April 2024 Medical Image of the Month: Wind Instruments Player Exhibiting Exceptional Pulmonary Function

Figure 1.  Representative view from computed tomography (CT) scan (axial plane) showing clear lungs.

Figure 2.  Pulmonary function testing results demonstrating exceptional pulmonary function

A 64-year-old man was referred to our pulmonary clinic for evaluation of his pulmonary status.  He had a 7-year history of rheumatoid arthritis and was treated initially with steroids and subsequently maintained on methotrexate and monthly adalimumab injections. The patient reported that his rheumatoid arthritis symptoms were controlled.  He experienced no joint pain or morning stiffness at the time of evaluation. From a pulmonary perspective, he denied respiratory symptoms such as exertional shortness of breath, cough, wheezing, or chest tightness.  He reported no limitations in physical activities. The patient has an occupational history of 45-years as a welder, with exposure to dust, metal fumes, benzene, and sulfur gas. The patient also has a 15 pack-year smoking history but quit 35 years ago.

A high-resolution chest CT (Figure 1) ordered by his rheumatologist showed normal lung parenchyma. The first pulmonary function test (PFT), conducted on the initial pulmonary clinic visit, revealed lung volumes significantly higher than the reference range. This is despite the patient’s occupational history, smoking history, and the fact that he is currently on methotrexate and adalimumab therapy. The patient remained asymptomatic from a pulmonary standpoint on annual checkups. Three years later, a repeat PFT (Figure-2) demonstrated similar results.  Further history revealed that the patient had regularly used wind instruments, including the saxophone and harmonica, since high school. Initially, he played at irregular intervals, but for the last 15 years, he consistently practiced 1-2 hours daily and performed weekly at local venues.

Several studies have investigated the pulmonary effects of wind instrument playing, offering insights into the relationship between musical activities and respiratory function. Fiz et al. (1) found that maximum respiratory pressures were elevated in trumpet players.  Munn et al. (2) reported on the pulmonary function of commercial glass blowers [2]. Barbenel et al. (3) explored mouthpiece forces during trumpet playing and Kahane et al. (4) evaluated the upper airway and larynx in professional bassoon players. Cossette et al. (5) examined chest wall dynamics during flute playing. Schorr-Lesnick et al. (6) studied pulmonary function in singers and wind-instrument players [6], and Navratil et al. (7) assessed lung function in wind instrument players and glass blowers. Borgia et al. (8) provided physiological observations on French horn musicians. While existing studies present conflicting findings on the impact of wind instrument playing on respiratory function, our case adds to the growing body of evidence suggesting a potential positive correlation between long-term wind instrument training and enhanced respiratory muscle strength.

This observation prompts further exploration and investigation into the field of pulmonary rehabilitation with the hope of uncovering therapeutic benefits for individuals with chronic pulmonary conditions.

Abdulmonam Ali, MD

Pulmonary & Critical Care

SSM Health

Danville, IL USA

References

1. Fiz JA, Aguilar J, Carreras A, Teixido A, Haro M, Rodenstein DO, Morera J. Maximum respiratory pressures in trumpet players. Chest. 1993 Oct;104(4):1203-4. [CrossRef] [PubMed]
2. Munn NJ, Thomas SW, DeMesquita S. Pulmonary function in commercial glass blowers. Chest. 1990 Oct;98(4):871-4. [CrossRef] [PubMed]
3. Barbenel JC, Kenny P, Davies JB. Mouthpiece forces produced while playing the trumpet. J Biomech. 1988;21(5):417-24. [CrossRef] [PubMed]
4. Kahane JC, Beckford NS, Chorna LB, Teachey JC, McClelland DK. Videofluoroscopic and laryngoscopic evaluation of the upper airway and larynx of professional bassoon players. J Voice. 2006 Jun;20(2):297-307. [CrossRef] [PubMed]
5. Cossette I, Monaco P, Aliverti A, Macklem PT. Chest wall dynamics and muscle recruitment during professional flute playing. Respir Physiol Neurobiol. 2008 Feb 1;160(2):187-95. [CrossRef] [PubMed]
6. Schorr-Lesnick B, Teirstein AS, Brown LK, Miller A. Pulmonary function in singers and wind-instrument players. Chest. 1985 Aug;88(2):201-5. [CrossRef] [PubMed]
7. Navratil M, Bejsek K. Lung function in wind instrument players and glass blowers. Ann NY Acad Sci. 1968; 155:276-83.
8. Borgia JF, Horvath SM, Dunn FR, von Phul PV, Nizet PM. Some physiological observations on French horn musicians. J Occup Med. 1975 Nov;17(11):696-701. [PubMed]

