X-Ray RoundsChris McCrossin

Presentation

45 y/o M

presents with progressive SOB over past week

RR now 60!!

T 38.9, HR 130, BP 120/80

Can’t get much of a history because he’s too SOB to talk

You order a stat portable CXR

Diagnosis Now?

Principles of Pleural Effusions & CXR’s

Effusions when free-flowing follow the force of gravity and accumulate in the most dependent parts of the thoracic cavity

Lungs recoil proportionately when they collapse secondary to elastic recoil and maintains its original shape. The lung floats on the fluid

Fluid layers evenly anterior to posterior in an upright position

CXR Features of Subpulmonic

EffusionsUp to 1 liter can be present without blunting of the diaphragms

Elevated hemidiaphragm peaks more laterally than expected with a steep lateral slope

Pulmonary vessels are not clearly visible below the surface of the hemidiaphragm on lateral projection

A lateral decubitus view will show free flowing pleural fluid parallel to the xray table

Patient Outcome

ICU Called

Taken to the unit

Small chest tube inserted in R thorax

Drained > 1 liter of frank pus

RR 30 min post chest tube: 16 bpm

Take-Home Points

Pleural effusions and subpulmonic effusions/abscess can look very different

Both can be confused as infiltrates or atelectasis

When you have a patient who is in extremis and you suspect a infiltrative process in the lungs, ask yourself if there is something you can possibly drain, consider a lateral decubitus if you are uncertain