Answer - CXR Quiz 3
A 32 year old male is found near a nightclub with an initial GCS of 5.
He is intubated and taken to hospital. Low sats and "grotty" looking sputum.
- What does the X-ray show?
- List 3 possible causes
- What management would you implement?
The patient is intubated, but the tube is probably not quite deep enough and should be advanced.
There are signs of right upper lobe collapse. Loss of airspace is noted - there is crowding of the ribs on the right compared with the left , there is superior displacement of the horizontal fissure, the right hemidiaphragm is elevated and there is deviation of the trachea to the right.
Notice how the opacity looks a bit like the sail of a yacht - this is the classical "Sail Sign" of right upper lobe collapse.
Causes of airway obstruction are generally broken into 3 key groups :
- Luminal obstruction (vomitus, broken teeth, sputum plug)
- Mural pathologies such as a bronchogenic tumour
- Extrinsic compression (eg tumour, lymph node)
A common cause of right upper lobe collapse is right main bronchus intubation. When the endotracheal tube is inserted to far in adults it often goes down the RMB. Because the right upper lobe bronchus originates very early in the course of the RMB, it is easily obstructed by the ETT.
In this particular case, the tube was initially sited in the right main bronchus, causing RUL collapse, but was then withdrawn a little too far. An alternative is a dislodged tooth, or blood / secretions obstructing the airway.
Management involves bronchoscopy to remove obstructing objects and increasing PEEP and chest physiotherapy to encourage re-inflation.