Drs. Claire Milam and Alyssa Thomas are Emergency Medicine Residents and interested in medical education. With the guidance of Dr. Michael Gibbs, a notable Professor of Emergency Medicine, they aim to help augment our understanding of emergent imaging. Follow along with the EMGuideWire.com team as they post these monthly educational, self-guided radiology slides on: • Spontaneous Pneumothorax • Esophageal Stent • Iatrogenic Pneumothorax • Pleural Effusion • Shoulder Dislocation • Proximal Humeral Fracture • Aspiration Event • Subcutaneous Emphysema • Metastatic Germ Cell Cancer • ARDS • Right Lower Lobe Pneumonia • Mediastinal Mass

1. Adult Chest X-Rays Of The Month
Alyssa Thomas MD & Claire Milam MD
Department of Emergency Medicine
Carolinas Medical Center & Levine Children’s Hospital
Michael Gibbs MD, Faculty Editor
Chest X-Ray Mastery Project
May 2020

2. Disclosures
 This ongoing chest X-ray interpretation series is proudly sponsored by the
Emergency Medicine Residency Program at Carolinas Medical Center.
 The goal is to promote widespread mastery of CXR interpretation.
 There is no personal health information [PHI] within, and ages have been
changed to protect patient confidentiality.

3. Process
 Many are providing cases and these slides are shared with all contributors.
 Contributors from many CMC/LCH departments, and now from EM
colleagues in Brazil, Chile and Tanzania.
 Cases submitted this month will be distributed next month.
 When reviewing the presentation, the 1st image will show a chest X-ray
without identifiers and the 2nd image will reveal the diagnosis.

4. Visit Our Website
www.EMGuidewire.com
For A Complete Archive Of Chest X-Ray Presentations And Much More!

5. Airway
Bones
Cardiac
Diaphragm
Effusion
Foreign body
Gastric
Hilum

6. It’s All About The Anatomy!

7. 59-Year-Old Male
Presents With
Shortness of
Breath

8. 59-Year-Old Male
Presents With
Shortness of
Breath
Diagnosis: Spontaneous Pneumothorax

9. Pneumothorax Resolved with Pigtail
Chest Tube
Note the Development of
Subcutaneous Emphysema
59-Year-Old Male
Presents With
Shortness of
Breath

10. Follow Up Chest X-Ray.
What do you notice?
59-Year-Old Male
Presents With
Shortness of
Breath

11. Follow Up Chest X-Ray.
What do you notice?
Recurrence of
Pneumothorax
59-Year-Old Male
Presents With
Shortness of
Breath

12. Patient Further Deteriorated, and Now Has Both a
Large Bore Chest Tube and an Endotracheal Tube.
What is Missing in This View?
Sentinel Hole

13. Could Not See the Costophrenic Angle or Chest
Tube Insertion Site and Required Second Image

14. How Many Tubes
Can You Find Now?
Patient Has Persistent Pneumothorax

15. How Many Tubes
Can You Find Now?
1) Endotracheal Tube
2) Large Bore Chest Tube
3) Pigtail Chest Tube
4) Orogastric Tube
Patient Has Persistent Pneumothorax

16. What Secondary Finding of
Pneumothorax is Present?
Patient Has Persistent Pneumothorax

17. Subcutaneous Emphysema
Notice the Outline of the Pectoralis Muscle
Patient Has Persistent Pneumothorax

18. Patient Extubated post
VATS and Chemical
Pleurodesis, but
Clinically Deteriorated.
Worsening Subcutaneous Emphysema

19. Patient Extubated post
VATS and Chemical
Pleurodesis, but
Clinically Deteriorated.
Patient Underwent:
 Intubation
 Bedside Bronchoscopy
 Bronchial Blocker Placement
 Taken to the OR

