Atelectasis due to Hypoventilation and Mucus Plug

Author: V. Dimov, M.D.
Reviewer: S. Randhawa, M.D.

A 57 yo AAM is admitted to the hospital with CC: SOB for 3-4 days. He is confused and c/o cough productive of yellow sputum. He remembers falling 4 times over the last 3 weeks without loosing consciousness. In the ER the patient was very tachypneic and hypoxic, and was intubated.

CXR showed a right lung opacification.

What is the most likely reason for the lung opacification?
Pneumonia?
Effusion?
Atelectasis?

The CXR is shown below:


Right lung atelectasis with mediastinal shift. ETT ends at the level of clavicles. The optimal position is in the middle between the clavicles and the carina. This ETT needs to be advanced 2 cm.

What happened?
The CXR showed a right lung atelectasis with multiple rib fractures bilaterally.

The patient had a lot of secretions in his airway and after suctioning, the oxygenation improved. The follow-up CXR showed a resolution of the right lung atelectasis.

Note the position of the trachea on the CXR. The ETT is very close to the right bronchus and needs to be pulled out 2-3 cm.


Re-expansion of the right lung after suctioning and Mucomyst (TM) aerosols. The ETT is at the level of the right main bronchus and needs to be pulled back 2-3 cm.


Close-up of the right-sided rib fractures.

Final diagnosis:
Right lung atelectasis. Bilateral pneumonia. Bilateral rib fractures.

What did we learn from this case?
The sequence of events was: falls, multiple rib fractures, hypoventilation, atelectasis, pneumonia and respiratory failure.

Atelectasis is a common cause of lung opacification. Atelectasis pulls the trachea and the mediastinum to its side. The pneumonia does not change the position of the mediastinal structures. A large pleural effusion can push the mediastinum to the opposite side.

Also, note the size of the intercostal spaces and compare the left and right side. The intercostal spaces are diminished in atelectasis and may be widened with a large pleural effusion and pneumothorax.

Published: 02/16/2004

4 comments:

  1. Good post. I had a very similar patient just a few weeks ago. I ended up doing bronchoscopy on this patient. The CXR actually showed where the right mainstem was occluded by mucous plug.

    ReplyDelete
  2. Ralph,

    Please post a link/image.

    ReplyDelete
  3. The link is here:
    http://realicu.com/content/mucous-plugging-right-lung-collapse

    TY

    ReplyDelete
  4. Sorry to say something off topic here:

    I know such remark would surely be sneered at, but I can't hold it in anymore...Was it all that necessary to invent a new word for every technical term? Wouldn't medical students learn much more useful practices if they can skip the time memorizing these terms?

    Excuse my ignorance, but I don't at all understand the difference between using a jargon and a familiar term. If it's necessary to learn them for interpreting previous medical journals and records, why not having an expert in translating these documents?

    I just thought one writing in normal language would be more accessible to public...doctors do wish their patients to have more health knowledge base, don't they?

    Again, I'm not an expert and is simply raising a personal question, don't get me wrong.

    ReplyDelete