Chest Xray Quiz 6

Question

A 61 year old male returns to ICU following 3 vessel coronary artery bypass grafting.  He remains hypoxic on 70% oxygen.

A CXR is performed.  Describe the features.

DITF151xr.jpg

ANSWER

The Xray shows a right sided pneumothorax, the only evidence of which is the deep sulcus sign.  This is despite the presence of a right intercostal catheter.

There are also bilateral infiltrates suggesting pulmonary oedema, which may be cardiac or due to bypass lung dysfunction.  Additionally, there may be widening of the mediastinum consistent with possible haemorrhage, though the film is partly rotated, making interpretation difficult.  

Blurring of the left diaphragm is consistent with collapse and effusion.

The endotracheal tube is appropriately placed.  A nasogastric tube, left intercostal catheter and right subclavian central line are also present.

 

Tutorial :

This film is a great example of the "Deep Sulcus Sign" [1], where the costophrenic angle seems to disappear below the level of the film. 

When patients are lying supine, the air in a pneumothorax rises, sitting in front of the lung and anterior diaphragm, resulting in this classic appearance.  Notice the outline of the liver also appears particularly sharp (this would be the case with the spleen if the pneumothorax was on the left).

The deep sulcus sign may be the only sign of a pneumothorax in a supine patient.  The classic sign of a pleural edge, as seen in erect patients, may not be visible.

 

Reference:

1. Sabbar, Saweera; Nilles, Eric James (2012). "Deep Sulcus Sign"New England Journal of Medicine366: 552

 

 

Past QUizzes

Chest Xrays

Quiz 1 - Chest trauma

Quiz 2 - Fall from a bike

Quiz 3 - Hypoxia after intubation

Quiz 4 - Anatomical variant

Quiz 5 - Vomiting, fever and shortness of breath

Abdominal Xrays

Quiz 1 - Fever and distension

CT Brain

Quiz 1 - Altered conscious state

CT Chest

Quiz 1 - Acute Chest pain

Biochemistry

Quiz 1 - Increasing weakness

 

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