Yesterday I hit you with a chest x-ray after chest tube insertion in a young man who presented with a pneumothorax. The lung was not yet expanded (chest x-ray taken less than 5 minutes after the procedure).
So what’s wrong? I had a lot of good guesses yesterday (@ResusReview, @uclamutt, and others in the comments to name a few), but nobody quite got it. Yes, the lung is not up yet. No, the tube is not in a fissure. The person inserting the tube worked up a sweat doing it, taking about 10 minutes to get it in. But some air came out initially, and the tube rotated freely on its axis.
Here’s another one to challenge your skills! A young male presents to your ED after minor chest trauma with pleuritic chest pain and slight shortness of breath. A chest x-ray is obtained which shows a large pneumothorax on the right. You insert a chest tube, and the procedure goes well.
Another x-ray taken immediately after insertion looks like this:
The lung is not yet fully expanded, but the patient already feels better.
What is wrong in this picture? Tweet or leave comments. Hints tomorrow if I don’t receive the correct answer.
Pneumothorax is typically diagnosed radiographically. Significant pneumothoraces show up on chest xray, and even small ones can be demonstrated with CT.
Typically, a known pneumothorax is followed with serial chest xrays. If patient condition permits, these should be performed using the classic technique (upright, PA, tube 72" away). Unfortunately, physicians are used to ordering the chest xray as a bundle of both the PA and lateral views.
The lateral chest xray adds absolutely no useful information. The shoulder structures are in the way, and they obstruct a clear view of the lung apices, which is where the money is for detecting a simple pneumothorax. The xray below is of a patient with a small apical pneumothorax. There is no evidence of it on this lateral view.
Bottom line: only order PA views (or AP views in patients who can’t stand up) to follow simple pneumothoraces. Don’t fall into the trap of automatically ordering the lateral view as well!
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