Medical Image of the Week: Mucous Plugs Forming Airway Casts

Figure 1. Bronchoscopic view of the mucous plug.

Figure 2. Cast removed with cryo-adhesion probe.

A 64 -year-old man with a recent diagnosis of acute lymphocytic leukemia (ALL) on chemotherapy presented with acute hypoxic respiratory failure, multifocal pneumonia, neutropenic fever and septic shock. The patient was intubated and required vasopressors for septic shock. His blood and sputum cultures grew Pseudomonas aeruginosa. Chest computed tomography demonstrated extensive consolidation of the left lung mainly the left lower lobe with extensive endobronchial mucus plugs. The patient underwent bronchoscopy after noninvasive measures failed to resolve the left lung atelectasis. After multiple attempts to retrieve the mucus plugs (Figure 1) with suction failed, a cryo-adhesion probe was used to freeze and retrieve the mucus plug. The plug formed a cast taking the shape of the airway (Figure 2).

Flexible bronchoscopy is warranted in patients who have persistent atelectasis or pneumonia that is either of unknown cause or suspected of being due to airway obstruction (1). The use of cryo-adhesion and extraction has been particularly useful in the management of airway obstruction caused by foreign bodies especially mucus plugs and blood clots that are not easily extracted by more standard means such as suction or forceps (2).

Huthayfa Ateeli, MBBS and Cameron Hypes MD, MPH

Division of Pulmonary, Critical Care, Sleep and Allergy Medicine

University of Arizona, Tucson, AZ USA

References

1. Feinsilver SH, Fein AM, Niederman MS, Schultz DE, Faegenburg DH. Utility of fiberoptic bronchoscopy in nonresolving pneumonia. Chest. 1990 Dec;98(6):1322-6. [CrossRef] [PubMed]
2. Strausz J, Bolliger CT. Interventional pulmonology. Sheffield: European Respiratory Society; 2010: 165.

Cite as: Ateeli H, Hypes C. Medical image of the week: mucous plugs forming ariway casts. Southwest J Pulm Crit Care. 2017;15(6):278-9. doi: https://doi.org/10.13175/swjpcc147-17 PDF 

Medical Image of the Week: The Luftsichel Sign

Figure 1. Anteroposterior chest radiograph demonstrating partial opacification of the left hemithorax, with preservation of the diaphragmatic border. A central mass is seen (thin arrow), as well as a radiolucent stripe bordering the aorta (thick arrows). Tracheal deviation to the left, a right-sided chest tube and a small right-sided pneumothorax are also noted.

Figure 2. Axial computed tomographic of the chest at the level of the carina (A) and left upper lobe bronchus (B) demonstrate opacification and volume loss of the left upper lobe with occlusion of the left upper lobe bronchus. The superior segment of the left lower lobe is interposed between the aorta and the atelectatic upper lobe (arrows). The right-sided pneumothorax is demonstrated and ground glass opacities are noted in the left lower lobe (arrowheads).

A 59-year old woman with recently diagnosed small cell carcinoma with metastases to liver and spine presented after a fall presented with lower extremity weakness and incontinence. She was diagnosed with intertrochanteric femoral fracture and prior to planned transfer to our hospital for neurosurgical evaluation she underwent operative fixation of the fracture. An indwelling venous access port was also placed on the same day which was complicated by a pneumothorax requiring chest tube placement

Upon arrival to our institution, she had normal vital signs and was in no distress. On respiratory examination, breath sounds were clear bilaterally on auscultation of the posterior chest but reduced on the left side on anterior auscultation. A chest tube was in place in the right mid-axillary line with no evidence of an air leak.

Chest x-ray demonstrated the right-sided chest tube and partial opacification of the left hemithorax, with a left hilar mass (Figure 1). The radiographic findings of left tracheal deviation, preservation of the left hemidiaphragm, and identification of the luftsichel sign suggested collapse of the left upper lobe. Computed tomography (CT) scan of the chest confirmed left upper lobar collapse due to extrinsic compression of the left upper lobar bronchus by a left upper lobe lung mass (Figure 2).

