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In elderly with poor premorbid, advance management decision is complex and difficult.
Â Case report
An elderly gentleman with underlying history of chronic obstructive pulmonary disease presented gasping with respiratory failure type II. He had minimal mobility at home for the past five months. He could only walk from his bed to the toilet. However he was ventilated two months ago and discharged well. On examination, the lungs were fairly clear. The CXR revealed a significant pneumothorax on the right side. He had presented two months ago, with pneumothorax also, and chest tube was inserted then. As the chest tube was bubbling persistently, a CT thorax was done. No bronchopleural fistula was found. Subsequently talc pleurodesis was performed and patient discharged on a pneumostat. The pneumostat was found leaking a month ago, and was removed.Â
Should we intubate this patient? If we did were to intubate this patient, would the ventilation cause the pneumothorax to worsen? Is needle aspiration indicated as a life saving procedure, as the patient was in type II respiratory failure? The patient was connected to a BiPAP NIV, while discussion were underway as to the right choice of management in an elderly with seemingly poor premorbid. A decision was made not to insert the chest tube, but to intubate the patient. Half an hour post intubation, as the patient was about to be pushed to the CT scan room, the BP blood pressure(BP) dropped. He was given intravenous fluid, and subsequently started on high dose of triple inotropes to maintain his BP. He was stable enough to go for the CT thorax, where initially a CT guided pigtail insertion was requested.
He returned to ED, post CT scan, where BP was stable, with no pigtail. Subsequent decision on whether to insert a CT guided pigtail, was made. What would your decision be?
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