Breathlessness and plethora

A 61 year old man presented to the emergency department with sudden onset breathlessness associated with cough productive of purulent sputum. He had been diagnosed with squamous cell carcinoma of the bronchus one month earlier. His staging was T4N2M1. Two weeks earlier he had developed a pathological clavicular fracture and was due to start radiotherapy. On admission he had no haemoptysis or chest pain. However, his blood pressure was 80/40 mm Hg, pulse rate was 140-160 beats/min, and respiratory rate was 18 breaths/min.

On examination he had swelling and plethora of the face and neck. Crepitations were heard in the right mid zone of his lung field. Heart sounds were normal. His jugular venous pressure was non-pulsatile and was raised to the level of his ear lobes. His breathlessness and facial swelling were exacerbated by lying flat and coughing.

Electrocardiography showed sinus tachycardia. Arterial blood gas on room air showed a partial pressure of oxygen of 7 kPa, and a partial pressure of carbon dioxide of 4.2 kPa.

Chest radiography was performed (fig 1⇓).

An echocardiogram showed no pericardial effusion but moderate left ventricular function and no right ventricular dysfunction. Figure 2⇓ is a picture of the patient at admission.