August 2023 Imaging Case of the Month: Chew Your Food Carefully

Michael B Gotway MD¹ and Yasmeen M Butt MD²

¹Departments of Radiology and ²Laboratory Medicine, Division of Anatomic Pathology

Mayo Clinic-Arizona

Scottsdale, Arizona USA

History of Present Illness

A 50-year-old woman presents with a history of chronic dyspnea and cough, becoming particularly problematic following COVID-19 infection 4 months prior to presentation. While she did experience significant periodic oxygen desaturations during her COVID-19 infection, she was not hospitalized for this illness. The patient also reported wheezing in the previous few weeks. 

Past Medical History, Family History and Social History

The patient’s past medical history was also notable for gastroesophageal reflux disease as well as both Coombs positive and iron deficiency anemia. She reports a history of asthma, well controlled with inhaler use.

The patient’s past surgical history included adenoidectomy, cholecystectomy, and gastric laparoscopic band placement.

Her medications included prednisone (20 mg daily), dextroamphetamine-amphetamine, furosemide, omeprazole, fluoxetine, zolpidem (Ambien), daily Bactrim, occasional Loratadine (Claritin). She also utilized an albuterol inhaler and Fluticasone-based (both Flonase and Breo Ellipta) inhalers.

The patient is a former smoker, ½ pack-per day for 26 years, having quit 11 years prior to presentation. She also reported a history of vaping (agent inhaled unclear) for 8 years, quitting 3 years earlier. She has no known allergies. She drinks alcohol socially and denied illicit drug use.

Physical Examination

The patient’s physical examination showed her temperature to be 99°F with normal pulse and respiratory rate but her blood pressure elevated at 160/90 mmHg. She was obese (263 lbs., BMI= 41). Bilateral basal rales were noted at her examination, but no other abnormal physical examination findings were detected.

Laboratory Evaluation

The patient’s room air pulse oximetry was 85%. A complete blood count showed an upper normal white blood cell count at 1.9 x10⁹/L (normal, 4.5 – 11 x10⁹/L). Her hemoglobin and hematocrit values were 10.7 gm/dL (normal, 12 – 16 gm/dL) and 37.1% (normal, 36 – 46%). The patient’s serum chemistries and liver function studies were entirely normal. The patient had an elevated anti-nuclear antibody titer at 1:320. An echocardiogram noted diastolic dysfunction but normal left ventricular contractility.

Frontal chest radiography (Figure 1) was performed.

Figure 1. Frontal chest radiography.

Which of the following statements regarding this chest radiograph is accurate? (Click on the correct answer to be directed to the second of 11 pages)

1. Frontal chest radiography shows normal findings
2. Frontal chest radiography shows marked cardiomegaly
3. Frontal chest radiography shows mediastinal lymphadenopathy
4. Frontal chest radiography shows pleural effusion
5. Frontal chest radiography shows multifocal peribronchial consolidation

Cite as: Gotway MB, Butt YM. August 2023 Imaging Case of the Month: Chew Your Food Carefully. Southwest J Pulm Crit Care Sleep. 2023;27(2):15-22. doi: https://doi.org/10.13175/swjpccs034-23 PDF

Medical Image of the Month: An Unexpected Cause of Chronic Cough

Figure 1. Axial image from a contrast-enhanced CT demonstrates a hollow, calcified structure in the bronchus intermedius with thickening suggesting inflammation in the surrounding bronchial wall (arrow).

 

Figure 2. Photograph of chicken bone fragment retrieved from bronchus intermedius during flexible bronchoscopy (A).  In retrospect, this fragment of bone is visible on the topogram from the chest CT (B) and is circled. Note the prominent notch that is visible on CT and on the actual bone fragment (arrowheads).

Sometimes it is as simple as it looks!  A previously healthy nonsmoking 40 years old man presented with a 7-month history of dry cough which was misdiagnosed as asthma. He had persistent cough despite appropriate asthma treatment including empiric PPIs. This patient had undergone extensive lab work up and evaluation; from negative viral and fungal panel, repeated pulmonary function tests which were within normal limits, chest x-rays, and CT scans which had shown small local calcification in the bronchus intermedius with significant thickening of the surrounding bronchial wall (Figure 1). The decision was made to proceed with flexible bronchoscopy, which yielded a chicken bone fragment with surrounding granulation tissue as shown in Figure 2A. In retrospect the bone is visible within the  bronchus intermedius on the topogram from the CT scan, see Figure 2B.

