Amphoric breath

Specialty: Respiratory.

• bottle puff
• auscultatory amphoric murmur

Why it occurs

• Large spontaneous pneumothorax with persistent bronchopleural communication (the passage of air through the fistula into a large pleural cavity generates a metallic resonance or "blowing on the neck of an empty bottle" noise during auscultation)
• Giant tuberculous cavern empty with rigid walls and connected to a patent bronchus
• Large lung abscess completely evacuated of purulent material with a thin and elastic wall
• Infected giant thin-walled lung cyst in the drainage phase
• Large diaphragmatic hernia with passage of intestinal loops with gas into the thoracic cavity.

Initial workup

Urgent digital chest x-ray; Computed tomography (CT) of the chest with multiplanar reconstruction (to precisely delineate the location and size of the cavity or the presence of pleural free air); Diagnostic thoracentesis or placement of guided pleural drainage if appropriate.

Standard management

• Management is fundamentally interventional or surgical — chest tube placement or rescue video thoracoscopy
• Codeine — 15-30 mg orally every 8 hours to control irritative cough that perpetuates the passage of air through the fistula
• Paracetamol (500-1000 mg orally to control associated pain).