3. Case1 32歳女性: 呼吸苦 ショック
A) ER portable 挿管（-）
B) 左第３－７肋骨骨折がみられる。また、左胸部に軽度の皮下気腫を認め
る。（頸部は提示されていない）
C) 左側 CP angle は dull です。
D) 気管・右左気管支とも激しく右方に偏移。
E) 縦隔は極端に右側へ偏位している（圧排されている） 。心拡大なし。左
右の心辺縁および、下大静脈もスムーズに追え、左右肺門部の拡大は
ありません。
F) 左側胸壁から肺が虚脱し、左横隔膜が下方に偏移している。
Chest X-ray of left-sided pneumothorax (seen on the right in this image). The
left thoracic cavity is partly filled with air occupying the pleural space. The
mediastinum is shifted to the opposite side
48. Supine Pneumothorax
Distribution of pneumothorax in the supine and
semirecumbent critically ill adult.
Tocino IM, Miller MH, Fairfax WR.
AJR Am J Roentgenol. 1985 May;144(5):901-5.
Although a number of radiologic signs of pneumothorax in the supine
patient have been reported, the frequency of involvement of various
pleural recesses has not been emphasized. In 88 critically ill patients with
112 pneumothoraces, the anteromedial (38%) and subpulmonic (26%)
recesses were the most commonly involved in the supine and
semirecumbent position. In this study, 30% of pneumothoraces were
not initially detected by the clinician or radiologist, and half of these
progressed to tension pneumothorax. Knowledge of the most common
recesses involved in pneumothorax and aggressive use of additional
radiographic views, including computed tomography, should increase
detection of pneumothoraces in critically ill patients.
49. Supine Pneumothorax
Pneumothorax in supine patient
Dr Yuranga Weerakkody and Dr Vinod G Maller et al.
A pneumothorax does not display classical signs when a patient is positioned
supine for a chest radiograph. Instead, it may be demonstrated by looking for
the following signs:
• relative lucency of the involved - basilar hyperlucency
• deep, sometimes tongue like costophrenic sulcus - deep sulcus sign
• anteromedial pneumothorax (earliest location)
increased sharpness of the adjacent mediastinal margin and diaphragm
increased sharpness of the cardiac borders
• visualization of the anterior costophrenic sulcus - double diaphragm sign
• visualization of the inferior edge of the collapsed lung above the diaphragm
• depression of the ipsilateral hemidiaphragm- depression of diaphragm
50. Anteromedial pneumothorax
(Anteromedial Recess)
AP chest X-ray showing right
pneumothorax with complete lung collapse.
Transverse CT confirms this finding.
The classical appearance in the upright
position is the presence of radiolucent air
and the absence of lung markings between
the shrunken lung and the parietal pleura.
In the supine ventilated patient, gravity and
the effects lung disease often give rise to a
different appearance of the so-called
‘supine pneumothorax’. The pneumothorax
is usually anteromedial or sub-pulmonic
causing lucent upper quadrants of the
abdomen, sharp superior surfaces of the
diaphragm, the deep sulcus sign, and
visualization of the inferior surface of
consolidated lung.[9] Less often, the
pneumothorax is apical, lateral (displaces
the minor fissure from the chest wall), or
posteromedial. False-positive appearances
may occur from skin folds, overlying
tubing/dressing/lines, and prior chest tube
tracks.
53. Medial Stripe Sign
縦隔・心陰影の左側に沿って
透亮影が大動脈弓を越えて続
く。
Sign of LUL(left upper lobe) collapse -looks like an "air crescent", where
hyperexpanded superior segment of LLL
surrounds aortic arch
- lucent stripe between the medial edge
of the collpased segment and the aortic
arch.
The is lower lube that has been pulled up
by the collpased lung (Luftsichel Sign)
54. Deep Sulcus Sign
Chest X-ray demonstrating
the deep sulcus sign
suggestive of left anterior
pneumothorax in a supine
ventilated patient.
62. Safe Triangle
The 'safe triangle' for
inserting a chest drain.
The most common position for
chest tube insertion is in the midaxillary line, through the ‘safe
triangle’ . This position
minimizes risk to underlying
structures such as the viscera
and internal mammary artery and
avoids damage to muscle and
breast tissue resulting in
unsightly scarring. A more
posterior position may be chosen
if suggested by the presence of a
loculated collection. While this is
relatively safe, it is not the
preferred site as it is more
uncomfortable for the patient to
lie on after insertion and there is
more risk of the drain kinking.