Foreign body aspiration in adults reported in low rates (0.66 per 100 000) (1). Despite being uncommon, neurological disorders, alcohol abuse, advanced age and altered level of consciousness all found to be the main underlying cause of foreign body aspiration in adults (2). Still, 10% of adult patients with foreign body aspiration have no known risk factors (3). Usually, diagnosis of foreign body aspiration in adults is straightforward only if the patient’s history involves aspiration or choking event. But, if the initial event goes unnoticed, the clinical picture maybe similar to obstructive lung diseases such as COPD or asthma.

Yazan Khair ¹, Hussam Al-Jawaldeh², Ayah AL Mufleh³ , Maxim Abu Joudeh⁴, Emad Hammode⁵  

¹Pulmonary department, Royal Medical Services (RMS), Amman, Jordan

²Internal Medicine Resident, Canyon Vista Medical Center, Sierra Vista, AZ USA                

³Internal Medicine transitional program, King Hussein Cancer Center, Amman, Jordan

⁴Internal Medicine Resident, Canyon Vista Medical Center, Sierra Vista, AZ USA

⁵Program Director of Canyon Vista Medical Center Internal Medicine program, Sierra Vista, AZ USA

References

1. Lund, ME. Foreign body removal in: Ernst A, Herth, FJF eds. Principles and Practice of Interventional Pulmonolgy. New York, NY: Springer; 2013:477-488.
2. Singh A, Kaur M. Recurrent pneumonitis due to tracheobronchial foreign body in an adult. JIACM, 2007:8:242-44.
3. Mise K, Jurcev Savicevic A, Pavlov N, Jankovic S. Removal of tracheobronchial foreign bodies in adults using flexible bronchoscopy: experience 1995-2006. Surg Endosc. 2009 Jun;23(6):1360-4. [CrossRef] [PubMed]

Cite as: Khair Y, Al-Jawaldeh H, Mufleh A, Joudeh M, Hammode E. Medical Image of the Month: An Unexpected Cause of Chronic Cough. Southwest J Pulm, Crit Care & Sleep. 2022;25(2):23-24. doi: https://doi.org/10.13175/swjpccs032-22 PDF 

June 2022 Medical Image of the Month: A Hard Image to Swallow

Alessandra Carrillo, DO

Robert Ondracek, DO

Shil Punatar, DO

Andrew Ondracek, DO

Ravi Sundaram, DO

Department of Critical Care Medicine

Franciscan Health

Olympia Fields, Illinois USA

Figure 1. Portable chest x-ray demonstrating marked dilatation of the esophagus with food impaction and bilateral aspiration of food particles. There is also a small left pleural effusion.

Figure 2. Coronal view CT-chest/abdomen/pelvis demonstrating marked dilatation of the esophagus with food impaction seen and food particles seen in his lungs bilaterally.

Introduction

Esophageal food impactions are common occurrences in gastroenterology, however, under 20% of cases require intervention (1)  .The clinical condition of the esophagus and the consistency of food being swallowed contribute to the development of food bolus impactions, with patients having underlying esophageal pathology in most cases (2). Unfortunately, radiographic evidence is often difficult to obtain as food is radiolucent and poorly visualized on radiograph. Here, we demonstrate the risk associated with severe food impaction.

Case Presentation

An 86-year-old man with a past medical history of achalasia with laparoscopic Heller myotomy complicated by distal esophageal perforation, was admitted after presenting with complaints of chest pain and inability to tolerate a solid diet. Additionally, he suffered a 90-pound weight loss over 1 year. He was seen by speech therapy and provided with a dysphagia appropriate diet. Eight days into the patient stay, the family presented to the patient's bedside to assist in 1-to-1 feeding of the patient per their request. One hour following the completion of the patient’s feeding, a CODE BLUE was called.  The patient was unresponsive and without a pulse. PEA protocol was initiated and return of spontaneous circulation was achieved. Post intubation chest x-ray demonstrated a markedly dilated esophagus (Figures 1). Thereafter, CT chest was ordered demonstrating markedly dilated appearance of the patient’s esophagus with internal food material without as a large obstructing lesion (Figure 2). This was deemed to be the cause of the patient's cardiac arrest with concomitant aspiration. Overall, the dilatation significantly progressed from previous imaging. The patient was made NPO, transitioned to total parenteral nutrition and plans were made for a follow-up disimpaction via esophagogastroduodenoscopy (EGD). Ultimately, the patient was too unstable to pursue EGD and expired 9 days after his initial arrest.

