Tag Archives: Dyspnea

WWWTP #22 (What’s Wrong With This Picture?) Answer…

February 3, 2015

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Patient presented short of breath.  Here is his chest xray:

WWWTP #22 PA WWWTP #22 LA

What’s wrong with this picture?

The findings are very subtle.  This patient has multiple lucencies in the bony structures including ribs, clavicles, scapula, and visualized proximal humerus:

WWWTP 22 edited

This patient turned out to have leukemia.  His shortness of breath was actually symptomatic anemia and he had a severe leukocytosis with a WBC nearing 180 K/MM3.

Remember to approach all imaging with a systematic approach so you don’t miss subtle findings like this!

Author:  Russell Jones, MD

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WWWTP #22 (What’s Wrong With This Picture?)

January 27, 2015

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Patient presented short of breath.  Here is his chest xray:

WWWTP #22 PA WWWTP #22 LA

What’s wrong with this picture?

Answer to follow.

Author:  Russell Jones, MD

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WWWTP #21… Answer

October 28, 2014

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This is an interesting X-ray of a newborn with respiratory distress:

WWWTP 21

WWWTP 20

 

The upper Chest X-ray has an endotracheal tube near the carina (probably should be pulled back a bit).  It also has cardiomegally with vascular congestion.  The line coming up from below is an umbilical venous catheter in the inferior vena cava.

The “baby gram” below shows the same.  This image gives a better view of the umbilical line.

An umbilical venous catheter should traverse as this one does.  It comes straight up from the umbilicus to just above the diaphragm near the right atrium and inferior vena cava junction.  If the catheter does not go straight up and veers to the left side of the patient, it may have erroneously entered the hepatic vasculature.  This can result in hepatic complications.

The patient ended up having a double outlet right ventricle (both the aorta and main pulmonary artery are attached to the right ventricle) which is one of many anatomic heart abnormalities that can lead to congestive heart failure.  There was also a patent ductus arteriosus and a large ventral septal defect (VSD) that allowed for mixing of deoxygenated and oxygenated blood.  Without the large VSD the patient would not have been able to survive.

Author:  Russell Jones, MD

 

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Multiple masses chest..

April 3, 2014

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Late 20s male presents with shortness of breath…

Chest masses Chest masses CT

This Xray and CT show a phenomena called “Cannonball Metastases.”  This refers to innumerable descreet masses in the chest.  Two tumors are highly suspected in this case: renal cell carcinoma and choriocarcinoma.   Others that have a higher prediliction to multiple lung mets are prostate, endometrial, and synovial sarcoma (1). 

This patient ended up having a choriocarcinoma of the testes. 

Image Contributors:  Kevin Murphy, MD and Mary Bing, MD

Author:  Russell Jones, MD

References:

1.  Knipe H, Bickle I, et al.  Cannonball Metastases. www.radiopaedia.org

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COPD and dyspnea…

October 18, 2013

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This patient has a history of COPD (Chronic Obstructive Pulmonary Disease) and presented with acute shortness of breath:

COPD and PTXCOPD and PTX 2

One of the complications of COPD are pulmonary bullae.  Bullae are thin-walled, air-filled spaces that enlarge over months to years.  Sometimes they can burst, causing pneumothoracies.  This Xray demonstrates a pneumothorax on the left side in which a chest tube was placed for reexpansion.  On the right side the patient has multiple large apical bullae which are also at risk of rupture.  The chest tube is in good position with the side-port visualized inside the thoracic cavity and reexpansion of the lung is demonstrated.

Author:  Russell Jones, MD

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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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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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Holy Cardiomegally Batman…

November 18, 2012

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Just saw this guy, he presented with severe dyspnea:

 

 

This is severe cardiomegally!  He looked very bad, had HTN in the 220/120 range, and sounded wet even though his xray doesn’t appear particularly full of pulmonary edema.  IT IS CRUCIAL THAT YOU RULE OUT CARDIAC TAMPANODE WITH THIS XRAY!

Turns out this guy wasn’t that interesting.  Bedside ultrasound didn’t show an effusion.  He had a severely dilated cardiomyopathy and once we got his blood pressure under control with nitrates he improved dramatically. 

Author:  Russell Jones, MD

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Dyspnea

November 1, 2012

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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

4.  Empyema

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

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