Lines/Tubes/Devices – Page 2

Case 21

Chronic & ILD, Lines/Tubes/Devices / Age >61, Atelectasis (Lobar), COPD, Emphysema, Endobronchial Valve, Eventration, Hiatal Hernia, Luftsichel Sign

This radiograph demonstrates several findings:

First, this is a COPD patient with very few lung markings seen in the right upper lobe due to severe emphysema.

Second, this patient has undergone endobronchial valve placement leading to complete lobar atelectasis in the left upper lobe. The valves themselves are visible projecting over the left hilum. There is expected volume loss in the left hemithorax, with increased opacity in the left lung due to superimposition of the collapsed left upper lobe and aerated left lower lobe.

Third, a named sign is demonstrated: The luftsichel sign (German for “air crescent”), which is seen as a crescentic lucency in the paramedian left upper lung and indicates left upper lobe collapse. The lucency is created by a portion of the aerated left lower lobe that insinuates itself between the mediastinal wall and the collapsed upper lobe.

Fourth, there is an incidentally noted small hiatal hernia seen as a rounded opacity projecting just to the left of midline at the level of the diaphragm. Diaphragmatic eventration is also noted.

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Case 20

Chronic & ILD, Lines/Tubes/Devices / Age 31-60, Bronchiectasis, Cystic Fibrosis, Port

This radiograph shows severe cylindrical bronchiectasis, also referred to as tubular bronchiectasis, in an adult patient with cystic fibrosis. This patient has symmetric upper lobe disease which is a common pattern in this condition, though other distributions are also seen.

An implanted right internal jugular port is also seen with the tip terminating in the superior vena cava, presumably for administration of antibiotics due to recurrent infections in this patient population. The port reservoir is placed in the inferior chest wall in this patient, which is an unusual location.

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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, Midline Sternotomy, Portable, Sternotomy, Watchman

This radiograph shows a malpositioned enteric tube which is looped in the oropharynx/hypopharynx and projects over the lower neck. There are a number of incidental findings including an appropriately positioned endotracheal tube, a loop recorder projecting over the left hemithorax, sternotomy wires with a prosthetic aortic valve, and a Watchman™ left atrial appendage occlusion device which is difficult to see on the default window and level. Linear subsegmental atelectasis is seen 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 shows 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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Case 14

Lines/Tubes/Devices / Age >61, Azygous Vein, Malposition, Peripherally Inserted Central Catheter, PICC, Portable

This radiograph shows a malpositioned left upper extremity PICC (peripherally inserted central catheter). The catheter takes an unexpected superior turn after entering the superior vena cava and is beginning to course medially, consistent with placement in the azygous vein. A lateral radiograph would provide further confirmation if available, but in this case the location can be confidently deduced with just an AP view. The study is otherwise unremarkable.

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Case 13

Lines/Tubes/Devices / Age >61, Left Atrial Appendage Closure Device, Portable, Watchman

This radiograph demonstrates an endovascular left atrial appendage closure device, in this case a Watchman™ device, projecting over the left heart. This prevents clot formation in the appendage, a particularly susceptible location in patients with atrial fibrillation due to stasis. Clots from the heart could embolize to the brain and cause a stroke. The exam is otherwise unremarkable.

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Case 10

Lines/Tubes/Devices / Age >61, Nerve Stimulator, Vagal Nerve Stimulator

This radiograph shows a vagal nerve stimulator. The generator projects over the left hemithorax and a single thin lead tracks to the left base of neck. At first glance this may be mistaken for a pacemaker, but the course and caliber of the lead indicate that this is a different device. The exam is otherwise unremarkable.

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