Discussion

Through literature review, a majority of cases of food bolus impaction are self-limited. In most cases described, boluses pass on their own or with the assistance of an EGD. In most cases, underlying esophageal or motility dysfunction is known. With few case reports, food disimpaction has been assisted with cola products or nifedipine (3,4). Though trivially regarded, our case demonstrates that food bolus revel against more gruesome esophageal pathology in both presentation, prompt intervention, and adverse on outcomes.

Conclusions

We illustrate a common presentation to gastroenterologists and physicians of a food bolus impaction. Though, due to the profound radiographic presentation and severe morbidity of our clinical scenario, we hope to bring attention to the need for rapid evaluation, treatment, and consideration of adverse outcomes in patients presenting with food boluses as well as the severity and life-threatening outcomes that may preside with the previously trivially described pathology.

References

1. Yao CC, Wu IT, Lu LS, Lin SC, Liang CM, Kuo YH, Yang SC, Wu CK, Wang HM, Kuo CH, Chiou SS, Wu KL, Chiu YC, Chuah SK, Tai WC. Endoscopic Management of Foreign Bodies in the Upper Gastrointestinal Tract of Adults. Biomed Res Int. 2015;2015:658602. [CrossRef] [PubMed]
2. Sperry SL, Crockett SD, Miller CB, Shaheen NJ, Dellon ES. Esophageal foreign-body impactions: epidemiology, time trends, and the impact of the increasing prevalence of eosinophilic esophagitis. Gastrointest Endosc. 2011 Nov;74(5):985-91. [CrossRef] [PubMed]
3. Gelfond M, Rozen P, Gilat T. Isosorbide dinitrate and nifedipine treatment of achalasia: a clinical, manometric and radionuclide evaluation. Gastroenterology. 1982 Nov;83(5):963-9. [PubMed]
4. Karanjia ND, Rees M. The use of Coca-Cola in the management of bolus obstruction in benign oesophageal stricture. Ann R Coll Surg Engl. 1993 Mar;75(2):94-5. [PubMed]

Cite as: Carrillo A, Ondracek R, Punatar S, Ondracek A, Sundaram R. June 2022 Medical Image of the Month: A Hard Image to Swallow. Southwest J Pulm Crit Care Sleep. 2022;24(6):93-95. doi: https://doi.org/10.13175/swjpccs022-22 PDF 

Medical Image of the Month and Brief Review: Aspiration Pneumonia in an Intubated Patient with COVID-19

 

Figure 1. Severe aspiration changes on CT. Bronchial wall thickening (white arrow) could barely be perceived elsewhere given the dense layering secretions (black arrows) in bilateral mainstem bronchi and filling the dependent segmental bronchi. Atelectatic collapse (black arrowhead) can be seen distal to the obstructed bronchi. Rounded consolidation (white arrowhead) as seen later in the course of SARS2 COVID-19.

A woman in her 60’s likely acquired COVID-19 through community transmission. When she developed respiratory distress, she came to the emergency department, was found to have abnormalities on chest x-ray and was intubated, testing positive on COVID-19 PCR. She developed worsening hypoxia over the course of one night after a fairly stable ICU course. CT was obtained and demonstrated severe aspiration changes including bronchial filling and collapse of the dependent lower lobes. Increased attention to suctioning helped with the desaturations, and she eventually recovered and was extubated. This case serves as a reminder to ensure adequate suctioning while patients are intubated to prevent aspiration, obstruction and related ventilator-associated pneumonia.

Discussion

Aspiration is a relatively common event which typically resolves with no clinical sequelae. In fact, recent studies have estimated that up to 50% of healthy adults aspirate while in their sleep (1). Pulmonary symptoms of aspiration generally only occur when there is compromise to the usual defenses that protect the lower airways (cough reflex, glottis closure, etc.) and when an inoculum is introduced which has a direct toxic effect on the lower airways, resulting in inflammation. Common predisposing conditions which can lead to aspiration include reduced consciousness (commonly seen in patients with alcohol abuse or IV drug use), dysphagia from neurologic deficits, disorders of the upper GI tract, or mechanical disruption of glottis closure due to endotracheal intubation, bronchoscopy, endoscopy, or NG feeding (2,3). Endotracheal intubation is a key risk factor in ventilator associated pneumonia (4). This brief review will focus on ventilator-associated pneumonia.

