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Original Article

Clinical profile, etiology, and management of

hydropneumothorax: An Indian experience
Vasunethra Kasargod, Nilkanth Tukaram Awad
Department of Pulmonary Medicine, Lokamanya Tilak Municipal Medical College, Sion, Mumbai, Maharashtra, India

ABSTRACT

Introduction: Hydropneumothorax is an abnormal presence of air and fluid in the pleural space. Even though the
knowledge of hydro‑pneumothorax dates back to the days of ancient Greece, not many national or international
literatures are documented. Aim: To study clinical presentation, etiological diagnosis, and management of the patients
of hydropneumothorax. Materials and Methods: Patients admitted in a tertiary care hospital with diagnosis of
hydropneumothorax between 2012 and 2014 were prospectively studied. Detailed history and clinical examination were
recorded. Blood, pleural fluid, sputum investigations, and computed tomography (CT) thorax (if necessary) were done.
Intercostal drainage (ICD) tube was inserted and patients were followed up till 3 months. Results: Fifty‑seven patients were
studied. Breathlessness, anorexia, weight loss, and cough were the most common symptoms. Tachypnea was present in
68.4% patients. Mean PaO2 was 71.7 mm of Hg (standard deviation ±12.4). Hypoxemia was present in 35 patients (61.4%).
All patients had exudative effusion. Etiological diagnosis was possible in 35 patients by initial work‑up and 22 required
CT thorax for arriving at a diagnosis. Tuberculosis (TB) was etiology in 80.7% patients, acute bacterial infection in 14%,
malignancy in 3.5%, and obstructive airway disease in 1.8%. All patients required ICD tube insertion. ICD was required
for 24.8 days (±13.1). Conclusion: Most patients presented with symptoms and signs of cardiorespiratory distress along
with cough, anorexia, and weight loss. Extensive pleural fluid analysis is essential in establishing etiological diagnosis.
TB is the most common etiology. ICD for long duration with antimicrobial chemotherapy is the management.

KEY WORDS: Hydropneumothorax, intercostal drainage, tuberculosis

Address for correspondence: Dr. Nilkanth Tukaram Awad, Department of Pulmonary Medicine, Room No. 12, 1st Floor, College Building, Lokamanya Tilak
Municipal Medical College, Sion, Mumbai ‑ 400 022, Maharashtra, India. E‑mail: nta1960@gmail.com

INTRODUCTION presentation, etiological diagnosis, and management

profile of the patients of hydropneumothorax.
Hydropneumothorax is the abnormal presence of
air and fluid in the pleural space. The knowledge of MATERIALS AND METHODS
hydropneumothorax dates back to the days of ancient
Greece when the Hippocratic succussion used to be A prospective, observational, hospital‑based study was
performed for the diagnosis.[1] There have been tremendous conducted. Population studied was patients of adult
advancements in the field of laboratory and radiological age group attending a tertiary hospital in Western India
diagnosis and therapeutic management for pleural for a period of approximately 2 years. Only patients of
pathologies. However, not many national or international hydropneumothorax diagnosed on clinical and radiological
literature are documented regarding hydropneumothorax. grounds were considered. Traumatic hydropneumothorax
The purpose of this study is to throw light on the clinical
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DOI: How to cite this article: Kasargod V, Awad NT. Clinical profile,
10.4103/0970-2113.180804 etiology, and management of hydropneumothorax: An Indian
experience. Lung India 2016;33:278-80.