Cite as: Ali A. April 2024 Medical Image of the Month: Wind Instruments Player Exhibiting Exceptional Pulmonary Function. Southwest J Pulm Crit Care Sleep. 2024;28(4):56-58. doi: https://doi.org/10.13175/swjpccs007-24 PDF

February 2024 Imaging Case of the Month: Connecting Some Unusual Dots

Michael B. Gotway MD

Mayo Clinic Arizona

Phoenix, AZ USA

Clinical History: A 37-year-old woman presents with abdominal pain, tongue and throat swelling, and intermittent shortness of breath and dyspnea on exertion. She also notes some pain on swallowing.

The patient’s past medical history was largely unremarkable. Her one prior surgery included cholecystectomy for cholelithiasis, and she was not taking any prescription medications.

The patient is a lifelong non-smoker, her only reported allergy due to medications containing sulfa, and she drinks alcohol only socially and denied illicit drug use.

Laboratory: A complete blood count showed a normal white blood cell count at 9.7 x 10⁹/L (normal, 3.4 – 9.6 x 10⁹/L), with an elevated absolute neutrophil count of 8.18 x 10⁹/L (normal, 1.4 – 6.6 x 10⁹/L); the percent distribution of lymphocytes, monocytes, and eosinophils was normal. Her hemoglobin and hematocrit values were 15 gm/dL (normal, 13.2 – 16.6 gm/dL) and 46% (normal, 34.9 – 44.5%). The platelet count was normal at 220 x 10⁹/L (normal, 149 – 375 x 10⁹/L). The patient’s serum chemistries and liver function studies were normal, including an albumin level at 4.3 gm/dL (normal, 3.5 – 5 gm/dL). SARS-CoV-2 PCR testing was negative. The erythrocyte sedimentation rate was normal at 6 mm/hr (normal, 0-29 mm/hr), although her C-reactive protein was mildly elevated at 4.8 mg/L (normal, <2 mg/L).  

Radiology: Frontal chest radiography (Figure 1) was performed.

Figure 1. Frontal chest radiography at presentation shows normal heart size, clear lungs, and no pleural abnormality.

Which of the following statements regarding this chest radiograph is accurate? (click on the correct answer to be directed to the first of twelve additional pages)

1. Frontal chest radiography shows normal findings
2. Frontal chest radiography shows mild cardiomegaly
3. Frontal chest radiography shows mediastinal lymphadenopathy
4. Frontal chest radiography shows pleural effusion
5. Frontal chest radiography shows numerous small nodules

Cite as: Gotway MB. February 2024 Imaging Case of the Month: Connecting Some Unusual Dots. Southwest J Pulm Crit Care Sleep. 2024;28(2):9-17. doi: https:doi.org/10.13175/swjpccs001-24 PDF

May 2022 Medical Image of the Month: Pectus Excavatum

Figure 1. Thoracic CT in lung windows showing severe pectus excavatum. The distance from the sternum to the vertebral body was 14.7 mm (green line) and the transverse diameter of the chest of 257 mm (red line). This gives a calculated Haller index (shortest AP diameter/transverse diameter) of approximately 17.4.

Case Presentation

A 78-year-old man presented to the emergency department with abdominal discomfort and was ultimately diagnosed with a small bowel obstruction requiring laparoscopic surgery. The patient woke up early in the morning with abdominal pain, which was constant. Nothing alleviated his symptoms. 3 hours later he developed dyspnea and, at that point, went to the hospital. The patient subsequently underwent enhanced commuted tomography of the chest, abdomen, pelvis. Patient was found to have an acute small bowel obstruction and mesenteric swirling and mistiness. Patient was also found to have severe pectus excavatum with the inferior body of the sternum measuring 1.3 cm from the anterior border of T11 vertebral body. General surgery was consulted. Patient ultimately underwent laparoscopic surgery with removal of adhesions and a small bowel serosal tear was repaired. The patient recovered well.