Overview and epidemiology: Ventilator-associated pneumonia is defined as new onset pneumonia at least 48 hours following intubation. Despite being frequently thought of as partially protective, the presence of an endotracheal tube may actually serve as a mechanism of transport of organisms from the oropharyngeal tract (most commonly) or GI tract (less commonly) to the lung (5,6). Recent data from 2012 to 2013 suggest that the percentage of patients on ventilator support who go on to acquire aspiration pneumonia is 9.7% (7).  Common pathogens associated with this condition include aerobic gram-negative bacilli (Escherichia coli, Klebsiella pneumoniae, Enterobacter spp, Pseudomonas aeruginosa, Acinetobacter spp) or gram-positive cocci including MRSA and Streptococcus Pneumoniae.

Prevention: Patients should be placed in the semi-recumbent position (45 degrees) and have intermittent (every 3-6 hours) or continuous subglottic drainage (8,9). Studies have found there isn’t a significant difference in clinical outcomes between intermittent and continuous drainage and that intermittent drainage may be associated with less adverse effects (10). The use of acid reducing agents should also be avoided, although sucralfate use decreased ICU-acquired pneumonia (11). Gastric volume monitoring had long been the standard of clinical practice with an aim to prevent vomiting and subsequent aspiration, however recent studies have suggested that gastric volume monitoring correlates poorly with aspiration risk and may lead to a decrease in caloric delivery (12,13).

Symptoms/Signs

• Important signs include fever, tachypnea, increased purulent secretions or hemoptysis; systemic signs including encephalopathy or sepsis may also be present (12).
• Ventilator: Reduced tidal volume, increased inspiratory pressures
• Labs: worsening hypoxemia, leukocytosis
• Imaging:
  • New or progressive infiltrates on CXR commonly with alveolar infiltrates or silhouetting of adjacent solid organs
  • Air bronchograms are common

Treatment

Empiric treatment choices should be guided by local distribution of pathogens and susceptibility of those pathogens to antimicrobials (14-16). Treatment options should also take into consideration the likelihood of MDR organisms or MRSA. In a meta-analysis of 15 studies, factors associated with an increased risk of MDR VAP were IV antibiotics in the last 90 days, >5 days of hospitalization prior to onset of symptoms, septic shock on presentation of VAP, ARDS before VAP, and renal replacement therapy prior to VAP. Risk factors for MRSA include treatment in units where >10 to 20% of S. Aureus isolates are methicillin resistant, treatment in a unit where prevalence of MRSA is not known, or prior history of MRSA infection. In the absence of risk factors for MDR or MRSA, patients with VAP should receive one agent that has activity against Pseudomonas, other gram-negative bacilli, and MSSA. Patients with risk factors for MDR or MRSA should receive two agents with activity against P. Aeruginosa and other gram-negative bacilli and one agent with activity against MRSA (15). An algorithm guiding specific regimens for treatment of VAP can be found on UpToDate’s article: Treatment of hospital-acquired and ventilator-associated pneumonia in adults (17).

