Traumatic Rupture of Diaphragm and Chest Wall Secondary to COPD Exacerbation

A 67-year-old woman with history of COPD and tobacco abuse disorder presented to the ED for sudden onset of left upper quadrant pain after a forceful productive cough with yellow sputum that she developed two days prior with nausea and shortness of breath with deep breathing and was admitted to surgery for evaluation. The patient was moderately dyspneic, with diminished breath sounds bilaterally and tenderness to palpation in the left upper quadrant. On physical examination on admission, there was tenderness to palpation and ecchymosis noted on her left abdominal and chest wall. Chest radiography showed a suspected defect along the lateral aspect of the left hemidiaphragm, which was suspicious for diaphragmatic rupture that extended into the soft tissues of the left chest wall (Fig. 1). A subsequent CT scan showed a lateral left diaphragmatic rupture with herniation of the stomach through the defect and through an additional left chest wall defect between the seventh and eighth ribs (Fig. 2). Surgery consultation was requested for repair of the herniation of her stomach up through her chest and exiting her chest wall. Given the findings on the patient’s CT scan, the patient was taken to the operating room for left thoracotomy and repair of the traumatic diaphragmatic herniation. The chest wall hernia was repaired, and implantation of FlexHD (Johnson & Johnson, Cincinnati, OH) for buttressing of the diaphragmatic hernia repair was performed. A defect could easily be palpated in between the ribs, and an incision was made over this level. Dissection was carried down the subcutaneous tissue. On dividing the latissimus muscle, there was an obvious pocket within the subcutaneous tissues at this level. There was an obvious chest wall hernia that was identified as well. The latissimus was divided. The chest wall was then opened, and the chest cavity was easily explored. There was no obvious injury to the lung. The diaphragm was torn from its anterior portion along the costal margin to the lateral portion. The stomach as well as the omentum and the spleen were herniated up into the chest and through the chest wall itself. These were reduced back into an intraabdominal position. Elements of the abdomen that could be explored through the diaphragmatic defect revealed no other abnormalities. We then repaired the diaphragm buttressing the repair with strips of FlexHD with a 4 · 7 cm segment divided in half. Horizontal mattress Polydioxanone Sutures were used to complete this. A postoperative CT scan of the chest showed stable skin staples over the left hemithorax and stable right Internal Jugular Central Venous Catheter. Figure 3 shows stable left-sided pleural effusion with adjacent atelectasis versus infiltrate. There has been one case that described the traumatic diaphragmatic rupture with pulmonary herniation into the abdominal cavity;1 however, there have been no cases of diaphragmatic rupture due to a COPD exacerbation where herniation of abdominal contents occurred via the diaphragm. There are many factors that can cause diaphragmatic weakening in COPD patients.2 Inspiratory muscle weakness was shown to be related to dyspnea, and weakness of the diaphragm can be caused by hyperinflation-induced diaphragmatic shortening.3 There have been several studies showing differences in metabolic and structural changes in patients with and without COPD in terms of their diaphragm.3 COPD can significantly reduce the ventilatory capacity of the diaphragm because it has been found that patients with COPD have lower transdiaphragmatic pressures compared with healthy subjects without COPD.4 This lowered pressure is due to diaphragmatic shortening because of the hyperinflation of the lungs.5 Although blunt injury of the diaphragm is very common and usually secondary to severe injury, other coexisting injuries can mask its initial presentation. Diaphragmatic rupture is usually due to a sudden increase in intra-abdominal pressure, resulting in tear of the diaphragm; however, our patient presented without Address correspondence and reprint requests to Kevin Londe, O.M.S.-IV, Department of Surgery, Edward Via College of Osteopathic Medicine, 5672 Mango Lane, Hilliard, OH 43026. E-mail: klonde21@gmail.com.