EM REMS

This chest xray was posted several days ago:

What’s wrong with this picture?

1.  There is an endotracheal tube in the upper trachea, it needs to be advanced!

The other finding on this xray is a right middle lobe pneumonia.  At first this may appear to be a pleural effusion due to the relatively linear appearance to the upper edge of the infiltrate.  However this is a supine film and the diaphragm can be easily seen on the right side.  Effusions, unless loculated, will layer posteriorly in a supine film and the entire lung space will look more radio opaque than the opposing lung.  The fact that the diaphragm can be seen indicates the infiltrate doesn’t come into contact with the diaphragm (see prior post describing “silhouette” phenomena).  Thus, this is a right middle lobe infiltrate.

Author:  Russell Jones, M.D.

Just a quick image of left lower lobe pneumonia today:

In this image the left heart border is obscured and there is an infiltrate taking up airspace in the left lower lung.  That’s it, nothin’ fancy about it.

The symptoms of pneumonia described by Hippocrates (c. 460 BC – 370 BC) (1):

Peripneumonia, and pleuritic affections, are to be thus observed: If the fever be acute, and if there be pains on either side, or in both, and if expiration be if cough be present, and the sputa expectorated be of a blond or livid color, or likewise thin, frothy, and florid, or having any other character different from the common… When pneumonia is at its height, the case is beyond remedy if he is not purged, and it is bad if he has dyspnoea, and urine that is thin and acrid, and if sweats come out about the neck and head, for such sweats are bad, as proceeding from the suffocation, rales, and the violence of the disease which is obtaining the upper hand.

Begs the question:  what does “purged” mean?

Author:  Russell Jones, MD

References

1.  Pneumonia History. http://www.news-medical.net/health/Pneumonia-History.aspx

This patient presented with a cough, fever, and dyspnea.  Here is her Chest Xray:

This is a great example of a right middle lobe (RML) pneumonia.  Some features that help distinguish the lobe include:

The right diaphragm is visible.  The lobe overlying the diaphragm is the lower lobe and a RML will sometimes not “silhouette” the right diaphragm.  ”Silhouette” is when a radiographically dense material such as fluid comes into contact with another radiodense thoracic structure such as the diaphragm.  Silhouetting can be seen with the right heart border.  Thus, this fluid on the xray is touching the right heart border but not the diaphragm.  The lobe that corresponds with this is the RML.

A lateral radiograph can also help you identify which lobe is involved (not provided here).

Author:  Russell Jones, MD

Don’t you love working Jan and Feb in the Peds ED?  Or as I like to refer to it as the Mucus ED.

What findings on Chest Xray are consistent with viral pneumonia?

Viral respiratory infections commonly cause an “interstitial” pattern on Chest XR.   Interstitial patterns can also be found in atypical bacterial pneumonia from organisms such as Bordatella pertussis, Chlamydia pneumonia, and Mycoplasma.  Findings include peribronchial cuffing, perihilar infiltrates or “haze”.  Peribronchial cuffing can be seen on the XR above:

Other findings in interstitial patterns can include fluid in fissures, bands of atelectasis.

Bronchioles are usually very difficult, if not impossible to identify in cross-section on a Chest XR.  They look like a small clear circle with a thin wall.  However, when they are inflammed and have surrounding edema peribronchial cuffing occurs.  Basically you see a dense fluid around an air-filled bronchiole.  This can be seen in asthma, viral illnesses, heart failure, pertussis, and other pathology (1).  Here is a link to a good web image of peribronchial cuffing close up and on crossection:

http://www.torontonotes.ca/interstitial-disease/peribronchial-cuffing

It is important to note that the Chest XR can support your diagnosis of viral respiratory infection but it is not 100%.  Keep in mind the atypical organisms and prescribe antibiotics if highly suspicious.  Prescribing antibiotics in respiratory infections is a controversial topic with many different thoughts and practice patterns.  I’m not going to poke that sleeping bear…

Author:  Russell Jones, MD

References

1.  Broder JS.  Diagnostic Imaging for the Emergency Physician.  Elsevier 2011.  Pg. 241.

Here is a good Chest XR showing an infiltrate which shows up on the lateral projection.  On the AP you can get a hint of infiltrate along the L cardiac border but it isn’t very impressive.  However on the lateral you can really see the infiltrate as you get into the diaphragmatic recess.  Normally on the lateral projection the vertebral bodies will become more lucent (darker) as you approach the diaphragm.  One of the signs of a left lower lobe pneumonia is loss of the vertebral lucency on the lateral projection (as in this case).  Other signs can be silhouetting of the diaphragm (the diaphragm will be obscured by infiltrate).

Author:  Russell Jones, MD