The Unofficial Guide to Radiology by Mohammed Rashid Aktar Na'eem Ahmed Nihad Khan Mark Rodrigues Zeshan Qureshi

Author:Mohammed Rashid Aktar,Na'eem Ahmed,Nihad Khan,Mark Rodrigues,Zeshan Qureshi
Language: eng
Format: epub
Publisher: National Book Network International
Published: 2017-04-20T16:00:00+00:00

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CASE 42: REPORT – HYDROPNEUMOTHORAX

Patient ID: Anonymous

Projection: PA mobile erect

Penetration: Adequate – vertebral bodies just visible behind heart

Inspiration: Adequate – 7 anterior ribs visible

Rotation: The patient is slightly rotated to the left

AIRWAY

The trachea is central after factoring in patient rotation.

BREATHING

There is homogeneous opacification of the right mid and lower zones. Its upper margin is horizontal and there is complete loss of bronchovascular markings in the right upper zone, consistent with an air-fluid level.

The left lung field and pleural spaces are clear. The lungs are not hyperinflated.

Normal left pulmonary vascularity.

CIRCULATION

The right heart border is not visible. The cardiac size therefore cannot be commented on. The left heart border is clear.

The aorta appears normal.

The mediastinum is central, not widened, with clear borders.

The right hilum is not visible. Normal size, shape and position of the left hilum.

DIAPHRAGM + DELICATES

The right hemidiaphragm is obscured. Normal position and appearance of the left hemidiaphragm.

No pneumoperitoneum.

The imaged skeleton is intact with no fractures or destructive bony lesions visible.

The visible soft tissues are unremarkable with no surgical emphysema.

EXTRAS + REVIEW AREAS

No vascular lines, tubes, or surgical clips visible.

Lung Apices: Right sided pneumothorax. Normal left apex

Hila: Right hilum not visible. Normal left hilum

Behind Heart: Right retrocardiac position obscured. Normal on the left

Costophrenic Angles: Right obscured. Normal left costophrenic angle

Below the Diaphragm: Normal

SUMMARY, INVESTIGATIONS & MANAGEMENT

This X-ray demonstrates a large right-sided hydropneumothorax, with an air-fluid level. The mediastinum appears central. This may be within normal limits 4 weeks postpneumonectomy. However, the patient is septic with haemoptysis and the amount of air in the right hemithorax is concerning. These features may indicate a bronchopleural fistula and empyema.

This is an acutely unwell patient that needs urgent resuscitation. 100% oxygen should be administered via a non-rebreathe mask and there should be a low threshold for escalation of respiratory support. Two points of intravenous access should be rapidly achieved, with an arterial blood gas sent, alongside venous bloods for FBC, U/Es, LFTs, coagulation, CRP, and blood cultures. Sputum cultures should be obtained if possible.

The patient should be given a fluid bolus and appropriate intravenous antibiotics. They should be urgently discussed with cardiothoracic surgery.

The current X-ray needs to be compared with the previous imaging to assess the change in size of the postpneumonectomy space (which should get progressively smaller as it is replaced by fluid). A significant increase in the amount of air in the right hemithorax is suspicious for a bronchopleural fistula +/- empyema. An ultrasound-guided pleural aspiration should be performed to assess for empyema.

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