20. In the OR, Patient Had a
Third Chest Tube Placed
Can You Identify All of the Tubes/Lines?

21. In the OR, Patient Had
Third Chest Tube Placed
Can You Identify All of the Tubes/Lines?

22. Fortunately, After Multiple Interventions, the Patient Improved and Was Able to Be
Discharged to Home.

23. Primary Spontaneous Pneumothorax (PSP)
Recurrence rates vary widely; recent meta-analysis showed that 32% of patients will
experience PSP recurrence with most occurring within the first year.
Risk Factors for Recurrence
 Female sex
 Low BMI
 Smoking
 Insufficient evidence to support the presence of bullae on imaging as a
predictor of recurrence
Citation: Steven P. Walker, Anna C. Bibby, Paul Halford, Louise Stadon, Paul
White, Nick A. MaskellEuropean Respiratory Journal Sep 2018, 52 (3) 1800864;
DOI: 10.1183/13993003.00864-2018

24. Indications for Video-assisted thoracoscopic surgery (VATS) Pleurodesis
Citation: Sawada S, Watanabe Y, Moriyama S. Video-Assisted Thoracoscopic Surgery for Primary
Spontaneous Pneumothorax. Chest. 2005;127(6):2226-2230. doi:10.1378/chest.127.6.2226.

25. Citation: Sawada S, Watanabe Y, Moriyama S. Video-Assisted Thoracoscopic Surgery for Primary Spontaneous Pneumothorax.
Chest. 2005;127(6):2226-2230. doi:10.1378/chest.127.6.2226.

26. Video-assisted thoracoscopic surgery (VATS) Pleurodesis
What does pleurodesis mean?
“Desis” means “binding” in Greek; binding the visceral and parietal
pleura together to prevent accumulation of air or fluid in the pleural
space
How is pleurodesis performed?
Pleurodesis is performed either mechanically or chemically
The idea is to create pleural irritation  inflammatory reaction
leading to fibrogenesis

27. • This typically occurs during VATS
• There is variation amongst institutions and surgeons
• Common mechanisms:
• Creating a pleural abrasion with dry gauze
• Parietal or full pleurectomy
• Intrapleural insufflation of a chemical (Talc or
tetracycline derivative)
• Combination of the above
• This typically occurs in nonsurgical candidates
• Intrapleural injection of a chemical irritant via
chest tube
• Antibiotics (i.e tetracycline derivative)
• Talc (cheap sclerosant that is very
effective)
Pleurodesis
Mechanical Pleurodesis Chemical Pleurodesis
Nonsurgical pleurodesis is not as
effective as mechanical pleurodesis and
has higher recurrence rates

28. 62-Year-Old Male
Presents With
Shortness of
Breath

29. 62-Year-Old Male
What Other Finding Can You See that Gives us a
Hint into this Patient’s History?
Patient Has Bilateral
Opacities Concerning for
Pneumonia/ARDS
(Note Endotracheal Tube)
However, What Else Could
Be Going On?

30. 62-Year-Old Male
Presents With
Shortness of
Breath
Esophageal Stent
Should Consider Esophageal Perforation, etc

31. 41-Year-Old
Female Presents
for CT-Guided
Lung Biopsy

32. 41-Year-Old
Female Presents
for CT-Guided
Lung Biopsy

33. Diagnosis: Iatrogenic Pneumothorax

34. Resolved Post Pigtail Chest Tube

35. 72-Year-Old
Female Presents
with Shortness of
Breath after
Lobectomy

36. 72-Year-Old
Female Presents
with Shortness of
Breath after
Lobectomy
Also Notice the Staples from
Her Recent Procedure
Diagnosis: Pleural Effusion

37. Diagnosis: Pleural Effusion
72-Year-Old
Female Presents
with Shortness of
Breath after
Lobectomy

38. 72-Year-Old Male
Presents with
Difficulty
Breathing

39. 72-Year-Old Male
Presents with
Difficulty
Breathing
Diagnosis: Mediastinal Mass and RLL Opacification

40. 72-Year-Old Male
Presents with
Difficulty
Breathing
Mass Causing Bronchial Obstruction
and RLL Atelectasis