Jeremy P. Head BS and Michael C. Larson MD

Department of Medical Imaging

University of Arizona

Tucson, AZ USA

References

1. Huxley EJ, Viroslav J, Gray WR, Pierce AK. Pharyngeal aspiration in normal adults and patients with depressed consciousness. Am J Med. 1978;64(4):564-568. [CrossRef] [PubMed]
2. Lo WL, Leu HB, Yang MC, Wang DH, Hsu ML. Dysphagia and risk of aspiration pneumonia: A nonrandomized, pair-matched cohort study. J Dent Sci. 2019;14(3):241-247. [CrossRef] [PubMed]
3. Mandell LA, Niederman MS. Aspiration Pneumonia. N Engl J Med. 2019;380(7):651-663. [CrossRef] [PubMed]
4. Rouzé A, Jaillette E, Nseir S. Relationship between microaspiration of gastric contents and ventilator-associated pneumonia. Ann Transl Med. 2018;6(21):428. [CrossRef] [PubMed]
5. Garrouste-Orgeas M, Chevret S, Arlet G, et al. Oropharyngeal or gastric colonization and nosocomial pneumonia in adult intensive care unit patients. A prospective study based on genomic DNA analysis. Am J Respir Crit Care Med. 1997;156(5):1647-1655. [CrossRef] [PubMed]
6. Jaillette E, Girault C, Brunin G, et al. Impact of tapered-cuff tracheal tube on microaspiration of gastric contents in intubated critically ill patients: a multicenter cluster-randomized cross-over controlled trial. Intensive Care Med. 2017;43(11):1562-1571. [CrossRef] [PubMed]
7. Metersky ML, Wang Y, Klompas M, Eckenrode S, Bakullari A, Eldridge N. Trend in Ventilator-Associated Pneumonia Rates Between 2005 and 2013. JAMA. 2016;316(22):2427-2429. [CrossRef] [PubMed]
8. Wang L, Li X, Yang Z, et al. Semi-recumbent position versus supine position for the prevention of ventilator-associated pneumonia in adults requiring mechanical ventilation. Cochrane Database Syst Rev. 2016;2016(1):CD009946. [CrossRef] [PubMed]
9. Caroff DA, Li L, Muscedere J, Klompas M. Subglottic Secretion Drainage and Objective Outcomes: A Systematic Review and Meta-Analysis. Crit Care Med. 2016;44(4):830-840. [CrossRef] [PubMed]
10. Mao Z, Gao L, Wang G, et al. Subglottic secretion suction for preventing ventilator-associated pneumonia: an updated meta-analysis and trial sequential analysis. Crit Care. 2016;20(1):353. Published 2016 Oct 28. [CrossRef] [PubMed]
11. Alquraini M, Alshamsi F, Møller MH, et al. Sucralfate versus histamine 2 receptor antagonists for stress ulcer prophylaxis in adult critically ill patients: A meta-analysis and trial sequential analysis of randomized trials. J Crit Care. 2017;40:21-30. [CrossRef] [PubMed]
12. Meduri GU. Diagnosis and differential diagnosis of ventilator-associated pneumonia. Clin Chest Med. 1995;16(1):61-93. [PubMed]
13. McClave SA, Lukan JK, Stefater JA, et al. Poor validity of residual volumes as a marker for risk of aspiration in critically ill patients. Crit Care Med. 2005;33(2):324-330. [CrossRef] [PubMed]
14. Kalil AC, Metersky ML, Klompas M, et al. Executive Summary: Management of Adults With Hospital-acquired and Ventilator-associated Pneumonia: 2016 Clinical Practice Guidelines by the Infectious Diseases Society of America and the American Thoracic Society [published correction appears in Clin Infect Dis. 2017 May 1;64(9):1298] [published correction appears in Clin Infect Dis. 2017 Oct 1;65(7):1251]. Clin Infect Dis. 2016;63(5):575-582. [CrossRef] [PubMed]
15. Beardsley JR, Williamson JC, Johnson JW, Ohl CA, Karchmer TB, Bowton DL. Using local microbiologic data to develop institution-specific guidelines for the treatment of hospital-acquired pneumonia. Chest. 2006;130(3):787-793. [CrossRef] [PubMed]
16. Jones RN. Microbial etiologies of hospital-acquired bacterial pneumonia and ventilator-associated bacterial pneumonia [published correction appears in Clin Infect Dis. 2010 Nov 1;51(9):1114]. Clin Infect Dis. 2010;51 Suppl 1:S81-S87. [CrossRef] [PubMed]
17. Klompas M. Treatment of hospital-acquired and ventilator-associated pneumonia in adults. UpToDate. July 31, 2020. Available at: https://www.uptodate.com/contents/treatment-of-hospital-acquired-and-ventilator-associated-pneumonia-in-adults (requires subscription).

Cite as: Head JP, Larson MC. Medical image of the month and brief review: aspiration pneumonia in an intubated patient with COVID-19. Southwest J Pulm Crit Care. 2020;21(2):35-8. doi: https://doi.org/10.13175/swjpcc040-20 PDF 