Discussion

Pectus excavatum is a deformity of the chest wall that is characterized by sternal depression. It accounts for 90% of anterior chest wall disorders and treatment and clinical significance depends on severity of chest wall defect, cardiopulmonary morbidity, and psychosocial impact. In severe cases there can be cardiopulmonary impairment. These impairments can worsen as the patient ages. Complications that are associated with pectus excavatum are lung compression caused by the deformity, decreased exercise tolerance, arrythmias such as atrial fibrillation, and mitral valve prolapse. In 20-60% of cases, mitral valve prolapse has also been reported. PFTs that are done on these individuals are significant for a restrictive pattern and patients can have severe exercise intolerance due to this. Indications for operative management include cardiopulmonary impairment and desire to correct defect of the chest due to its appearance. Prior to surgical intervention, the Haller index is used to quantify severity of the deformity and is a ratio of thoracic height and width measured from axial CT image. The Haller index is calculated by dividing the transverse diameter of the chest by the anterior-posterior distance on CT of the chest on the axial slice that demonstrates the smallest distance between the anterior surface of the vertebral body and the posterior surface of the sternum. A significant Haller index is >3.35. For the surgical correction, the preferred operation is the Nuss procedure. It is a minimally invasive procedure and involves placing three bars behind the sternum to hold it in a normal position. In most cases the bars are removed after 3 years. In one study it was noted after Nuss procedure there was a 44% improvement in cardiac stroke volume as well as 40.6% improvement in cardiac output. Furthermore, there was improvement in exercise tolerance following the procedure.

Overall, this is an important topic because pectus excavatum has been seen as a physical deformity, but can have significant impact on cardiac function, pulmonary function, and even psychosocial factors. For example, the presence of pectus excavatum has multiple considerations in the clinical course of the patient. The diminished lung volume places this patient at increased risk of complications with general anesthesia. In this particular patient, the heart rested completely in the right side of the chest. Should a cardiac arrest have occurred, cardiopulmonary resuscitation would have been complicated. Proper resuscitation of this patient would have included right-sided rib compressions rather than sternal placement.

Cameron Barber DO, Jessica Nash DO, Dylan Carroll MD, Karen Randall DO, and Kourtney Aylor-Lee DO

Parkview Medical Center

Pueblo, CO USA

References

1. Andre Hebra, MD. “Pectus Excavatum Treatment & Management: Medical Care, Surgical Care, Consultations.” Pectus Excavatum Treatment & Management: Medical Care, Surgical Care, Consultations, Medscape, 8 Nov. 2019, Available at: https://emedicine.medscape.com/article/1004953-treatment#d6 (accessed 3/30/22).
2. Das BB, Recto MR, Yeh T. Improvement of cardiopulmonary function after minimally invasive surgical repair of pectus excavatum (Nuss procedure) in children. Ann Pediatr Cardiol. 2019 May-Aug;12(2):77-82. [CrossRef] [PubMed]
3. Shaalan AM, Kasb I, Elwakeel EE, Elkamali YA. Outcome of surgical repair of Pectus Excavatum in adults. J Cardiothorac Surg. 2017 Aug 29;12(1):72. [CrossRef] [PubMed]

Cite as: Barber C, Nash J, Carroll D, Randall K, Aylor-Lee K. May 2022 Medical Image of the Month: Pectus Excavatum. Southwest J Pulm Crit Care Sleep. 2022;24(5):72-3. doi: https://doi.org/10.13175/swjpccs015-22 PDF

Medical Image of the Month: Mounier-Kuhn Syndrome

Figure 1. AP chest x-ray showing significant tracheomegaly (diameter 30.8 mm), bilateral interstitial infiltrates with dense consolidation more at the lower lobes (left>right).

Figure 2. Axial thoracic CT in lung windows (A-D) and soft tissue windows (E-F). Sagittal CT in soft tissue windows (G-H). A: tracheal diameters in 2 dimensions (coronal 30.4 mm, sagittal 37.6 mm), para-septal emphysema (yellow arrows). B: showing tracheomegaly (23.2 x 34.3 mm) and para-septal emphysema changes (yellow arrows. C: enlarged mainstem bronchi diameters (right mainstem 22.3 x 30.6 mm, left mainstem 24.4 x 16.0 mm). In addition to central bronchiectatic changes (red arrows), left lower lobe consolidative changes (blue arrow). D: dense left lower lobe consolidation and para-septal emphysema. E: Significant tracheomegaly (31.5 x 41.a mm) and dilated esophagus (orange arrow). F: Significant tracheomegaly and dilated esophagus.

