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Your Name and Date Here RADY 403 Case Presentation Smrithi Valsaraj 23 July 2021 Focused patient history and workup • 10 year old male s/p laryngotracheal reconstruction who is now on mechanical ventilator List of imaging studies • Portable chest radiographs AP Chest Radiograph Lines and Tubes Endotracheal Tube at Lines and Tubes the level of clavicle Endotracheal Tube at Lines and Tubes the level of clavicle Endotracheal Tube at Lines and Tubes the level of clavicle Chest wall drain over the left hemithorax s/p rib harvest Endotracheal Tube at Lines and Tubes the level of clavicle Chest wall drain over the left hemithorax s/p rib harvest Endotracheal Tube at Lines and Tubes the level of clavicle Chest wall drain over the left hemithorax s/p rib harvest Feeding tube with guide wire in the distal stomach/proximal small bowel Endotracheal Tube at Lines and Tubes the level of clavicle Chest wall drain over the left hemithorax s/p rib harvest Feeding tube with guide wire in the distal stomach/proximal small bowel Endotracheal Tube at Lines and Tubes the level of clavicle Mediastinal clip at the level of ductus Chest wall drain over the left hemithorax s/p rib harvest Feeding tube with guide wire in the distal stomach/proximal small bowel Findings on the Chest Radiograph (AP View) 1. Absence of lung markings on the left side Findings on the Chest Radiograph (AP View) 1. Absence of lung markings on the left side 2. Deepening of the left costophrenic angle Findings on the Chest Radiograph (AP View) 1. Absence of lung markings on the left side 2. Deepening of the left costophrenic angle 3. Rightward shift of the mediastinum Findings on the Chest Radiograph (AP View) 1. Absence of lung markings on the left side 2. Deepening of the left costophrenic angle 3. Rightward shift of the mediastinum Diagnosis? Findings on the Chest Radiograph (AP View) 1. Absence of lung markings on the left side 2. Deepening of the left costophrenic angle 3. Rightward shift of the mediastinum Diagnosis? Tension pneumothorax on the left !! How did we treat this patient? How did we treat this patient? Small-bore Chest Tube (Pigtail Catheter) How did we treat this patient? Chest radiograph before chest tube was placed: Visible visceral pleural line Small-bore Chest Tube Absent lung markings on the left (Pigtail Catheter) Deep sulcus sign How did we treat this patient? Chest radiograph before chest tube was Chest radiograph after chest tube was placed: removed: No visceral pleural line visible Visible visceral pleural line Small-bore Chest Tube Absent lung markings on the left (Pigtail Catheter) No absent lung markings Deep sulcus sign No deep sulcus sign What is pneumothorax? • When air enters the pleural space, the negative pressure in the pleural space rises higher than the intra-alveolar pressure • Results in lung collapse Image from Free Vector What are the types of pneumothorax? • Simple: no shift of the mediastinal structures • Tension: shift of the mediastinal structures away from the side of the pneumothorax. • LIFE THREATENING CONDITION • Pt is hemodynamically unstable. Increased central venous pressure causes obstructive shock! What are the types of pneumothorax? • Simple: no shift of the mediastinal structures • Tension: shift of the mediastinal structures away from the side of the pneumothorax LIFE THREATENING CONDITION Pt is hemodynamically unstable. Increased central venous pressure causes obstructive shock! What are the image findings on a radiograph for pneumothorax? • Visceral pleural line . a must for the diagnosis • Convex curve of the visceral pleural line paralleling the contour of the chest wall Usually visceral and parietal pleura are not visible • An absence of lungWhen markings air enters the pleuralperipheral space, the visceral pleura to the visceral pleuralretracts and line becomes (most visible times) • The deep sulcus sign of an inferiorly displaced costophrenic angle on a supine chest Image from Learning Radiology What are the image findings on a radiograph for pneumothorax? • Visceral pleural line . a must for the diagnosis • Convex curve of the visceral pleural line paralleling the contour of the chest wall • An absence of lung markings peripheral to the visceral pleural line (most times) • The deep sulcus sign of an inferiorly displaced costophrenic angle on a supine chest Dotted white arrows = cyst Solid white arrow = pneumothorax Image from Learning Radiology What are the image findings on a radiograph for pneumothorax? • Visceral pleural line . a must for the diagnosis • Convex curve of the visceral pleural line paralleling the contour of the chest wall • An absence of lung markings peripheral to the visceral pleural line (most times) • The deep sulcus sign of an inferiorly displaced costophrenic angle on a supine chest Image from Learning Radiology What are the image findings on a radiograph for pneumothorax? • Visceral pleural line . a must for the diagnosis • Convex curve of the visceral pleural line paralleling the contour of the chest wall • An absence of lung markings peripheral to the visceral pleural line (most times) • The deep sulcus sign of an inferiorly displaced costophrenic angle on a Solid black arrow: deep sulcus sign with left supine chest costophrenic sulcus displaced inferiorly compared to the right What is the next step if you strongly suspect pneumothorax but not entirely sure? • Lateral decubitus view of the chest • Air is more visible against the lateral chest wall than over the apex Solid black arrows shows the visceral pleural line. Image from Pediatric Clinics of North America What are some pitfalls when diagnosing pneumothorax with radiographs? • Absence of lung markings mistaken as pneumothorax • These findings are also seen in: • Large cysts in the lungs • Pulmonary embolism (reduced perfusion causes hyperlucency of the affected region) • Hyperinflated lung from foreign body • Ensure that the visceral pleural is parallel to the curve of the chest wall Solid white arrow: pneumothorax with visceral line parallel • Skinfolds mistaken as pneumothorax to the curvature of the chest wall • Skinfold forms an edge and visceral line forms a line Image from Learning Radiology • Medial border of the scapula mistaken as pneumothorax • Trace the outlines of the scapula What are some pitfalls when diagnosing pneumothorax with radiographs? • Skin folds mistaken as pneumothorax • Skin fold forms an edge and visceral line forms a line • Medial border of the scapula mistaken as pneumothorax • Trace the outlines of the scapula Dotted white arrow: skin fold; Solid white arrow: pneumothorax Image from Learning Radiology What are some pitfalls when diagnosing pneumothorax with radiographs? • Medial border of the scapula mistaken as pneumothorax • Scapula is usually high density Solid white arrow: edge of scapula Image from Learning Radiology. Why does this matter? • None of the previously mentioned diseases other than pneumothorax would be treated with the insertion of a chest tube • Accurate diagnosis of pneumothorax can help with early appropriate intervention (chest tube placement) UNC Top Three • Visceral pleural line is necessary for a diagnosis of pneumothorax • Tension pneumothorax has mediastinal shift and is a life-threatening condition • Avoid pitfalls when diagnosing pneumothorax for efficient diagnosis of pneumothorax References • Herring W. 10 Recognizing Pneumothorax, Pneumomediastinum, Pneumopericardium, and Subcutaneous Emphysema. In: Learning Radiology: Recognizing the Basics. Philadelphia, PA: Elsevier; 2020. • Johnson NN, Toledo A, Endom EE. Pneumothorax, Pneumomediastinum, and Pulmonary Embolism. Pediatric Clinics of North America. 2010;57(6):1357-1383. doi:10.1016/j.pcl.2010.09.009 • McKnight CL, Burns B. Pneumothorax. [Updated 2020 Nov 16]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK441885/ • Pneumothorax Course by Radiology Revealed. Radiology Revealed. https://radiologyrevealed.com/course/pleural-disease/lessons/lesson-1/. Published December 14, 2020. Accessed July 21, 2021..
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