41. 33-Year-Old Male
Presents with
Cough

42. 33-Year-Old Male
Presents with
Cough
Diagnosis: Metastatic Germ Cell Cancer

43. 33-Year-Old Male
Presents with
Cough
Diagnosis: Metastatic Germ Cell Cancer

44. Mediastinal Masses
Mediastinal masses are relatively uncommon, only representing 3% of tumors seen within the chest.
They can be primary or secondary with secondary mediastinal tumors being the most common
The mediastinal space is composed of three compartments and location is helpful in differentiating the
mass:
Anterior: Thymoma, germ cell, thyroid disease, lymphoma
Middle: Congenital cysts
Posterior: Neurogenic tumors
Clinical Presentation
 Asymptomatic, incidental finding
 Symptomatic from compression or direct invasion of surrounding structures
 Systemic symptoms from the tumor itself
Citation: Aroor AR, Prakasha S R, Seshadri S, S T, Raghuraj U. A study of clinical characteristicsof
mediastinal mass. J Clin Diagn Res. 2014;8(2):77‐80. doi:10.7860/JCDR/2014/7622.4013

45. Two year prospective study on 35 patients with confirmed mediastinal masses
Most of the patients were seen in the 3rd decade (25.71%)
Majority were symptomatic at presentation (94.3%)
Malignant lesions (68.57%) were more common than benign (31.43%)
Mediastinal widening on chest X-ray was seen in 27 cases (77.14%)
Anterior mediastinum was the commonest compartment involved (42.86%)
Citation: Aroor AR, Prakasha S R, Seshadri S, S T, Raghuraj U. A study of clinical characteristicsof mediastinal mass. J
Clin Diagn Res. 2014;8(2):77‐80. doi:10.7860/JCDR/2014/7622.4013

46. 72-Year-Old Male
with Mass
Causing Bronchial
Obstruction
Post Stenting

47. Notice the Difference with Appropriate Rotation.
RLL Atelectasis Improved

48. 52-Year-Old Male
Presents with
Cough

49. 52-Year-Old Male
Presents with
Cough
Diagnosis: Right Lower Lobe Pneumonia

50. Always Get a
Lateral View
When Able!
Notice the “Spine Sign”

51. 36-Year-Old Male
Presents After
Car Accident

52. 36-Year-Old Male
Presents After
Car Accident
Diagnosis: Left Proximal Humerus Fracture
DON’T FORGET ABOUT THE BONES!

53. Notice fracture is
not seen, though
Notice Poor Rotation on the Left Image Causing Abnormal Appearing Mediastinum.
Repeat CXR on the Right with Better Rotation and More Normal Appearance.
Look at the Clavicles for Rotation

54. 36-Year-Old Male
Presents After
Car Accident
Diagnosis: Left Proximal Humerus Fracture

55. 25-Year-Old Male
Presents after Fall

56. 25-Year-Old Male
Presents after Fall
Diagnosis: Right Shoulder Dislocation
DON’T FORGET ABOUT THE BONES!

57. 37-Year-Old Male
Presents with
Shortness of
Breath

58. Notice Lung
Collapse
Diagnosis: Large Right-Sided
Pneumothorax

59. 37-Year-Old Male
Presents with
Shortness of
Breath
Re-expansion of Right Lung
with Chest Tube

60. 20-Year-Old
Female Presents
after Car Accident

61. 20-Year-Old
Female Presents
after Car Accident
Initial CXR Normal in Trauma Bay

62. 20-Year-Old
Female Presents
after Car Accident
Intubated for Hip Reduction

63. 20-Year-Old
Female Presents
after Car Accident
Patient was Extubated Post
Procedure.
Unfortunately, She was
Found Not Protecting Her
Airway and Required
Reintubation for Hypoxia for
Presumed Aspiration Event.

64. 20-Year-Old
Female Presents
after Car Accident
Diagnosis: ARDS

65. 20-Year-Old
Female Presents
after Car Accident
Worsening ARDS and RUL Opacity
Consistent with Aspiration Event

66. 20-Year-Old
Female Presents
after Car Accident
Patient Now on ECMO

67. Summary Of Diagnoses This Month
 Spontaneous Pneumothorax
 Esophageal Stent
 Iatrogenic Pneumothorax
 Pleural Effusion
 Shoulder Dislocation
 Aspiration Event
 Subcutaneous Emphysema
 Metastatic Germ Cell Cancer
 ARDS
 Humeral Fracture
 Right Lower Lobe Pneumonia
 Mediastinal Mass

68. See You Next Month!