What is the best imaging option for a post-operative adult with a history of migraines, presenting with sudden onset of right-sided chest pain, shortness of breath, tachycardia, tachypnea, hypoxia, and absent breath sounds on the right side, 1 hour after a lung biopsy?

Best Imaging for Post-Lung Biopsy Pneumothorax

An upright chest radiograph should be obtained immediately—this is the standard of care for rapid confirmation of pneumothorax in the perioperative period following lung biopsy. 1, 2

Clinical Context

This patient presents with classic signs of post-procedural pneumothorax:

• Sudden onset right-sided chest pain and dyspnea occurring 1 hour post-lung biopsy 1, 2
• Tachycardia (HR 120 bpm), tachypnea (RR 30), and hypoxia (SpO2 90%) 2
• Absent breath sounds on the right side—a pathognomonic finding 1
• Pneumothorax occurs in up to 61% of lung biopsies and typically presents within the first hour 1, 2

Immediate Diagnostic Algorithm

First-Line Imaging: Upright Chest Radiograph

• Obtain an erect chest radiograph immediately to detect pneumothorax, pulmonary hemorrhage, hemothorax, or pleural effusion 1, 2
• The British Thoracic Society guidelines specify that 98% of post-biopsy pneumothoraces are detectable on radiographs taken within the first hour 1, 2
• This imaging modality is rapid, readily available in the PACU setting, and sufficient for diagnosis 1

Why Not CT in This Scenario?

• While CT is more sensitive than chest radiography for detecting small pneumothoraces, it is not necessary for rapid confirmation when clinical findings are obvious (absent breath sounds, hypoxia, hemodynamic changes) 1
• CT would delay management and is not the standard perioperative imaging approach 1, 2
• The ACR Appropriateness Criteria support chest radiography as the initial imaging modality for suspected pneumothorax in the acute setting 1

Immediate Concurrent Management

While obtaining the chest radiograph:

• Administer supplemental oxygen immediately to address hypoxia (SpO2 90%) 1, 2
• Monitor vital signs continuously, as tension pneumothorax can develop rapidly with hemodynamic collapse 1, 2
• Prepare for immediate intervention if clinical deterioration occurs before imaging is obtained 2

Critical Pitfalls to Avoid

• Do not delay imaging based on the assumption that post-biopsy pain is "normal"—catastrophic complications including tension pneumothorax can develop rapidly 2
• Do not order CT as the first imaging study in the perioperative period when chest radiography is faster and adequate for diagnosis 1, 2
• Do not assume a negative immediate post-biopsy radiograph rules out pneumothorax, as delayed presentations can occur up to 24 hours later, but this patient is already symptomatic at 1 hour 1, 2
• Do not wait for imaging if tension pneumothorax is suspected (severe hypotension, tracheal deviation, cardiovascular collapse)—immediate needle decompression takes precedence 1, 2

Post-Imaging Management Algorithm

Based on chest radiograph findings:

If pneumothorax is confirmed:

• Small, asymptomatic pneumothorax: observation with repeat imaging 1
• This patient is symptomatic (tachycardic, tachypneic, hypoxic): requires immediate intervention with aspiration or chest tube insertion 1, 2
• Enlarging or large pneumothorax: chest drain insertion 1

If massive hemothorax is identified:

• Immediate chest tube insertion and surgical consultation 1, 2

Special Consideration for This Patient

The history of migraines is clinically irrelevant to the acute management of suspected post-biopsy pneumothorax and should not influence imaging decisions 3, 4, 5, 6, 7