The luftsichel sign, a long-described marker of left upper lobe collapse on chest radiography, is a para-aortic stripe of radiolucency so-named for its course along the straight proximal descending aorta and curved aortic knob (in the German, luft for air, sichel for sickle) (1). Once theorized to be a result of herniation of the right lung into the left hemithorax after left-sided volume loss, CT correlation studies of radiographic signs in the 1980s verified the superior segment of the left lower lobe as the source of the lucency (2). Collapse of the left upper lobe displaces the major fissure anteriorly; the consequent movement of the left lower lobe results in expansion and interposition of its superior segment between the aorta and the atelectatic lung, as demonstrated in the correlate CT images in our patient.

Luke Gabe MD and Linda Snyder MD

Division of Pulmonary, Allergy, Critical Care and Sleep

Banner-University Medical Center, Tucson, AZ USA

References

1. Blankenbaker DG. The luftsichel sign. Radiology. 1998 Aug;208:319-20. [CrossRef] [PubMed]
2. Khoury MB, Godwin JD, Halvorsen RA Jr, Putman CE.CT of obstructive lobar collapse. Invest Radiol. 1985 Oct;20(7):708-16. [CrossRef] [PubMed]

Cite as: Gabe L, Snyder L. Medical image of the week: the luftsichel sign. Southwest J Pulm Crit Care. 2017;14(1):26-7. doi: https://doi.org/10.13175/swjpcc003-17 PDF 

Medical Image of the Week: Tracheobronchial Foreign Body Aspiration

Figure 1. Panel A: The chest x-ray failed to show the aspirated foreign body. Panels B and C: Flexible bronchoscopy was performed and the insulin syringe cap was visualized in the right mainstem bronchus and retrieved with forceps.

Figure 2. Panel A: CT chest shows interval development of ground glass opacities and air fluid level in the right middle lobe (arrow). Panel B: The foreign body is visualized in the right lower lobe bronchus as an endobronchial-filling defect (arrow). Panel C: Flexible bronchoscopy was performed and cashew piece was retrieved with suction.

Case 1 (Figure 1) is a 58-year-old man who accidentally inhaled his insulin syringe cap while swinging on his recliner with the cap perched in his mouth. He developed a dry irritating cough. On exam he had mild stridor in the upper airways and bilateral wheezing. The insulin cap was visualized by bronchoscopy in the right mainstem bronchus and retrieved with forceps.

Case 2 (Figure 2) is a 65-year-old man with chronic dysphagia and poor dentition who choked on a cashew. It took repeated coughing attempts to produce the cashew, but it was unclear whether the entire content was cleared. He then developed non-massive hemoptysis that persisted for 2 weeks. Thoracic CT showed ground glass opacities and an air fluid level in the right middle lobe. The foreign body was visualized in the right lower lobe bronchus as an endobronchial-filling defect. Bronchoscopy revealed a cashew piece in the right lower lobe bronchus. Forceps trials failed due to fragility of the foreign body, which was ultimately retrieved with scope suction.

Rigid bronchoscopy is the gold standard for diagnosis and management of tracheobronchial foreign body aspiration, but flexible bronchoscopy is another accepted method that is also more comfortable for the patient (1). Virtual bronchoscopy is a noninvasive procedure that can assist with localizing the foreign body and may have a role to play in follow-up assessment of airway patency (2). Pneumonia and atelectasis are common complications. Less common complications include bronchiectasis, bronchostenosis, hemoptysis, tracheal perforation, pneumomediastinum, and even cardiopulmonary arrest (3). Tracheal foreign bodies pose more danger than bronchial foreign bodies; in such cases the foreign body should be pushed to distal airways, crumbled if it is organic, and then extracted (1).

Khushboo Goel, MD¹, Huthayfa Ateeli, MBBS², Joshua Dill, DO2, Dena L’Heureux MD³

¹Department of Internal Medicine, University of Arizona, Tucson, AZ, USA

²Department of Internal Medicine, Division of Pulmonary, Critical Care, Sleep, and Allergy Medicine, University of Arizona, Tucson, AZ, USA

³Department of Internal Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, Southern Arizona VA Health Care System, Tucson, AZ, USA