278 © 2016 Indian Chest Society | Published by Wolters Kluwer - Medknow

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Kasargod and Awad: Hydropneumothorax in India

was excluded from the study. Patients who satisfied the Mean pH of patients was 7.4 (standard deviation [SD] ±0.1),
inclusion criteria were then explained about the study and mean Paco 2 was 35.1 mm of Hg (SD ± 10.2), Pao 2
valid consent taken for their participation. All the patients was 71.7 mm of Hg (SD ± 12.4), and mean HCO 3
were enquired regarding symptoms such as breathlessness, was 21.4 mEq (SD ± 4.3). Hypoxemia was present in
fever, cough, chest pain, constitutional symptoms such 35 patients (61.4%). Sputum examination for AFB by
as loss of appetite and loss of weight. Patients were also Ziehl–Neelsen staining was positive in 10 patients (17.5%).
enquired regarding presence of comorbidities such as
diabetes mellitus, hypertension, ischemic heart disease, and Pleural fluid biochemistry showed protein of 4.46 g/dL
history of tuberculosis (TB) and immunocompromised state. (±0.9 g/dL) and glucose of 32.6 mg/dL (SD ± 41.56). On the
Detailed clinical examination was done. Patients underwent basis of Light’s criteria, all patients had exudative pleural
initial laboratory examination of arterial blood gases effusion. Pleural fluid was lymphocyte predominant in
examination, complete blood count, random blood sugars, 41 patients (71.9%) and polymorph predominant in the
serum proteins, and serum lactate dehydrogenase. Sputum remaining 16 patients.
for acid‑fast bacilli (AFB) was examined by Ziehl–Neelsen
stain. Pleural fluid was subjected to pathological (routine Pleural fluid AFB smear was positive in eight patients (14%)
microscopy), biochemical (proteins, glucose, cholesterol, and Lowenstein–Jenson media showed growth of TB bacilli
lactate dehydrogenase, and adenosine deaminase [ADA] in five patients (9%). Due to technical difficulties, MGIT of
levels), and microbiological examination (bacterial culture 42 patients were sent, of which positive growth was seen
and drug sensitivity, fungal culture and sensitivity, in 10 patients (23.9%). Pleural fluid bacterial culture was
Lowenstein–Jenson culture, and pleural fluid for AFB positive in seven patients (12.3%). Etiological diagnosis
staining). Due to technical difficulties, mycobacterial growth was possible in 35 patients with the above clinical and
indicator tube (MGIT) culture of all patients was not sent. laboratory investigations.
In patients in whom diagnosis could not be established
by above investigations were subjected to computed Remaining 22 [Table 1] patients required CT thorax in
tomography (CT) (contrast‑enhanced with high resolution which cavitary consolidation with V‑Y pattern was seen in
CT). All patients were treated with intercostal drainage (ICD) 15 patients (26.3%) suggestive of TB, consolidation with
tube insertion. As per the etiological diagnosis, patients air‑bronchogram was seen in 15 patients suggestive of acute
were treated on medical grounds as well. Patients were bacterial infection, emphysematous changes were seen in
followed‑up for 3 months with weekly ICD status and chest only one patient (1.8%) suggestive of obstructive airway
X‑ray examination. ICD tube was clamped and removed disease, and pleural nodules and mass lesion suggestive of
when air‑leak stopped and drainage of pleural fluid was malignancy was seen in one patient each (1.8%).
below 50 ml/day and chest X‑ray showed complete lung
expansion. Number of days required for the same was TB [Table 2] was the most common etiological diagnosis
documented. All the data were initially entered in Microsoft seen in 46 patients (80.7%), acute bacterial infection
Excel and later transferred to Statistical Package for the Social was noted in eight patients (14%), malignancy in two
Sciences (SPSS) SPSS Inc. Released 2008. SPSS statistics for patients (3.5%), and obstructive airway disease with
Windows, version 17.0. Chicago: SPSS Inc. All the variables bacterial infection in one patient (1.8%).
of hydropneumothorax were analyzed separately and as per
their type and distribution, appropriate test was applied and All patients were treated with insertion of ICD
analyzed in the SPSS software version 17.0. tube. Mean number of days of ICD tube in situ was

