lateral chest radiographs for detecting pneumothorax in supine trauma patients

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REFERENCES 1. Reid C, Chan L. Emergency Medicine terminology in the United Kingdom—time to follow the trend? Emerg Med J 2001;18:79 – 80. 2. Curry C. Accident—an anachronism? Arch Emerg Med 1992;9: 331–2. e LATERAL CHEST RADIOGRAPHS FOR DETECTING PNEUMOTHORAX IN SUPINE TRAUMA PATIENTS e To the Editor: In a recent issue of this journal, Henderson and Shoenberger reported on a case of a pneumothorax that was initially missed on the supine chest film (1), a problem that has also been documented by others (2,3). As Henderson and Shoenberger indicate, most of these pneumothoraces are subsequently detected by computed tomography (CT) im- aging, but the delay in diagnosis can lead to complications including progression to tension pneumothorax and death, particularly among intubated patients receiving positive- pressure ventilation (4). It would be preferable to diagnose the pneumothorax in the Emergency Department before leaving for the CT scanner. There is extensive discussion in the Radiology literature regarding optimal patient positioning for the detection of pneumothorax, and supine anterior-posterior imaging is widely regarded to be among the least sensitive (5). Erect antero-posterior and left lateral decubitus images are more sensitive, but are contraindicated in patients who may har- bor spine injuries, are intubated, or exhibit hemodynamic instability (6,7). Fortunately, lateral “shoot-through” radio- graphs are very sensitive for detecting a pneumothorax (8,9). Patients are imaged in the supine position in a manner similar to that used in cross-table lateral spine imaging, but with the x-ray beam positioned approximately 6 inches caudad, in alignment with the patient’s axillae. Imaging should take less than 30 s. The supine lateral chest radiograph can increase the detection of anterio-medial and subpulmonic pneumothora- ces—the most common sites of pneumothorax in supine patients, and allow clinicians to definitively address related issues before leaving the resuscitation area (10). Patients may still need a chest CT scan to evaluate other injuries, and CT imaging may occasionally detect a pneumothorax that was not visible on supine lateral radiographs. More- over, it is sometimes difficult to lateralize the pneumothorax on the lateral film if there are not other indicators (rib fractures, stab wounds, gunshots) of which side has the injury. However, there is still utility of this rapid, easily- performed and interpreted, low radiation study for improv- ing our detection of pneumothorax in the ED. Edward S. Cotner, MD Olive View/UCLA Emergency Medicine Residency Program Los Angeles, California doi:10.1016/j.jemermed.2005.03.003 REFERENCES 1. Henderson S, Shoenberger J. Anterior pneumothorax and a nega- tive chest x-ray in trauma. J Emerg Med 2004;26:231–2. 2. Kane T, Nuttall M, Bowyer R, Patel V. Failure of detection of pneumothorax on initial chest radiograph. Emerg Med J 2002;19: 468 –9. 3. Collins J, Samra G. Failure of chest X-rays to diagnose pneumo- thoraces after blunt trauma. Anaesthesia 1998;53:774 – 8. 4. Bridges K, Welch G, Silver M, Schinco M, Esposito B. CT detection of pneumothorax in multiple trauma patients. J Emerg Med 1993;11:179 – 86. 5. Tocino I. Pneumothorax in the supine patient. Radiographics 1985; 5:557– 86. 6. Carr J, Reed J, Choplin R, Pope T, Case L. Plain and computed radiography for detecting experimentally induced pneumothorax in cadavers: implications for detection in patients. Radiology 1992; 183:193–9. 7. Glazer H, Anderson D, Wilson B, Molina P, Sagel S. Pneumotho- rax: apperance on lateral chest radiographs. Radiology 1989;173: 707–11. 8. Morgan R, Owens C, Collins C, Evans W, Hansell D. Detection of pneumothorax with lateral shoot-through digital radiography. Clin Radiol 1993;48:249 –52. 9. Hoffer F, Ablow R. The cross-table lateral view in neonatal pneu- mothorax. AJR Am J Roentgenol 1984;142:1283– 6. 10. Tocino I, Miller M, Fairfax W, Distribution of pneumothorax in the supine and semirecumbent critically ill adult. AJR Am J Roentgenol 1985;144:901–5. e UPPER AIRWAY MASS MIMICKING NEAR-FATAL ASTHMA e To the Editor: We read with interest the article by Kokturk et al. (1) on subglottic mass mimicking near-fatal asthma. We would like to share our experience by describing a case of upper airway mass mimicking near-fatal asthma. A 62-year-old woman went to a hospital with wheez- ing, shortness of breath, and dry cough. She was diag- nosed with bronchial asthma and her symptoms seemed to improve slightly after use of bronchodilators. One year later, however, she developed acute onset of severe re- spiratory distress and bloody sputum. A computed to- mography (CT) scan of the neck and chest showed a tumor at the isthmus of the thyroid gland and an intra- tracheal mass having the same density as the tumor and obstructing almost the entire lumen at the level of the fifth cervical vertebra. The patient was referred to our hospital. On admission, she was critically ill, frightened, and tachypneic, using accessory respiratory muscles and 104 Letters to the Editor

