January 2018 Imaging Case of the Month

Michael B. Gotway, MD

Department of Radiology

Mayo Clinic Arizona

Scottsdale, AZ USA

Clinical History: An 81-year-old woman with little significant past medical history complained of a dry cough for the previous 1.5 years, but without hemoptysis or shortness of breath. The patient’s past medical history was remarkable only for hypothyroidism, for which she was taking levothyroxine. She smoked for 1 year only, at age 19. Her past surgical history was negative and she denied any alcohol use. Her only other medications included vitamin D3 supplementation and over-the-counter cough medicine.

Physical examination was remarkable only for coarse, left-greater-than-right basal rales. The patient’s oxygen saturation was 98% on room air. The patient’s vital signs were within normal limits and she was afebrile.

Laboratory evaluation showed a normal complete blood count, electrolyte panel, and liver function tests. Frontal chest radiography (Figure 1) was performed.

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

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

1. Chest radiography shows basilar fibrosis
2. Chest radiography shows left lower lobe consolidation
3. Chest radiography shows mediastinal and peribronchial lymphadenopathy
4. Chest radiography shows multiple small nodules
5. Chest radiography shows normal findings

Cite as: Gotway MB. January 2018 imaging case of the month. Southwest J Pulm Crit Care. 2018;16(1):16-27. doi: https://doi.org/10.13175/swjpcc001-18 PDF 

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 

September 2017 Imaging Case of the Month

Michael B. Gotway, MD

Department of Radiology

Mayo Clinic Arizona

Scottsdale, Arizona USA 

Clinical History: A 48-year-old woman with no previous medical history presented with complaints of intermittent cough persisting several months following a recent upper respiratory tract infection. No hemoptysis was noted.

Physical examination was largely unremarkable and the patient’s oxygen saturation was 98% on room air. Upon close inspection, the right thorax appeared slightly asymmetrically smaller than the left.

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. 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 nine 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 large lung volumes
4. The chest radiograph shows multifocal consolidation and pleural effusion
5. The chest radiograph shows small cavitary pulmonary nodules

Cite as: Gotway MB. September 2017 imaging case of the month. Southwest J Pulm Crit Care. 2017;15(3):104-13. doi: https://doi.org/10.13175/swjpcc109-17 PDF 

July 2017 Imaging Case of the Month

Michael B. Gotway, MD

Department of Radiology

Mayo Clinic Arizona

Scottsdale, Arizona USA

Clinical History: A 56-year-old man with no significant past medical history presented with complaints of cough, shortness of breath, and productive sputum. Frontal and lateral chest radiography (Figure 1) was performed.

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

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

1. The chest radiograph shows a diffuse linear, interstitial pattern
2. The chest radiograph shows a large pleural effusion
3. The chest radiograph shows a mediastinal mass
4. The chest radiograph shows numerous small nodules
5. The chest radiograph shows right lower lobe consolidation

Cite as: Gotway MB. July 2017 imaging case of the month. Southwest J Pulm Crit Care. 2017;15(1):17-27. doi: https://doi.org/10.13175/swjpcc090-17 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