A 62-year-old male presented with dyspnea and a portable upright chest X-ray looked like this:
The radiograph shows a complete opacification of the right hemithorax with tracheal deviation in that direction. The differential diagnosis for this radiograph includes:
1. Large pleural effusion
2. Hemothorax (especially in trauma and known malignancy)
3. Pneumonia involving all right lobes
5. Obstructing mainstem bronchus (mass or foreign body)
6. Massive aspiration
If this patient is in extremis bedside ultrasound would be very beneficial to see if this is a drainable effusion. It turns out this patient was not in severe respiratory distress, bedside ultrasound was not consistent with pleural effusion, and the patient went to CT scan. Chest CT showed a completely obstructed mainstem bronchus and fluid-filled lung parenchyma with associated atelectasis. There was no pleural effusion.
One of the interesting points of the radiograph is the tracheal deviation. This usually indicates a volume loss on the side of the deviation or a volume gain on the opposite side. Since there is no identifiable volume gain (pneumothorax) on the left side this indicates a volume loss in the form of atelectasis on the right side. This is a good example of why one should be wary of immediately performing therapeutic thoracentesis with this X-ray. Use your bedside ultrasound if you have it!
Author: Russell Jones, MD