Portable

Case 23

Emergency & Trauma, Infectious/Inflammatory / , , , ,

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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Case 19

ICU/Surgery, Lines/Tubes/Devices / , , , , , , , , , ,

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 18

Emergency & Trauma, Infectious/Inflammatory / , , , , , , , ,

This radiograph shows hazy consolidation in the right lung base, with more subtle left lower lobe consolidation projecting over the heart. There is a displaced left mid-clavicular fracture. Lines and tubes include an endotracheal tube, an enteric tube, and an esophageal temperature probe which are all appropriately positioned. The distribution is typical for aspiration, with or without infection. Contusion is also a consideration in a trauma patient. In this case, the EMS report included witnessed aspiration which makes it the most likely etiology.

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Case 16

ICU/Surgery, Lines/Tubes/Devices / , , , , , , , , , , ,

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 / , , , , , ,

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 / , , , , ,

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 / , , ,

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 9

Malignancy / , , , , ,

This radiograph demonstrates a paramedian mass in the right lung apex, colloquially referred to as a Pancoast tumor. The lateral margin of the mass is visible above the clavicle, which localizes the mass to the posterior mediastinum (negative cervicothoracic sign). The patient is slightly rotated to the left. Multiple healed bilateral rib fractures are present. A nipple ring projects over the left hemithorax.

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Case 1

Normal/Variants & Congenital / , , , , ,

This radiograph shows a skin fold projecting over the right hemithorax that could be easily mistaken for a pneumothorax. Skin folds are frequently identified as such because they cross anatomic boundaries such as the mediastinum or lateral chest wall. The lack of clinical symptoms such as shortness of breath can be reassuring, but not definitive. In this case, the most definitive imaging finding that distinguishes the skin fold from a pneumothorax is the minor fissure which remains intact across the pseudo-pleural separation. A repeat chest radiograph was obtained with instruction to the technologist to smooth the patient’s skin and clothing prior to acquisition and the finding was no longer present. A left lateral decubitus radiograph would have also been an appropriate next step.

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