Imaging
Those who care for patients with pulmonary, critical care or sleep disorders rely heavily on chest radiology and pathology to determine diagnoses. The Southwest Journal of Pulmonary, Critical Care & Sleep publishes case-based articles with characteristic chest imaging and related pathology.
The editor of this section will oversee and coordinate the publication of a core of the most important chest imaging topics. In doing so, they encourage the submission of unsolicited manuscripts. It cannot be overemphasized that both radiologic and pathologic images must be of excellent quality. As a rule, 600 DPI is sufficient for radiographic and pathologic images. Taking pictures of plain chest radiographs and CT scans with a digital camera is strongly discouraged. The figures should be cited in the text and numbered consecutively. The stain used for pathology specimens and magnification should be mentioned in the figure legend. Those who care for patients with pulmonary, critical care or sleep disorders rely heavily on chest radiology and pathology to determine diagnoses. The Southwest Journal of Pulmonary, Critical Care & Sleep publishes case-based articles with characteristic chest imaging and related pathology. The editor of this section will oversee and coordinate the publication of a core of the most important chest imaging topics. In doing so, they encourage the submission of unsolicited manuscripts. It cannot be overemphasized that both radiologic and pathologic images must be of excellent quality. As a rule, 600 DPI is sufficient for radiographic and pathologic images. Taking pictures of plain chest radiographs and CT scans with a digital camera is strongly discouraged. The figures should be cited in the text and numbered consecutively. The stain used for pathology specimens and magnification should be mentioned in the figure legend.
Medical Image of the Week: Bilateral Pneumothorax, Pneumomediastinum, and Massive Subcutaneous Emphysema
Figure 1. Computed tomography of the thorax showing subcutaneous air dispersed in the adipose tissue, separating the fascia of the pectoralis major, and the delineation of its fibers (top arrow), pneumothorax compressing the lung (middle arrow), and pneumomediastinum compressing the trachea (bottom arrow).
An 80 year old man with chronic obstructive pulmonary disease (COPD) presented to the emergency department with respiratory distress and poor oxygen saturation. Physical exam revealed an obese male in respiratory distress with poor air entry bilaterally and scattered wheezing. His chest, neck, tongue, and lips were swollen. The patient was intubated for respiratory failure, felt to be due to angioedema. His oxygen saturation immediately improved, however the patient developed progressive swelling throughout his body including his eyelids, fingers and toes. Diffuse crepitus was felt on palpation. Chest radiography and computed tomography (CT) of the chest revealed large bilateral pneumothoraces, pneumomediastinum, and subcutaneous emphysema (Figure 1). Bilateral chest tubes were inserted with re-expansion of both lungs. Over the next several days his respiratory parameters improved, with full re-expansion of the lungs and reabsorption of the pneumomediastinum and subcutaneous emphysema. The patient was extubated successfully and was discharged in good health.
Bilateral spontaneous pneumothorax, pneumomediastinum, and subcutaneous emphysema (SCE) are complications that may occur individually or rarely concomitantly, as in our case, during COPD exacerbations (the exact occurrence rate has not been described in the literature) (1-3). Bilateral spontaneous pneumthorax occurs in 1.9% of all spontaneous pneumothorax (4). The diagnosis is made with physical exam and appropriate imaging. Depending on the tension physiology, these conditions may lead to rapid respiratory failure and decreased cardiac output, especially when complicated by pulmonary barotrauma during mechanical ventilation (5,6). In severe cases, SCE may involve respiratory compromise by compressing the trachea.
The early diagnosis with meticulous physical exam and relevant testing is essential, in order to immediately initiate appropriate management, and hence avoid the life-threatening complications associated with spontaneous pneumothorax, pneumomediastinum, and subcutaneous emphysema.
