diffuse crepitations on his body involving the face, all the way down to the buttocks. Repeat CT chest and neck showed extensive subcutaneous emphysema in the face, neck, chest, and mediastinum with a right-sided pneumothorax at the level of the previous lung herniation (Figures -).\nThe prevertebral and retropharyngeal air was demonstrated as compressing the oropharynx (Figure ). His oxygen requirement went up to 6 liters nasal cannula. A blowhole incision was made on the anterior chest wall, and he was observed in the medical intensive care unit (MICU). Surgery to close the defect was deferred due to his other comorbidities and the higher risk of post-operative complications. He improved gradually over the course of the next few days, completed the course of antibiotics with steroids, and was discharged to a rehabilitation center and did well post-discharge.
A 20-year-old man with no remarkable past medical history was brought to the emergency department (ED) of a resource-limited hospital by ambulance with bilateral, anterior thoracic stab-wound lacerations ().\nThe patient was awake and responsive with a Glasgow Coma Scale of 15; he had a heart rate of 84 beats per minute, blood pressure of 90/60 millimeters of mercury, 22 breaths per minute, and oxygen saturation of 97% on room air. He complained of bilateral chest pain and shortness of breath. Physical exam primary survey revealed decreased breath sounds on the left, with bilateral large anterior chest wall lacerations. The left chest laceration had lung parenchyma protruding, and it expanded with each inspiration (). There were no other traumatic injuries or active hemorrhage on further primary survey, and secondary survey was unremarkable.\nCloser examination of the wounds showed the right chest wound at the ninth intercostal space (ICS) with no evidence of exposed lung, and the left chest wound also at the ninth ICS but clearly exposing lung parenchyma. Bedside focused assessment with sonography for trauma (FAST) did not demonstrate a pericardial effusion or intra-abdominal free fluid. The standard blood tests for trauma patients were collected in this patient and were unremarkable, including initial hemoglobin of 13.6 grams (g) per deciliter (dL) (reference range: 12.0 – 16.0 g/dL).\nInitial management included fluid resuscitation with one liter of normal saline (NS), analgesia with ketoprofen and tramadol intravenously, and oxygen facemask at six liters per minute. His blood pressure improved, and he did not require blood products or intubation in the ED. The eviscerated lung portion was left in place and covered with saline-saturated sterile towels. A portable radiograph machine was not immediately available, and CT was not performed because of concerns for clinical instability occurring while in CT. Instead the patient was assessed by the trauma team, which recommended immediate surgical intervention.\nThe patient was taken to the operating room (OR), and under general anesthesia the chest was explored using a left anterolateral thoracotomy at the fifth ICS. Injury to the heart, great vessels, and diaphragm was ruled out; surgical exploration revealed only a small amount of hemothorax. The left lung had no signs of laceration, necrosis, or thrombosis. The eviscerated portion of the lung was determined to be the lingula. After confirming the integrity of the vasculature, the lingula of the lung was retrieved back into the left hemithorax, the left hemithorax was irrigated with two liters of NS, and the patient was ventilated by the anesthesia team to assess the anatomic integrity of the parenchyma. Once the lung showed no signs of air leakage during the insufflation test, the NS irrigation and secretions were suctioned, and closure of the left thoracotomy incision was performed. A thoracostomy tube was placed in the left hemithorax and attached to underwater seal drainage. After 48 hours, a chest radiograph was obtained for evaluation of re-expansion of the lung ().\nThe patient was kept under observation for 12 hours in the postoperative care unit and spent the rest of his hospital stay in the general surgery ward, not requiring intermediate or intensive care unit admission. He received tramadol for analgesia, prophylactic antibiotics with ampicillin-sulbactam three grams intravenously every six hours for seven days as an in-patient, and then continued with amoxicillin-clavulanic acid 875/125 milligrams orally every 12 hours for three days upon hospital discharge. He had an uneventful postoperative course, with a fully expanded lung on postoperative radiograph and steady functional and cosmetic improvement at 15- and 30-day follow-up outpatient visits.