Thank you to the ICU team for presenting a chest xray with a pneumothorax c/b re-expansion pulmonary edema.
The deep sulcus sign
- The most common finding of a pneumothorax on chest xray is the loss of lung vascular markings.
- In a supine patient, the air can collect anteriorly and basally such that it does not show up in the classic way on a chest xray
- instead, the costophrenic angle appears abnormally, disproportionately deep.
- If you see an asymmetric, deep costophrenic angle on a chest xray, suspect a pneumothorax!
- see an example below
The ddx of pneumothorax
- primary pneumothorax – no underlying structural cause
- structural lung abnomalities
- cystic fibrosis
- lung malignancy
- PCP – causes 80% of pneumothoraces in patient with HIV. That’s why it’s called pneumocystis
- necrotizing pneumonia
- barotrauma from mechanical ventilation
- Anything else that changes the lung architecture including ILD
- catamenial pneumothorax (pneumothorax caused by thoracic endometriosis. Yikes.)
- Oxygen for all! watch out for hypercapnea in people with severe COPD
- Further management depends on size on chest xray
- >2cm – chest tube, small bore more comfortable than large bore and just as efficacious
- 1-2cm – needle aspiration vs small bore chest tube
- <1cm – oxygen and observation
A useful resource:
- Where did you get that stunning chest xay, you ask? From http://radiopaedia.org/articles/deep-sulcus-sign
- Radiopaedia is a curated (as in radiologists read, review, and update the entries) website to help you figure out what the heck is on that chest xray.
- They also do great april fools jokes: http://radiopaedia.org/cases/april-fools-2016-cactus-disease-paleo-induced-mineral-periostitis
Happy Monday everyone!