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Lung Mets…

August 16, 2013

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This patient has a history of recently diagnosed uterine cancer and came in with dyspnea:

Mets

Just a simple CXR showing multiple lesions highly suspect of secondary lung neoplasms (metastasized uterine cancer).

The most common type of uterine malignancy is endometrial carcinoma.  It commonly metastasizes to lung, liver, brain, vagina, bone, and abdominal and pelvic lymph nodes (1).  Almost any malignancy can metastasize to the lung due to its rich blood flow, however here is a list of some of the more common primary sites that metastasize to the lungs:

  • Bladder
  • Colon
  • Breast
  • Prostate
  • Wilm’s Tumor
  • Neuroblastoma

Author:  Russell Jones, MD

References

1.  Endometrial Cancer Treatment.  National Cancer Institute. http://www.cancer.gov/cancertopics/pdq/treatment/endometrial/HealthProfessional/page1.  Accessed 8/2013.

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“Doc I’m a little short of breath…”

July 9, 2013

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I had a man present the other day with dyspnea, mostly on exertion, minimal pleuritic chest pain.  He was hemodynamically stable while sitting in the gurney but would desaturate to the high 80s and become tachycardic with walking several feet.  He had a history of recently diagnosed multiple myeloma and was awaiting treatment initiation.  Here’s what we found on Chest CT:

Central PE 2Central PE 1

 

The chest CT shows a “saddle embolus.”  This is a pulmonary embolus that is very large and located in the proximal pulmonary artery before it bifurcates into the right and left pulmonary arterial tree.  This type of pulmonary embolus represents a large clot burden that can easily lead to hemodynamic instability and sudden death.  In fact, it was very suprising that this patient was so stable sitting in the gurney.  Initially he was reading a book on his tablet which I usually associate with no emergent pathology! 

This is a good time to review the indications for thrombolysis in pulmonary embolus:

  • Severe hypoxemia
  • Intractable hypotension
  • Large perfusion defect on ventilation-perfusion scans
  • Extensive embolic burden on computed tomography
  • Right ventricular dysfunction
  • Free-floating right atrial or ventricular thrombus
  • Patent foramen ovale
  • Cardiopulmonary resuscitation

These are all relative indications and it is important to weigh the risks of thrombolytics on a case-by-case basis.  There are no true indications for thrombolytics.  There are many widely accepted contraindications…I’ll leave it up to the reader to search for these. 

Author:  Russell Jones, MD

References:

1.  Tapson, VF.  Fibrinolytic (thrombolytic) therapy in acute pulmonary embolus and deep venous thrombosis.  www.uptodate.com.  Accessed 7/2013.

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10 month old female throwing up…

July 3, 2013

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This child was referred to the ED after an astute primary care doctor got a chest xray in the setting of a week of throwing up after eating:

FB 2Coin 1

The PA/LAT chest xray views above show a radioopaque object near the thoracic inlet.  The object resembles the shape and size of a penny.  Interestingly, on the lateral it almost looks like two pennies lying on top of each other.  The patient was taken to the OR and esophagoscopy was used to pull two pennies out of her upper esophagus. 

On xray, how can you differentiate between tracheal and esophageal foreign bodies?

Author:  Russell Jones, MD

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What is bronchiectasis…

June 26, 2013

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This patient presented with dyspnea and had “bronchiectasis:”

BronchiectasisBronchiectasis CXR

Bronchiectasis is a disease process in which there is localized, irreversible dilitation of the bronchial tree.  The dilitation occurs because of destruction of the normal musculature and elastic connective tissue surrounding the bronchi.  Clinically it presents as an obstructive respiratory picture similar to asthma and COPD.  The most common causes are cystic fibrosis and multiple infectious organisms (bacterial, aspergillosis, tuberculosis, histoplasmosis).  The dilated bronchi easily collapse causing air and mucus trapping, which in turn can lead to frequent respiratory infections.

