DID I COUGH OUT MY LUNG?

Abstract

1) Introduction

Lung herniation via intercostal muscle wall defect is rare, occurring most commonly after external trauma, surgery or excessive intrathoracic pressure. We present a case of massive Subcutaneous Emphysema (SE), as a result of a rupture in the chest wall, with presence of lung herniation secondary to excessive, violent cough.

2) Case Report

A 64-year-old gentleman, non-smoker with background medical history of Diabetes Mellitus and Hypertension presented to us with history of swelling over his face, neck and chest for 5 days. It was preceded with 2 weeks history of productive and excessive cough. Upon arrival, he was not in respiratory distress. Physical examination revealed and extensive swelling over his jaw and neck extending to his left lower chest region, which on palpation noted to be SE. A chest x-ray showed a classical gingko-leaf sign without any evidence of pneumothorax. We proceed with CT-Thorax which shows a left lung herniation through left 6^th and 7^th intercostals space wall defect associated with left hydropneumothorax, causing bilateral SE. Patient then underwent Left Video Assisted Thoracoscopic Surgery and chest wall defect repair.

3) Discussion and Conclusion

We present a unique case of spontaneous lung herniation.  The herniation can result from an increase in intrathoracic pressure, as occurs with coughing in this case. Lung herniation usually present with a pain bulge and can be concurrent with SE. The clinical diagnosis is usually confirmed by means of plain x-ray or computed tomography (CT). In Emergency setting, the is no urgent indication to blindly insert chest tube for all SE without finding the root cause. In regard to the necessity of repairing the hernias, general indications include increasing in size, pain, dyspnea and impending incarceration.