RESULTS Table 1: CT scan features

Features n (%)
Fifty‑seven patients of hydropneumothorax were Cavity 15 (26.3)
included in the study. Mean age of presentation was Consolidation 4 (7.0)
44.2 years (±16.3 years). Forty‑six out of 57 (80.7%) Emphysema 1 (1.8)
Mass 1 (1.8)
patients were males. Breathlessness was the most common NA 35 (61.4)
presenting symptom seen in 54 patients (94.7%), followed Pleural nodules 1 (1.8)
by cough seen in 53 patients (93%), fever was seen in Total 57 (100.0)
50 patients (87.7%), chest pain in 41 patients (71.9%), CT: Computed tomography, NA: Not available
weight loss in 39 (68.4.2%), and loss of appetite in
53 patients (93.2%). History of pulmonary TB was present Table 2: Etiology for pneumothorax
in 18 patients (31.6%) and smoking addiction was present Etiology n (%)
in 21 patients (36.8%). Diabetes mellitus was present in
Bacterial 8.0 (14.0)
12 patients (21.1%). Eight patients (14.0%) had hypotension Bacterial and COPD 1.0 (1.8)
at presentation, four patients (7%) were hypertensive, and Malignancy 2.0 (3.5)
rest 45 (78.9%) had normal blood pressure. Twenty‑eight TB 46.0 (80.7)
patients (49.1%) had tachycardia and tachypnea was Total 57.0 (100.0)
present in 39 patients (68.4%) of hydropneumothorax. TB: Tuberculosis, COPD: Chronic obstructive pulmonary disease

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Kasargod and Awad: Hydropneumothorax in India

24.8 days (SD ± 13.1 days). Only 22.81% patients had practice where the tube remains for longer time draining
complete improvement with ICD tube removal within 15 days. some amount of fluid due to underlying TB and most
Majority of patients (43.86%) had complete improvement of these patients had bronchopleural fistula as evident
between 15 days and 1 month. ICD was required for more by prolonged air leak in ICD. Multiple loculations and
than 30 days in 33.3% patients in whom 14 patients (73.68%) adhesions were noted in chest X‑ray also which contributes
had TB, three patients had bacterial etiology, and two patients for prolonged ICD. The duration of tube thoracostomy
had malignancy. All seven patients (12.3%) continued ICD ranged from 5 days to 6 months, with a mean duration
for more than 3 months who had TB. of 50 days in the series by Wilder et al.[9] Thoracoscopy
or other interventions were not performed due to lack of
DISCUSSION availability in our institute.

Hydropneumothorax has been common entity in this CONCLUSION

country. However, only isolated case reports have been
documented on hydropneumothorax and there has been a From our study, it could be concluded that most patients
dearth of large case studies. Majority of patients presented presented with symptoms and signs of cardiorespiratory
with symptoms of acute respiratory compromise that is distress along with cough, anorexia, and weight loss
breathlessness due to ventilation perfusion mismatch and which alerted toward diagnosis. Extensive pleural fluid
cough due to pleural involvement; however, fever and analysis and investigations including microbiological and
constitutional symptoms such as weight loss and anorexia biochemical work‑up is the cornerstone in establishing
were also commonly seen probably due to TB being the etiological diagnosis in hydropneumothorax. TB remains
major etiology. This correlated with studies done by Gupta the most common etiology for hydropneumothorax.
et al.[2] and Javaid et al.[3] where breathlessness was the ICD tube insertion remains the management along with
most common presenting symptom and present in 93% and antimicrobial chemotherapy. However, ICD is required for
98% patients, respectively. However, these were studies longer durations. As there is paucity in the literature about
on pneumothorax. The above symptoms of respiratory hydro‑pneumothorax, further research is required to aid
distress were associated with signs of tachypnea in 68% in the appropriate management of the same.
of patients and objective evidence of hypoxemia in 61%
of all patients in arterial blood gases. In our study, it was Financial support and sponsorship
noted that pleural fluid AFB smear was positive in 14%, Nil.
which correlates with a study by Heyderman et al.[4] In
our country where prevalence of TB is high, rupture of Conflicts of interest
cavity or TB focus could be the cause of pneumothorax There are no conflicts of interest.
or hydropneumothorax. Light originally developed Light’s
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280 Lung India • Vol 33 • Issue 3 • May - Jun 2016