ICU/Surgery – ChestDB.com

Case 36

ICU/Surgery, Infectious/Inflammatory, Lines/Tubes/Devices / Age <30, Central Venous Catheter, CVC, Empyema, Endotracheal Tube, Enteric Tube, Nodule (Cavitary), Pleural Effusion, Portable, Septic Embolism

This radiograph demonstrates typical findings of septic emboli. There are multiple bilateral nodules, many with cavitation. Metastatic disease would be within the differential for this finding, though in practice the clinical history is typically quite useful to distinguish between these two entities; In this case, the patient is young with a history of drug abuse (suggesting endocarditis as a source) and presents with sepsis. In addition, this patient has medium bilateral pleural effusions. In the setting of septic emboli this is concerning for empyema. CT is usually confirmatory.

Support devices include a central venous catheter in the right internal jugular vein, an endotracheal tube in the mid trachea, and an enteric tube entering the stomach and terminating inferiorly beyond the border of the study.

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Case 30

ICU/Surgery, Lines/Tubes/Devices / Age 31-60, IABP, Intra-Aortic Balloon Pump, Malposition, Peripherally Inserted Central Catheter, PICC, Portable, Pulmonary Edema, Swan-Ganz Catheter

This radiograph demonstrates a misplaced right IJ Swan-Ganz catheter. Not only is the catheter too deep in the right pulmonary artery, the course of the catheter extends all the way into the abdominal IVC before looping back into the right atrium and crossing the tricuspid valve. Other lines and devices include a left upper extremity PICC with the tip terminating in the SVC, and an intra-aortic balloon pump (IABP) with the distal marker appropriately located just inferior to the aortic knob.

The cardiac silhouette is prominent and there is mild interstitial edema, which makes sense in the context of an IABP indicating that the patient is in heart failure.

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Case 29

ICU/Surgery / Age <30, Pleurodesis, Pneumothorax, Pneumothorax, Subpulmonic, Wedge Resection

This radiograph demonstrates a left subpulmonic pneumothorax in the upright position. Typically pleural air would be expected to collect apically (anti-dependently) in this position. However, this patient has a history of wedge resection evident by the staple line seen in the apical left upper lobe. This was complicated by recurrent pneumothorax for which the patient underwent pleurodesis. The resultant pleural scarring is preventing the pleural air from rising, giving this appearance.

Other than the presence of EKG leads, the remainder of the exam is unremarkable.

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Case 27

ICU/Surgery / Age >61, Atelectasis (Compressive/Passive), Pneumothorax, Portable

This radiograph demonstrates a right pneumothorax without evidence of tension physiology. This case was iatrogenic due to an inadvertently damaged diaphragm during an abdominal surgery. Linear subsegmental atelectasis is also noted projecting over the left heart.

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Case 26

ICU/Surgery, Lines/Tubes/Devices / Age 31-60, Portable, Pulmonary Edema, Tracheostomy Mask, Tracheostomy Tube

This radiograph demonstrates unilateral pulmonary edema in the right lung. The differential for this appearance is limited and includes severe mitral regurgitation (such as a papillary muscle rupture), unilateral pulmonary venous obstruction, and lymphangitic spread of malignancy mimicking edema. Those etiologies rarely present with as much uniformity as this case, which was due to prolonged decubitus positioning that rapidly resolved on subsequent radiographs.

Incidentally noted is the presence of a tracheostomy tube with an overlying tracheostomy mask supplying oxygen to the patient.

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Case 19

ICU/Surgery, Lines/Tubes/Devices / Age <30, Enteric Tube, NAVA, Neonatal Respiratory Distress Syndrome, Neurally Adjusted Ventilatory Assist, PIE, Portable, Premature Neonate, Pulmonary Interstitial Emphysema, RDS (Neonatal), Surfactant Deficiency Disorder

This radiograph is of a premature infant in the first week of life. The right lung demonstrates diffuse microatelectasis typical of Neonatal Respiratory Distress Syndrome (RDS), also known as Surfactant Deficiency Disorder, caused by insufficient surfactant production in the setting of prematurity (typically <35 weeks gestation). The left lung is hyperinflated relative to the right lung, with diffuse linear lucencies radiating from the hilum. This appearance is typical for Pulmonary Interstitial Emphysema (PIE), a condition secondary to barotrauma from ventilation seen in premature infants in the first weeks of life. An NG/OG tube terminates in the body of the stomach. A second tube, thicker and denser than the NG/OG, with multiple rounded lucencies along the distal aspect is also seen. This is a NAVA tube (Neurally Adjusted Ventilatory Assist), which detects electrical activity of the diaphragm to improve synchrony with the ventilator.

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Case 16

ICU/Surgery, Lines/Tubes/Devices / Age >61, Aortic Valve Replacement, Atelectasis (Compressive/Passive), Endotracheal Tube, Enteric Tube, Left Atrial Appendage Closure Device, Loop Recorder, Malposition, Portable, Watchman

This radiograph demonstrates a malpositioned enteric tube which is looped in the oropharynx/hypopharynx. There are a number of incidental findings including an appropriately positioned endotracheal tube, a loop recorder projecting over the left chest wall, postsurgical changes of sternotomy with a prosthetic aortic valve, and a Watchman left atrial appendage occlusion device which is difficult to see on the default window and level. The lung volumes are low overall with some linear subsegmental atelectasis in the left lung base.

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Case 15

ICU/Surgery, Lines/Tubes/Devices / Age <30, Atelectasis (Lung), Bronchial Intubation, Endotracheal Tube, Enteric Tube, Malposition, Portable

This radiograph demonstrates a malpositioned endotracheal tube in the right main bronchus with resultant atelectasis of the entire left lung. The heart is shifted toward the left side. This supports the diagnosis of atelectasis over a large pleural effusion, which would look similar except that the heart would shift to the contralateral side. An enteric tube is also seen entering the stomach and terminating inferiorly beyond the border of the study. EKG wires, bra clasps, and bra underwires are seen externally.

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