References

1. Altunas B, Aydin Y, Eroglu A. Foreign bodies in trachea: a 25 year experience. Eurasian J Med. 2016;48(2):119-123. [CrossRef] [PubMed]
2. Kshatriya RM, Khara NV, Paliwal RP, Patel SN. Role of virtual and flexible bronchoscopy in the management of a case of unnoticed foreign body aspiration presented as a nonresolving pneumonia in an adult female. Lung India. 2016; 33(4):420-423. [CrossRef] [PubMed]
3. Altunas B, Aydin Y, Eroğlu A. Complications of tracheobronchial foreign bodies. Turk J Med Sci. 2016;46(3):785-800. [CrossRef] [PubMed]

Cite as: Goel K, Ateeli H, Dill J, L’Heureux D. Medical image of the week: tracheobronchial foreign body aspiration. Southwest J Pulm Crit Care. 2016;13(4):184-5. doi: http://dx.doi.org/10.13175/swjpcc092-16 PDF

Medical Image of the Week: Severe Atelectasis with Tracheal Shift

 

Figure 1. Panel A: Initial chest x-ray shows left lower lobe collapse due to mucus plugging and atelectasis with a significant shift of the trachea to the left (arrow). Panel B: Follow up chest x-ray shows marked improvement in aeration of the left lung and return of the trachea to midline (arrow).

A 59-year-old woman with severe oxygen dependent COPD presented with acute respiratory distress requiring intubation and was found to have left lower lobe collapse with tracheal shift. Her past medical history consists of severe malnutrition, alcohol abuse, and emphysema with recurrent pneumonias associated with acute respiratory failure often requiring intubation. She has greater than a 50-pack year history of tobacco use. She has undergone bronchoscopy and multiple CT Chest imaging without evidence of an endobronchial lesion or malignancy. Postural drainage and percussion along with antibiotics and inhaled bronchodilators resulted in marked improvement in the left lower lobe.

Ishna Poojary MD, Janet Campion MD

University of Arizona Medical Center

Tucson, AZ

Reference as: Poojary I, Campion J. Medical image of the week: severe atelectasis with tracheal shift. Southwest J Pulm Crit Care. 2014;9(3):160. doi: http://dx.doi.org/10.13175/swjpcc115-14 PDF

Medical Image of the Week: Unilateral Diaphragm Paralysis

Figure 1. CT scans showing unilateral diaphragm paralysis and atelectasis of right lower lobe (arrow).

An 85 year old woman with a history of COPD presented to the emergency department (ED) with shortness of breath and cyanosis of her fingers. Her symptoms have been waxing and waning since she recovered from pneumonia a year ago. A week prior to admission, she visited an outpatient clinic for worsening cough, which was treated with levofloxacin, however her shortness of breath and cyanosis persisted. O₂ saturation with 4 L oxygen was 85% and CT chest without contrast showed unilateral diaphragmatic paralysis with basilar atelectasis (Figure 1). She has no history of cardiac surgery, poliomyelitis or cervical spondylosis. Also, no cervical or lung mass was found on CT scan. Her diaphragmatic paralysis is most likely secondary to phrenic nerve injury.

Unilateral diaphragmatic paralysis is usually asymptomatic and does not require treatment in most of cases. However, patients with underlying lung disease can present with shortness of breath and cyanosis because of increased ventilatory demands on physical activity or superimposed pulmonary disease. Occasionally, patients with unilateral diaphragmatic paralysis can develop acute respiratory failure due to exacerbation of obstructive lung disease or respiratory infection, and require ventilatory support (1). Early and careful management of underlying lung disease is pivotal in these patients to prevent respiratory decompensation.

Seongseok Yun, MD PhD; Kahroba Jahan, MD; Natali Hua, DPM; Ibrahim Taweel, MD; Ismail Tabash, MD

Department of Medicine, University of Arizona, Tucson, AZ 85724, USA

Reference

Qureshi A. Diaphragm paralysis. Semin Respir Crit Care Med. 2009;30(3):315-20.  [CrossRef] [PubMed] 

Reference as: Yun S, Jahan K, Hua N, Taweel I, Tabash I. Medical image of the week: unilateral diaphragm paralysis. Southwest J Pulm Crit Care. 2014;8(1):68-9. doi: http://dx.doi.org/10.13175/swjpcc178-13 PDF

A Case of Mislabeled Identity

Reference as: Singarajah C, Park K. A case of mislabeled identity. Southwest J Pulm Crit Care 2010;1:22-27. (Click here for PDF version)

A 60-year-old man in the surgical intensive care unit for atrial fibrillation with rapid ventricular response, on his second post-operative day following colectomy, complained of worsening shortness of breath. A chest radiograph (Figure 1) was obtained. A chest radiograph performed one day previous to Figure 1 showed clear lungs, no pleural effusions, and no volume loss.