Figure 3. A: Sagittal CT scan (soft tissue window) showing significant tracheomegaly (sagittal diameter 35.8 mm). B: Sagittal CT chest (lung window) showing significant tracheomegaly, multiple tracheal diverticuli (green arrows) on the upper posterior tracheal wall.

Figure 4. Pulmonary function testing.

A 52-year-old non-smoking, Caucasian male patient with a past medical history of reported chronic obstructive pulmonary disease (COPD), recurrent lower respiratory tract infections, prior history of pneumothorax, and dysphagia presented with fevers and shortness of breathing associated with a productive cough for one week. Clinically, he was mildly tachypneic and chest auscultation revealed crackles bilaterally - more prominent at the left base. A chest radiograph (Figure 1) showed bilateral lower lobe pulmonary opacities (left more than right). Computed tomography (CT) of the chest demonstrated airspace disease in the lower lobes in addition to significant tracheobronchomegaly along with paraseptal emphysema and central bronchiectatic changes (Figures 2 and 3). Upper posterior tracheal wall diverticulae were also noted (Figure 3). Serum α₁-antitrypsin level and serum immunoglobulins, including IgE levels, were normal. Our patient declined performing diagnostic bronchoscopy. He had a pulmonary function test performed few months prior to his hospital admission which showed combined mild obstructive/restrictive pattern (Figure 4). He responded well to empiric antibiotics and chest percussion therapy. He was discharged in stable condition.

Discussion

On the basis of above findings, a diagnosis of Mounier-Kuhn syndrome complicated by pneumonia was made. The syndrome was first described by P. Mounier-Kuhn in 1932 (1). The diagnosis is usually made when the tracheal diameter is greater than 3 cm on a CT chest (measured 2 cm above the aortic arch) (2). Other diagnostic criteria include a mainstem bronchial diameter of 20-24 mm (right) and 15-23 mm (left) (3). Our patient’s tracheal diameter was around 37 mm. Both mainstem bronchi were dilated.

The abnormal tracheobronchial dilatation in this syndrome is attributed to atrophy of the muscular and elastic tissues in the tracheal and the bronchial walls (3). Hence, in addition to tracheobronchomegaly, these patients can also develop tracheal diverticulosis along with varicose and cystic bronchiectasis (3). These patients usually present in the 3rd or 4th decade of life with nonspecific respiratory symptoms including recurrent bronchitis and subsequently end up being misdiagnosed with COPD (3).

Three subtypes of this syndrome had been described. Subtype 1 has symmetric dilation of the trachea and mainstem bronchi. Subtype 2 demonstrates tracheal dilation and tracheal diverticula. Subtype 3 has diverticular and saccular structures extending to the level of the distal bronchi (3). Our patient likely fits subtype 3 of this syndrome. Overall, treatment is supportive - usually with antibiotics, physiotherapy and postural drainage. In rare instances, tracheal stenting has been used (4). Special consideration should be taken post intubation as achieving good cuff seal can be potentially challenging.

Dysphagia has not been well documented in this syndrome and could be a coincidental finding in our case. However, theoretically, the etiology of this patient’s dysphagia could be secondary to extrinsic compression of the anterior esophageal wall by his markedly dilated trachea. Historically, he underwent multiple esophageal dilatations and at least one Botox injection over the last 5 years without any significant improvement.

Abdulmonam Ali MD and Naga S. Sirikonda MD

Pulmonary and Critical Care

Good Samaritan Hospital

Mount Vernon, Illinois

References

1. Mounier-Kuhn P. "Dilatation de la trachee: constatations, radiographiques et bronchoscopies." Lyon Med. 1932;150:106-9.
2. Menon B, Aggarwal B, Iqbal A. Mounier-Kuhn syndrome: report of 8 cases of tracheobronchomegaly with associated complications. South Med J. 2008;101(1):83-7. [CrossRef] [PubMed]
3. Falconer M, Collins DR, Feeney J, Torreggiani WC. Mounier-Kuhn syndrome in an older patient. Age Ageing. 2008;37(1):115-6. [CrossRef] [PubMed]
4. Schwartz M, Rossoff L. Tracheobronchomegaly. Chest 1994;106(5):1589-90. [CrossRef] [PubMed]

Cite as: Ali A, Sirikonda NS. Medical image of the month: Mounier-Kuhn syndrome. Southwest J Pulm Crit Care. 2019;19(2):73-5. doi: https://doi.org/10.13175/swjpcc044-19 PDF 

Medical Image of the Month: Pectus Excavatum

Figure 1. A) PA chest radiograph at 38 years old demonstrates rib cage growth arrest at the time of pectus repair. B) and C) demonstrate the coronal and sagittal CT chest views.

