Correct!
2. Place patient with his left side down

 The post IBV chest x-ray shows a slightly larger right sided pneumothorax than before the IBV placements. The reason for this is likely atelectasis due to the correct functioning of the valves. The hypoxia, is hence, a result of this atelectasis and the associated areas of low VQ ratios (shunt). The patient was temporarily treated by turning him onto his left side, i.e. right side up. This improved his hypoxia by improving perfusion (Q) to the better lung and reducing perfusion (Q) to the shunting right lung. In most cases with IBVs, the degree of shunt physiology is moderate to minimal and resolves over a few hours.

The air leak was significantly reduced in this patient by this measure but not to the point of the patient tolerating a Heimlich valve attached to the chest tube. He was transitioned to palliative care and lived the rest of his short life in relative comfort with family.

Pearls

• Spontaneous contralateral pneumothoraces are rare complications of thoracentesis.
• Bronchopleural fistulas are difficult to treat; fortunately, only a minority are persistent.
• Intrabronchial valves are a new and potentially useful intervention for refractory bronchopleural fistulas.

References

1. Galbois A, Ait-Oufella H, Baudel JL, Kofman T, Bottero J, Viennot S, Rabate C, Jabbouri S, Bouzeman A, Guidet B, Offenstadt G, Maury E. Pleural ultrasound compared with chest radiographic detection of pneumothorax resolution after drainage. Chest . 2010;138(3):648-55.
2. Yarmus L, Feller-Kopman D. Pneumothorax in the critically ill patient. Chest. 2012;141(4):1098-105.

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