May 2018 Imaging Case of the Month

Michael B. Gotway, MD

Department of Radiology

Mayo Clinic Arizona

Scottsdale, AZ USA

Clinical History: A 79-year-old man with a past medical history significant for mild, intermittent asthma since childhood and mild aortic stenosis presents to the Emergency Room with fevers and chills for 5 days, associated with dry cough and dyspnea on exertion. His past medical history was otherwise relatively unremarkable, with coronary artery disease as evidenced by coronary artery calcium at a calcium scoring CT, hypothyroidism, and dyslipidemia. The patient has allergies to dust and penicillin, and his only medications included thyroid replacement, aspirin, and an albuterol inhaler as needed. He was a 15-pack-year smoker, quitting 30 years ago. His past surgical history was remarkable only for tonsillectomy, inguinal hernia repair, meniscal repair, and sigmoid colon resection for diverticular abscess 14 years earlier. The patient was afebrile, his heart rate was 96 beats / minute and regular, decreased breath sounds at the lung bases was noted, and the white blood cell count was normal. Electrocardiography showed no abnormalities. Oxygen saturation was 92% on room air. Frontal chest radiography (Figures 1A and B) was performed.

Figure 1. Frontal (A) and lateral (B) chest radiography.

Which of the following represents the most accurate assessment of the frontal chest imaging findings? (Click on the correct answer to proceed to the second of nineteen pages)

1. Chest frontal imaging shows bilateral pleural fluid collections
2. Chest radiography shows bilateral lower lobe bronchial wall thickening and patchy consolidation
3. Chest radiography shows cavitary lung disease
4. Chest radiography shows numerous small nodules
5. Chest radiography shows peribronchial and mediastinal lymphadenopathy

Cite as: Gotway MB. May 2018 imaging case of the month. Southwest J Pulm Crit Care. 2018;16(5):254-78. doi: https://doi.org/10.13175/swjpcc062-18 PDF 

October 2017 Imaging Case of the Month

Paul J. Conomos, MD¹

Michael B. Gotway, MD²

¹Arizona Pulmonary Specialists

Phoenix, AZ USA

²Mayo Clinic Arizona

Scottsdale, AZ USA

Clinical History: An 18-year-old man with no known previous medical history presented with complaints of intermittent cough persisting several months. No hemoptysis was noted.

Physical examination was largely unremarkable and the patient’s oxygen saturation was 99% on room air. The patient’s vital signs were within normal limits.

Laboratory evaluation was unremarkable.  Quantiferon testing for Mycobacterium tuberculosis was negative, and testing for coccidioidomycosis was unrevealing. Frontal and lateral chest radiography (Figure 1) was performed.

Figure 1. Figure 1. Frontal (A) and lateral (B) chest radiography.

Which of the following statements regarding the chest radiograph is most accurate? (Click on the correct answer to proceed to the second of eight pages)

1. The chest radiograph shows asymmetric reticulation and interlobular septal thickening
2. The chest radiograph shows bilateral reticulation associated with decreased lung volumes
3. The chest radiograph shows focal consolidation
4. The chest radiograph shows large lung volumes
5. The chest radiograph shows small cavitary pulmonary nodules

Cite as: Conomos PJ, Gotway MB. October 2017 imaging case of the month. Southwest J Pulm Crit Care. 2017;15(4):138-46. doi: https://doi.org/10.13175/swjpcc119-17 PDF

April 2016 Imaging Case of the Month

Michael B. Gotway, MD

Department of Radiology

Mayo Clinic Arizona

Scottsdale, AZ USA

Imaging Case of the Month CME Information  

Members of the Arizona, New Mexico, Colorado and California Thoracic Societies and the Mayo Clinic are able to receive  0.25 AMA PRA Category 1 Credits™. Completion of an evaluation form is required to receive credit and a link is provided on the last panel of the activity.

0.25 AMA PRA Category 1 Credit(s)™

Estimated time to complete this activity: 0.25 hours

Lead Author(s): Michael B. Gotway, MD. All Faculty, CME Planning Committee Members, and the CME Office Reviewers have disclosed that they do not have any relevant financial relationships with commercial interests that would constitute a conflict of interest concerning this CME activity. 

Learning Objectives:
As a result of this activity I will be better able to:    

1. Correctly interpret and identify clinical practices supported by the highest quality available evidence.
2. Will be better able to establsh the optimal evaluation leading to a correct diagnosis for patients with pulmonary, critical care and sleep disorders.
3. Will improve the translation of the most current clinical information into the delivery of high quality care for patients.
4. Will integrate new treatment options in discussing available treatment alternatives for patients with pulmonary, critical care and sleep related disorders.

Learning Format: Case-based, interactive online course, including mandatory assessment questions (number of questions varies by case). Please also read the Technical Requirements.