Radiographically, CT scan is the diagnostic modality of choice if bronchiectasis is suspected.  Classically on plain radiograph “tram-tracking” occurs (parallel thickening of the bronchial walls) as well as cystic changes.  CT scan can further deliniate bronchiectasis by showing “tree-in-bud” abnormalities as well as multiple other signs.  For more in-depth information on radiographic findings please refer to Radiopaedia.org:

Bronchiectasis

Author:  Russell Jones, MD

References

1.   Sandhyala A, Gaillard F, et al.  Bronchiectasis.  Radiopaedia.org.  http://radiopaedia.org/articles/bronchiectasis.  Accessed 6/12/13

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Great example of a pleural effusion

June 10, 2013

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This patient came in dyspenic, has a history of metastatic lung cancer:

Pleural effusion

This is a good example of a pleural effusion.  The upright chest xray shows a fluid level on the right representing a large right pleural effusion.  The patient had a therapeutic thoracentesis and felt much better.

Author:  Russell Jones, MD

Image Contributor:  Carieann Drenten, MD

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Answer to chest Xray…

June 2, 2013

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The other day I posted this Chest Xray on an individual with cough, fevers:

PJP PNA

The xray shows diffuse interstitial infiltrates concerning for an atypical pneumonia.  The patient had several weeks of weight loss, fatigue, fevers and he had profound hypoxia into the 40s on room air.  The differential diagnosis in this situation is broad and can include common atypical bacterial pneumonia organisms (Mycoplasma, chlamydia sp, legionella, etc).  ARDS can present like this with diffuse infiltrates and hypoxia.  Influenza is also on the list of pathology.  However, the significant hypoxia also brought up Pneumocystis Jiroveci pneumonia.  An LDH was added and came back at 439 U/L (normally <200).  The patient was empirically covered with common community-acquired antibiotics plus TMP/SMX, steroids for PJP and admitted to the hospital.  His CD4 count came back 10 and a broncheoalveolar was positive on immunofluroescence testing for Pneumocystis Jiroveci.

Author:  Russell Jones, MD

Image Contributor:  James Chenoweth, MD

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Cough, fevers, interesting Chest Xray…

May 27, 2013

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This patient came in with cough, chills, fevers.  The patient’s initial pulse oximetry was 46% on room air, came up into the 90s on a non-rebreather mask.  He has had several months of weight loss and night sweats.  His chest xray:

PJP PNA

What are the concerning features of this Chest Xray and what would be on your differential diagnosis?

Answer to follow.

Author:  Russell Jones, MD

Image Contributor:  James Chenoweth, MD

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PBJ in left mainstem bronchus…

April 28, 2013

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A recent patient who presented after choking on a peanut butter and jelly sandwich…

PBJ in L mainstem CTPBJ in L mainstem CXR

This was an interesting case because of the post-intubation conundrum we faced.  The patient came in peri-arrest from hypoxia, GCS was 3 with very poor respiratory effort and oxygen saturation of 60%.  Therefore we were unable to get a great respiratory exam prior to intubation.  Bag-valve mask ventilation with 100% oxygen did not improve the situation and the patient was very difficult to bag due to obviously increased airway pressure.  The intubation was very difficult and as we were checking for bilateral breath sounds post-intubation, we noticed none on the left side.  Capnography color change was good, no gastric sounds were heard, and moisture was in the tube.  Pulling back the endotracheal tube did not change the lack of left sided lung sounds.  The patient continued to be difficult to bag with hypoxia very slowly improving from initial saturations in the 60s now to the mid-70s.  At this point all of our heart rates were around 150 and we had that sinking feeling that occurs when oxygenation doesn’t improve after intubation.

For a few minutes we were concerned about pneumothorax on the left side.  As you can tell from the xray our external landmarks such as tracheal deviation, jugular venous distention were severely limited by body habitus.  Bedside ultrasound using the linear probe was limited as well and no lung-sliding was visualized.  We basically couldn’t identify what we were seeing on ultrasound (later we found out the lung was completely collapsed and we may have been seeing diaphragm, heart, and non-aerated lung).  In the heat-of-the-moment the ED treatment team was perplexed on how to rule out a tension pneumothorax in this situation.

