Ultrasound for Critical Care Physicians: Characteristic Findings in A Complicated Effusion

Emilio Perez Power MD, Madhav Chopra MD, Sooraj Kumar MD, Tammy Ojo MD, and James Knepler MD

Division of Pulmonary, Allergy, Critical Care and Sleep

University of Arizona College of Medicine

Tucson, AZ USA

Case Presentation

A 60-year-old man with right sided invasive Stage IIB squamous lung carcinoma, presented with a one week history of progressively worsening shortness of breath, fever, and chills. On admission, the patient was hemodynamically stable on 5L nasal cannula with an oxygen saturation at 90%. Physical exam was significant for a cachectic male in moderate respiratory distress using accessory muscles but able to speak in full sentences. His pulmonary exam was significant for severely reduced breath sound on the right along with dullness to percussion. His initial laboratory finding showed a mildly elevated WBC count 15.3 K/mm3, which was neutrophil predominant and initial chest x-ray with complete opacification of the right hemithorax. An ultrasound of the right chest was performed (Figure 1).

Figure 1. Ultrasound of the right chest, mid axillary line, coronal view.

Based on the ultrasound image shown what is the likely cause of the patient’s opacified right hemithorax?

1. Consolidation
2. Exudative pleural effusion
3. Pneumothorax
4. Transudative pleural effusion

Cite as: Power EP, Chopra M, Kumar S, Ojo T, Knepler J. Ultrasound for critical care physicians: characteristic findings in a complicated effusion. Southwest J Pulm Crit Care. 2018;17(6):150-2. doi: https://doi.org/10.13175/swjpcc122-18 PDF

April 2014 Critical Care Case of the Month: Too Much, Too Fast

Kenneth Sakata, MD

Richard A. Helmers, MD

Department of Pulmonary Medicine

Mayo Clinic Arizona

Scottsdale, AZ

History of Present Illness

A 69 year old man was admitted to the intensive care unit with shortness of breath and atrial fibrillation with a rapid ventricular response.

PMH, FH, SH

He has a history of peripheral vascular disease, end-stage renal disease and is receiving chronic hemodialysis.

Physical Examination

Afebrile. Pulse 135 and irregular. BP 105/65 mm Hg. SpO2 96% while receiving oxygen at 2L/min by nasal cannula.

HEENT: Unremarkable.

Neck: Jugular venous distention to the angle of the jaw while the head is elevated at 45 degrees.

Lungs: Decreased breath sounds at the right base.

Cardiovascular: Irregularly, irregular rhythm. 2-3+ pretibial edema.

Abdomen: no hepatosplenomegaly.

Radiography

The admission chest x-ray is shown in figure 1.

Figure 1. Admission portable chest x-ray.

Which of the following is the best interpretation of the chest x-ray given the clinical situation? (Click on the correct answer to move to the next panel)

1. Hepatomegaly elevating the right diaphragm
2. Large right pleural effusion
3. Paralyzed right diaphragm
4. Right lower lobe pneumonia
5. Right middle lobe pneumonia

Reference as: Sakata K, Helmers RA. April 2014 critical care case of the month: too much, too fast. Southwest J Pulm Crit Care. 2014;8(4):205-12. doi: http://dx.doi.org/10.13175/swjpcc031-14 PDF

July 2013 Critical Care Case of the Month: The Fortuitous Critical Care Consult

Clement U. Singarajah, M.D.

Elijah Poulos, M.D.

Phoenix VA Medical Center

Phoenix, AZ

History of Present Illness

A 70 year old male with squamous cell cancer of the hypopharynx had undergone a laser ablation and debridement as an outpatient. The ENT surgeon placed a # 6 Shiley DCT tracheostomy tube and the patient did well after the procedure. His chest x-ray after the procedure revealed right lower lobe atelectasis but was interpreted as otherwise normal (Figure 1).

Figure 1. Portable chest-ray after laser ablation and tracheostomy placement.

Due to aspiration and feeding issues, he was scheduled 2 weeks later for percutaneous endoscopic gastrostomy (PEG) tube placement as an outpatient. However, the gastroenterologist cancelled the procedure due to copious secretions from tracheal site, described as purulent and some mild respiratory distress. He was admitted to the general medicine service at the Phoenix VA Medical Center.  

Physical Examination

On examination of the patient, was non-toxic, talking, and alert. Vital signs were within normal limits, but with he had mild dyspnea and moderately thick secretions. A tracheostomy tube was in place in the neck. There were no areas of tenderness over his neck. The remainder of his physical examination was normal.

Radiography

A chest x-ray was performed (Figure 2). 

  

Figure 2. Admission PA (Panel A) and lateral (Panel B) chest x-ray.

Which of the follow are abnormal findings of the chest radiography?

1. The distal tip of the tracheostomy tube is not aligned with the tracheal stripe
2. There is a right pleural effusion
3. There is an air-fluid level in the right lower lung
4. There is right lower lobe atelectasis and/or consolidation
5. All of the above 

Reference as: Singarajah CU, Poulos E. July 2013 critical care case of the month: the fortuitous critical care consult. Southwest J Pulm Crit Care. 2013;7(1):10-16. doi: http://dx.doi.org/10.13175/swpcc075-13 PDF