An 85-year-old nursing home resident is brought to the emergency department due to worsening cough, difficulty breathing, and decreased responsiveness for 3 days. Medical conditions include hypertension, type 2 diabetes mellitus, and dementia. Following evaluation that reveals leukocytosis and lung infiltrates, the patient's respiratory distress progressively worsens. Endotracheal intubation is performed; mechanical ventilation is begun; the patient is given intravenous fluids and antibiotics; a central venous catheter is placed; and she is admitted to the intensive care unit (ICU). In the ICU, the patient requires increasing ventilatory support with elevated airway pressures. Temperature is 35.6 C (96 F), blood pressure is 84/40 mm Hg, pulse is 112/min, and respirations are 16/min. Pulse oximetry shows 92% on assist-control mode with a tidal volume of 300 mL, fraction of inspired oxygen (FiO₂) of 60%, and positive end-expiratory pressure (PEEP) of 5 cm H₂O. Examination reveals decreased breath sounds on the right, rhonchi on the left, and normal S1 and S2. The abdomen is soft and nontender. There is no extremity edema. Arterial blood gases and chest x-ray are shown below. Which of the following is the most appropriate next step in management of this patient?

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11ec193a_969c_0f02_853d_b5291d3b5b27_MD0002_00 This patient's chest radiograph reveals a large right-sided pneumothorax with air between the visceral pleura of the lung (red arrows) and parietal pleura of the chest wall, diaphragm, and mediastinum. Pneumothoraces can be spontaneous or nonspontaneous. Nonspontaneous causes include trauma and iatrogenic injuries from interventions such as positive pressure ventilation, central venous access, and thoracentesis. Accumulation of air in the pleural space can create tension and shift the mediastinum, which leads to hypotension, tachycardia, and hypoxemia. Tension pneumothoraces require urgent decompression of the pleural space via needle insertion at the second intercostal space and/or chest tube placement. (Choice A) Increasing the positive end-expiratory pressure is contraindicated as it would cause increased air pressure in the pleural space and worsen pneumothorax. (Choice C) Short-term neuromuscular paralysis can assist in oxygenation of some patients with severe hypoxemia (eg, due to severe acute respiratory distress syndrome), but it is not indicated in managing pneumothorax. (Choices D and E) Right mainstem bronchus intubation typically presents with hypoxemia due to large-volume atelectasis of the left lung and can be treated with repositioning of the endotracheal tube. Mucus plugging can also present with hypoxemia due to atelectasis and may improve with suctioning of respiratory secretions. However, a large pneumothorax, as evident on this patient's chest x-ray, requires decompression of the pleural space. Educational objective: Tension pneumothorax should be suspected in a patient with hemodynamic instability and iatrogenic risk factors for pneumothorax (eg, central-line placement). Urgent decompression of the pleural space with needle thoracostomy or chest tube placement is required. __________ References: Pneumothorax in the critically ill patient. (http://www.ncbi.nlm.nih.gov/pubmed/22474153)

An 85-Year-Old Nursing Home Resident Is Brought to the Emergency