CME Sponsor: University of Arizona College of Medicine at the Arizona Health Sciences Center.

Current Approval Period: January 1, 2015-December 31, 2016

Financial Support Received: None.

Clinical History: A 19 year-old man with no previous medical history was vacationing when he was found down, intoxicated, surrounded by vomit. He went into cardiac arrest, and, after several minutes, cardiopulmonary resuscitation was initiated. He was intubated in the field, and epinephrine was administered.

Once at the hospital, frontal chest radiography (Figure 1) was performed.

Figure 1. Frontal chest radiograph.

Which of the following statements regarding the chest radiograph is most accurate?

1. The frontal chest radiograph shows central venous catheter malposition
2. The frontal chest radiograph shows focal consideration
3. The frontal chest radiograph shows pleural fluid loculated within the major fissures
4. The frontal chest radiograph shows pneumomediastinum
5. The frontal chest radiograph shows pneumothorax

Cite as: Gotway MB. April 2016 imaging case of the month. Southwest J Pulm Crit Care. 2016 Apr;12(4):137-46. doi: http://dx.doi.org/10.13175/swjpcc035-16 PDF

Medical Image of the Week: Wide Mediastinum Due to Lung Infiltrates

Figure 1. Panel A: Admission chest x-ray showing an apparent widened mediastinum. Panels B & C: CT scan showing consolidation in the posterior lungs bilaterally. Panel D: Chest x-ray showing resolution of his widened mediastinum with an increase in positive end-expiratory pressure.

The patient is a 65-year-old man patient with a past medical history of poorly controlled hypertension and coronary artery disease who was admitted after a witnessed code arrest. He was found down, and paramedics arrived within 5 minutes and started chest compressions. His initial CXR showed a wide mediastinum (Figure 1A) that was concerning for possible aortic dissection especially with his history of poorly controlled hypertension. Due to his hemodynamic instability a chest CT scan couldn’t be done initially, but the patient underwent a trans-esophageal echo that was negative for aortic dissection.

When the patient became more stable a chest CT scan with contrast was done and showed consolidation of the medial parts of both lungs with 7 bilateral rib fractures (Figure 1 B & C). The impression was either lung contusion from the aggressive chest compression as evidenced by the bilateral 7 rib fractures or aspiration in the dependent parts of the lung. His apparent widened mediastinum resolved with increasing the positive end-expiratory pressure (PEEP) on the ventilator within 48 hours (Figure 1D).

Huthayfa Ateeli MBBS, Laila Abu Zaid MD

Department of Medicine

University of Arizona

Tucson, AZ.

References

1. Cohn SM. Pulmonary contusion: review of the clinical entity. J Trauma. 1997;42(5):973-9. [CrossRef] [PubMed]
2. Lai CC, Wang CY, Lin HI, Wang JY. Pulmonary contusion associated with chest compressions. Resuscitation. 2010;81(1):133. [CrossRef] [PubMed]

Reference as: Ateeli H, Zaid LA. Medical image of the week: widen mediastinum due to lung infiltrates. Southwest J Pulm Crit Care. 2015;10(2):77-8. doi: http://dx.doi.org/10.13175/swjpcc007-15 PDF 

July 2013 Imaging Case of the Month

Michael B. Gotway, MD

Department of Radiology

Mayo Clinic Arizona

Scottsdale, AZ

Clinical History

A 64-year-old woman with a history of multiple sclerosis (wheelchair-bound), neurogenic bladder, and a number of other chronic medical conditions, presented with complaints of non-radiating neck pain without tingling or numbness. The patient also reported mild subjective fever and occasional nausea, but denied shortness of breath. Frontal and lateral chest radiography (Figure 1) was performed.

      Figure 1. Frontal (Panel A) and lateral (Panel B) chest x-ray.                 

Which of the following statements regarding the chest radiograph is most accurate?

1. The chest radiograph shows bibasilar consolidation
2. The chest radiograph shows large lung volumes with cystic change
3. The chest radiograph shows multiple nodules
4. The chest radiograph shows no abnormalities
5. The chest radiograph shows symmetrical bilateral pleural effusions

Reference as: Gotway MB. July 2013 imaging case of the month. Southwest J Pulm Crit Care. 20130.;7(1):17-24. doi: http://dx.doi.org/10.13175/swjpcc087-13 PDF