Figure 2: Pulmonary function tests demonstrate severe restrictive ventilatory defect.

Clinical History

A 38-year-old man with obesity and history of pectus excavatum post-operative surgical repair at age 4 presented to the general pulmonary clinic with symptoms of severe dyspnea on exertion after walking one block. Chest x-ray and thoracic CT scan demonstrate anterior chest wall depression. (Figure 1). Pulmonary function testing demonstrated a severe restrictive lung disease (Figure 2).  High resolution CT demonstrated anterior chest wall depression. The Haller index was 2.5—mild excavatum—with associated scarring in the anterior right lung. Expiratory air-trapping was seen consistent with small airways disease.

Haller Index

The Haller index is calculated by dividing the transverse diameter of the chest by the anterior-posterior distance on the CT of the chest on the axial slice that demonstrates the smallest distance between the anterior surface of the vertebral body and the posterior surface of the sternum (1). Normal chest < 2.0; mild excavatum 2.0 – 3.2; moderate excavatum 3.2 – 3.5; severe excavatum > 3.5. Corrective surgery is considered for a Haller index of greater than or equal to 3.25.  Secondary thoracic dystrophy is a known consequence of too early repair of pectus excavatum (1).  Cases like our patient have changed when surgical repair is attempted until after puberty.

Michael Insel, MD and Janet Campion, MD

Division of Pulmonary, Allergy, Critical Care and Sleep Medicine

Banner University Medical Center-Tucson

Tucson, AZ USA

Reference

1. Haller JA Jr, Colombani PM, Humphries CT, Azizkhan RG, Loughlin GM. Chest wall constriction after too extensive and too early operations for pectus excavatum. Ann Thorac Surg. 1996 Jun;61(6):1618-24. [CrossRef] [PubMed]

Cite as: Insel M, Campion J. Medical image of the month: pectus excavatum. Southwest J Pulm Crit Care. 2019;18(2):50-1. doi: https://doi.org/10.13175/swjpcc124-18 PDF

Medical Image of the Week: Bilateral Vocal Cord Paralysis

Figure 1. Flow-volume curve demonstrating flattening of both the inspiratory and expiratory limbs consistent with extra-thoracic obstruction.

Figure 2. Video demonstrated the vocal cords essentially fixed in the adducted position during the inspiratory and expiratory cycle.

A 59-year-old morbidly obese woman with acute hypoxemic respiratory failure secondary to pulmonary emboli required emergency intubation. She was described by the anesthesiologist as having a difficult airway. The patient was liberated from the ventilator after two days. Following extubation she complained of hoarse voice and dyspnea. Physical exam revealed audible stridor. The upper airway was normal by CAT imaging. Flow-volume curve demonstrated marked flattening of both the inspiratory and expiratory limbs, consistent with a fixed extra-thoracic obstruction (Figure 1). Endoscopy revealed the vocal cords to be in the adducted position, with minimal movement throughout the respiratory cycle, consistent with bilateral vocal cord paralysis (Figure 2).

Traumatic intubation follows thyroid surgery as the most common cause of bilateral vocal cord paralysis (1). In a minority of patients spontaneous recovery may occur. Surgical treatment options include cordotomy or tracheostomy. Nocturnal BIPAP has been used in patients who decline surgery (2).

Charles J. Van Hook MD, Britt Warner PA-C, Angela Taylor MD,  and Jacquelynn Gould MD.

Longmont United Hospital

Longmont, CO USA

References

1. Brandwein M, Abramson AL, Shikowitz MJ. Bilateral vocal cord paralysis following endotracheal intubation. Arch Otolaryngol Head Neck Surg. 1986 Aug;112(8):877-82. [CrossRef] [PubMed]
2. Rosenthal LH, Benninger MS, Deeb RH. Vocal fold immobility: a longitudinal analysis of etiology over 20 years. Laryngoscope. 2007 Oct;117(10):1864-70.[CrossRef] [PubMed]

Cite as: Van Hook CJ, Warner B, Taylor A, Gould J. Medical image of the week: bilateral vocal cord paralysis. Southwest J Pulm Crit Care. 2017;15(2):82-3. doi: https://doi.org/10.13175/swjpcc099-17 PDF