Question 1 and Figure 1: What are the abnormal findings on the chest radiograph? In particular, what technical error has occurred? 

The frontal chest radiograph shows increased opacity in the bases bilaterally, greater on the side labeled left (see “L” in the image- this is the technologist’s marker). Note the shift of the trachea towards the side labeled left. However, note also the opacity along the superior mediastinum on the right side; this opacity has the appearance of the aortic arch. Note the appearance of the stomach below the diaphragm, ipsilateral to the aortic arch. Also, the opacity at the left lung base shows a configuration resembling the heart. Taken together, these findings raise the possibility that the radiograph is mislabeled, with the “Left” marker (“L”, Figure 1) improperly placed on the patient’s right side. Prior chest radiographs not shown) confirm the patient did not have situs inversus.

There is evidence of volume loss in the right thorax (labeled incorrectly as left in this image). Note the shift of the trachea towards the side with increased lung opacity. The entire left right thorax (again, incorrectly labeled left in this image) is small, and the air column in the right mainstem bronchus abruptly terminated, suggesting endobronchial obstruction.

Furthermore, the patient had no clinical reasons for a new large pleural effusion, and recent prior films showed no pleural fluid.

Surgery was consulted and a procedure was performed. The results of this procedure are shown in Figure 2.

Question 2: What procedure was performed by the surgery team?

The surgery team improperly placed a thoracostomy tube in the left thorax because they misinterpreted Figure 1 as showing a large left pleural effusion. Figure 2 shows the tip of the thoracostomy tube in the medial superior left thorax, associated with subcutaneous emphysema. Progressive volume loss is seen on the right side, again suggesting endobronchial obstruction- note that the residual air in the right upper thorax in Figure 1 is no longer present in Figure 2. The surgery team then improperly placed a thoracostomy tube on the right side, mistaking the small, opacified right thorax for pleural effusion on that side. Figure 3 shows the new right thoracostomy tube tip located over the cranial right thorax.

The surgical team was concerned that the thoracostomy tube showed little fluid output and a second thoracotomy tube was placed on the contralateral side (Figure 3).

 

This tube also did not show significant output. The pulmonary / critical care medicine team was then consulted. The pulmonary / critical care medicine physician performed a procedure which partially corrected the cause of the patient’s original complaints. The chest radiograph following this procedure is shown in Figure 4. 

Question 3: What procedure (s) was performed by the pulmonary / critical care medicine team?

Bronchoscopy was performed, and showed significant mucous plugging. The mucous plugs were removed resulting in improved right lung aeration (Figure 4).

Learning Points:

• Physical exam would have identified improperly labeled chest radiograph
• The chest radiograph shows volume loss, suggesting endobronchial obstruction due to mucous plugging- the side of the thorax showing increased attenuation shows reduced volume. In contrast, pleural effusion would show increased opacity associated with mass effect and shift of the cardiomediastinal structures away from the side of the thorax showing increased attenuation
• Time-outs are no substitute for clinical skills.The patient had two thoracostomy tubes, both placed for incorrect reasons, one of which was placed on the wrong side all together.
• Therapy for atelectasis and mucous plugging includes the following:
  •  Patient mobilization, ambulation, sitting up;
  • Minimize anti-tussive meds (narcotics, etc), minimizes sedation;
  • Chest physiotherapy for the affected lung;
  • Continuous lateral rotation therapy for patients with altered mental status who cannot mobilize  (for example, a Triadyne bed  made by KCI or manual turning);
  • Bronchoscopy, and;
  • Mucolytics are of equivocal benefit

Clement Singarajah MD.  Associate Chief Pulmonary and Critical Care Fellowship, Phoenix VA Hospital and Good Samaritan Regional Medical Center, Phoenix AZ.

Kevin Park, MD, Pulmonary and Critical Care Medicine fellow, Phoenix VA Hospital and Good Samaritan Regional Medical Center, Phoenix AZ.

Email csingarajah@earthlink.net