Luckily the patient’s oxygenation creeped above 90% and the patient didn’t have any blood pressure problems.  We took a deep breath, relaxed, and made the decision to obtain the above portable chest xray before performing empiric thoracostomy.  This turned out to be the correct decision as she had a complete obstruction of the left mainstem bronchus from aspiration of a peanut-butter sandwich.  CT chest (above) shows the obstruction at the level of the carina with collapse of the left lung.  Bronchoscopy was performed and a large amount of peanut butter, jelly, and sandwich fragments were removed with improvement in the patient’s chest xray post-procedure.

Moral of the story:  not all patients have pneumothorax or a malpositioned endotracheal tube when lung sounds are absent.

A brief alternative differential diagnosis when a patient has absent lung sounds on one side:

  1. Mainstem bronchus obstruction or compression
  2. Diaphragmatic hernia
  3. Large pleural effusion
  4. History of pneumonectomy

I’ve noticed a trend in ED training toward increased reliance on bedside ultrasound.  It is important to realize that if you are going to use ultrasound in the resuscitation decisions such as this, make sure that you are seeing something that reliably indicates the pathology you are seeking to correct.  We did not see signs that supported or refuted pneumothorax and thus the ultrasound was non-diagnostic.  I apologize for not having the ultrasound images.  We forgot to save them as we all had that panicked feeling when you’ve intubated someone and their pulse ox isn’t improving very fast!

Author:  Russell Jones, MD

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The Chest Xray you never want to see…

April 3, 2013

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…but probably most of us have!  One of the senior residents gave me this Chest Xray on a person that came in with cardiac arrest:

T PTX 1

This Chest Xray demonstrates a large pneumothorax on the right side with tension phenomena.  Tension Pneumothorax is when the air trapped in the pleural space places pressure on the mediastinal structures and you see a shift of the mediastinum in the opposite direction.

Physiologically this means that the anatomy has changed and blood flow back to the central circulation is limited by not only mechanical obstruction but increased intrathoracic pressure.

After thoracostomy:

T Ptx 2

Remember, tension pneumothorax is one of the 5h’s and 5T’s that cause cardiac arrest.  However, its unclear if this is a post CPR pneumothorax or if this was the cause of the cardiac arrest.  You can see some deformities suspicious for rib fractures mid-way down the right lung fields.  There was no indication of trauma in the patient’s presentation so these may be old or a complication of chest compressions…this could be a source of pneumothorax as well as the positive-pressure from endotracheal intubation.  Incidentally, the chest tube is inserted slightly far with kinking in the upper lung but it appears to be working with reexpansion and relief of the tension phenomena.

Author:  Russell Jones, MD

Image Contributor:  Ryan Hunt, MD

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Pediatric aspiration chest xray

March 2, 2013

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This a chest xray one of my colleagues sent me.  He is a 21 month old male who possibly aspirated part of an apple:

Aspiration 1

The interesting portion of this radiograph is the overall hyperinflation of the right lung when compared to the left.  With this clinical history, asymmetric hyperinflation is highly concerning for aspirated foreign body.  The foreign body acts as a “ball-valve,” trapping air on exhalation and therefore causing a hyperinflated lung.  It can, but often doesn’t lead to pneumothorax. 

In this case the asymmetry was visible on upright radiograph and the diagnosis of retained foreign body was made.  The child had a bronchoscopy and an apple fragment was pulled out of his right mainstem bronchus. 

Other imaging tricks in aspiration include decubitus films and expiratory films. 

1.  Expiratory films:  have the patient expire and take a plain upright radiograph.  This may accentuate the asymmetry if the ball-valve effect is causing air trapping.

2.  Decubitus films:  When laying on one’s side the dependent lung should be asymmetrically smaller than the opposing lung.  If one of the lungs stays symmetric while in the dependent position, this can be a sign of air trapping.  It is recommended to obtain films in both decubitus positions (left and right).

Also consider CT imaging as a final imaging modality.  However, the definitive study is bronchoscopy if your suspicion is high. 

Author:  Russell Jones, MD

Image Contributor:  Kendra Grether-Jones, MD

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