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?
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.
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.
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.