Zavier Ahmed MD, Manpreet Singh MD, Ricardo Lopez, MD
Icahn School of Medicine at Mount Sinai
Queens Hospital Center
82-68 164th Street
Queens, NY
References
- Williams-Johnson J, Williams EW, Hart N, Maycock C, Bullock K, Ramphal P. Simultaneous spontaneous bilateral pneumothoraces in an asthmatic. West Indian Med J. 2008;57(5):508-10.[PubMed]
- Karakaya Z, Demir S, Sagay SS, Karakaya O, Ozdinc S. Bilateral spontaneous pneumothorax, pneumomediastinum, and subcutaneous emphysema: rare and fatal complications of asthma. Case Rep Emerg Med. 2012; 242579. [PubMed]
- Limthongkul S, Wongthim S, Udompanich V, Charoenlap P, Nuchprayoon C. Spontaneous pneumothorax in chronic obstructive pulmonary disease. J Med Assoc Thai. 1992;75(4):204-12. [PubMed]
- Athanassiadi K, Kalavrouziotis G, Loutsidis A, Hatzimichalis A, Bellenis I, Exarchos N. Treatment of spontaneous pneumothorax: ten-year experience. World J Surg, 1998;22: 803–6. [CrossRef] [PubMed]
- Hashim T, Chaudry AH, Ahmad K, Imhoff J, Khouzam R. Pneumomediastinum from a severe asthma attack. JAAPA. 2013;26(7):29-32. [CrossRef] [PubMed]
- Sakamoto A, Kogou Y, Matsumoto N, Nakazato M. Massive subcutaneous emphysema and pneumomediastinum following endotracheal intubation. Intern Med. 2013;52(15):1759. [CrossRef] [PubMed]
Reference as: Ahmed Z, Singh M, Lopez R. Medical image of the week: bilateral pneumothorax, pneumomediastinum, and massive subcutaneous emphysema. Southwest J Pulm Crit Care. 2014;8(3):181-2. doi: http://dx.doi.org/10.13175/swjpcc020-14 PDF
Medical Image of the Week: Pneumomediastinum
Figure 1. Chest x-ray (CXR) shows subtle evidence of pneumomediastinum with air outlining left cardiac border and trachea (arrows).
Figure 2. Chest computerized tomography (CT) showing pneumomediastinum (Panel A) extending into lower neck (Panel B) without evidence of pneumothorax.
A 65 year old man presented with mild increase in shortness of breath. He had a past medical history of diabetes mellitus, hypertension, and severe malnutrition with percutaneous endoscopic gastrostomy (PEG) placement after a colectomy and end ileostomy for sigmoid volvulus. CXR (Figure 1) suggested a pneumomediastinum with subsequent chest CT (Figure 2) confirming moderate sized pneumomediastinum. He had a chronic cough from chronic obstructive pulmonary disease (COPD) as well as aspiration and chest CT also demonstrated emphysema with small blebs. He denied any significant chest pain. He was followed conservatively with imaging and discharged in stable condition.
Pneumomediastinum can be caused by trauma, esophageal rupture after vomiting (Boerhaave’s syndrome) and can be a spontaneous event if no obvious precipitating cause is identified (1). Valsalva maneuvers such as cough, sneeze, vomiting and childbirth, can all cause pneumomediastinum. Risk factors include asthma, COPD, interstitial lung disease and inhalational recreational drug use. Hamman's sign (a crunching sound in time with the heartbeat) can occasionally be heard. More commonly, subcutaneous emphysema is felt on exam (crepitus). Complications can include single or bilateral pneumothorax, tension pneumothorax and pleural effusion. CXR often does not identify mediastinal air and CT imaging is highly sensitive and confirmatory. Conservative management is recommended with close clinical follow up for possible complications.
Rene Franco, Jr MD, Mohammad Dalabih MD, Janet Campion MD
University of Arizona Medical Center, Tucson AZ
Reference
- Newcomb AE, Clarke CP. Spontaneous Pneumomediastinum. Chest. 2005;128:3298-3302. [CrossRef] [PubMed]
Reference as: Franco R Jr, Dalabih M, Campion J. Medical image of the week: pneumomediastinum. Southwest J Pulm Crit Care. 2014:8(1):46-7. doi: http://dx.doi.org/10.13175/swjpcc160-13 PDF