Hypoxia in a Patient With Massive Pleural Effusion

Case Study

A rapid response event was initiated by the bedside nurse for a patient who developed altered mentation and shallow breathing. On arrival of the condition team, the patient was found to be an 80-year-old female with a history of lung adenocarcinoma who presented a few hours ago for dyspnea on exertion and was found to have a large right-sided pleural effusion. Since admission, she had had progressive difficulty breathing, however, was awake and hemodynamically stable. The patient was planned for a thoracentesis under ultrasound guidance the following day.

Vital Signs

  • Temperature: 37.4 °F, axillaryBlood Pressure: 130/90 mmHg

  • Pulse: 120 beats per min – sinus tachycardia on the cardiac monitor

  • Respiratory Rate: 20 breaths per minPulse Oximetry: 75% on room air, 90% on 10 L high-flow nasal cannula

Focused Physical Examination

A quick exam showed an elderly cachectic female who appeared somnolent, not responsive to painful stimuli, using accessory muscles of respiration. No air entry was noted on the right lung field with dullness on percussion on auscultation. The remaining physical examination was unremarkable.


On a quick review of the prior charted data, admission chest radiography, and the history of lung adenocarcinoma, the patient appeared to be in acute hypoxic respiratory failure because of massive pleural effusion. A cardiac monitor and pads were attached for hemodynamic monitoring. Due to hypoxemic respiratory failure, decreased mentation, and inability to protect the airway, the patient was initially ventilated via Ambu-bag and then emergently intubated using the rapid-sequence-intubation technique. Stat chest X-ray and arterial blood gas were obtained. Arterial blood gas showed pH 7.40, pCO 2 40 mmHg, pO 2 60 mmHg, spO 2 90%, which was significant for hypoxemia. Chest X-ray showed an increase in the effusion size compared to admission ( Fig. 29.1 ). Once the patient was stabilized, she was transferred to the intensive care unit for emergent thoracentesis.

Fig. 29.1, Right-sided pleural effusion.

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