Portable – ChestDB.com

Case 49

Lines/Tubes/Devices / Age >61, Phrenic Nerve Stimulator, Portable, Remedē Device, Sternotomy

This radiograph demonstrates a transvenous phrenic nerve stimulator. The lead travels from the generator under the skin into the right subclavian vein, right brachiocephalic vein, left brachicephalic vein, and terminates in the left pericardiophrenic vein, which drains the superior diaphragm and pericardium. This allows the device to stimulate the left phrenic nerve, which courses alongside the left percardiophrenic vein (and artery). This device is approved for the treatment of central sleep apnea under the brand name Remedē.

This patient also has sternal wires from a prior, unrelated open sternotomy.

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Case 43

Emergency & Trauma, Mediastinum / Acute Aortic Syndrome, Age <30, Portable, Traumatic Aortic Injury, Widened Mediastinum, Widened Vascular Pedicle

This previously healthy young patient presented to the emergency department after a motor vehicle collision. There is marked widening of the vascular pedicle and loss of the normal contour of the aortic arch. This finding is consistent with acute traumatic aortic injury. The lungs are clear and there are no radiographically evident fractures.

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Case 39

Emergency & Trauma, ICU/Surgery, Mediastinum / Age 31-60, Chest Tube, Clamshell Sternotomy, Lung Transplant, Pneumopericardium, Pneumothorax, Portable

This case demonstrates both a right pneumothorax and pneumopericardium. In this case, the cause was iatrogenic during a bronchoscopy. A right chest tube is in place, though a small apical pneumothorax is still visible.

Clamshell sternotomy closure hardware is also seen, indicating that this is a lung transplant patient.

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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 34

Emergency & Trauma / Age <30, Atelectasis (Compressive/Passive), Central Venous Catheter, CVC, Kerley B Lines, Pleural Effusion, Portable, Pulmonary Edema

This radiograph demonstrates typical findings of pulmonary edema. The vessels are hazy with indistinct margins. Kerley B lines are seen peripherally. There are bilateral layering pleural effusions creating a gradient of opacification extending from the bases. Bibasilar opacities are silhouetting the diaphragm and the right heart border, representing a combination of pleural effusions and associated atelectasis.

A dual-lumen central venous catheter is also in place.

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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 28

Chronic & ILD / Age 31-60, Albers-Schönberg Disease, Fracture, Marble Bone Disease, Osteopetrosis, Portable

This radiograph demonstrates osteopetrosis (also known as marble bone disease and Albers-Schönberg disease), a disorder of osteoclasts which leads to unopposed osteoblastic activity. The bones are diffusely thickened and sclerotic. Multiple rib fractures are noted, highlighting the fragility of the disorganized bone.

The lungs and mediastinum are 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 23

Emergency & Trauma, Infectious/Inflammatory / Age <30, Asthma, Peribronchial Cuffing, Portable, Reactive Airway Disease

This is a radiograph demonstrates peribronchial cuffing, which is increased density around the bronchioles when viewed end-on. This may represent thickening of the wall itself or fluid around the wall due to lymphatic congestion. The finding is nonspecific and can be seen in pulmonary edema, infectious and inflammatory bronchiolitis, and reactive airway disease. This particular case was a toddler with a previous diagnosis of asthma who presented to the emergency department with an acute asthma exacerbation.

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