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Page 1: Lateral chest radiographs for detecting pneumothorax in supine trauma patients

REFERENCES

1. Reid C, Chan L. Emergency Medicine terminology in the UnitedKingdom—time to follow the trend? Emerg Med J 2001;18:79–80.

2. Curry C. Accident—an anachronism? Arch Emerg Med 1992;9:331–2.

e LATERAL CHEST RADIOGRAPHS FORDETECTING PNEUMOTHORAX IN SUPINETRAUMA PATIENTS

e To the Editor:

In a recent issue of this journal, Henderson and Shoenbergerreported on a case of a pneumothorax that was initiallymissed on the supine chest film (1), a problem that has alsobeen documented by others (2,3). As Henderson andShoenberger indicate, most of these pneumothoraces aresubsequently detected by computed tomography (CT) im-aging, but the delay in diagnosis can lead to complicationsincluding progression to tension pneumothorax and death,particularly among intubated patients receiving positive-pressure ventilation (4). It would be preferable to diagnosethe pneumothorax in the Emergency Department beforeleaving for the CT scanner.

There is extensive discussion in the Radiology literatureregarding optimal patient positioning for the detection ofpneumothorax, and supine anterior-posterior imaging iswidely regarded to be among the least sensitive (5). Erectantero-posterior and left lateral decubitus images are moresensitive, but are contraindicated in patients who may har-bor spine injuries, are intubated, or exhibit hemodynamicinstability (6,7). Fortunately, lateral “shoot-through” radio-graphs are very sensitive for detecting a pneumothorax(8,9). Patients are imaged in the supine position in a mannersimilar to that used in cross-table lateral spine imaging, butwith the x-ray beam positioned approximately 6 inchescaudad, in alignment with the patient’s axillae. Imagingshould take less than 30 s.

The supine lateral chest radiograph can increase thedetection of anterio-medial and subpulmonic pneumothora-ces—the most common sites of pneumothorax in supinepatients, and allow clinicians to definitively address relatedissues before leaving the resuscitation area (10). Patientsmay still need a chest CT scan to evaluate other injuries,and CT imaging may occasionally detect a pneumothoraxthat was not visible on supine lateral radiographs. More-over, it is sometimes difficult to lateralize the pneumothoraxon the lateral film if there are not other indicators (ribfractures, stab wounds, gunshots) of which side has theinjury. However, there is still utility of this rapid, easily-performed and interpreted, low radiation study for improv-ing our detection of pneumothorax in the ED.

Edward S. Cotner, MD

Olive View/UCLA Emergency MedicineResidency Program

Los Angeles, California

doi:10.1016/j.jemermed.2005.03.003

REFERENCES

1. Henderson S, Shoenberger J. Anterior pneumothorax and a nega-tive chest x-ray in trauma. J Emerg Med 2004;26:231–2.

2. Kane T, Nuttall M, Bowyer R, Patel V. Failure of detection ofpneumothorax on initial chest radiograph. Emerg Med J 2002;19:468–9.

3. Collins J, Samra G. Failure of chest X-rays to diagnose pneumo-thoraces after blunt trauma. Anaesthesia 1998;53:774–8.

4. Bridges K, Welch G, Silver M, Schinco M, Esposito B. CTdetection of pneumothorax in multiple trauma patients. J EmergMed 1993;11:179–86.

5. Tocino I. Pneumothorax in the supine patient. Radiographics 1985;5:557–86.

6. Carr J, Reed J, Choplin R, Pope T, Case L. Plain and computedradiography for detecting experimentally induced pneumothorax incadavers: implications for detection in patients. Radiology 1992;183:193–9.

7. Glazer H, Anderson D, Wilson B, Molina P, Sagel S. Pneumotho-rax: apperance on lateral chest radiographs. Radiology 1989;173:707–11.

8. Morgan R, Owens C, Collins C, Evans W, Hansell D. Detection ofpneumothorax with lateral shoot-through digital radiography. ClinRadiol 1993;48:249–52.

9. Hoffer F, Ablow R. The cross-table lateral view in neonatal pneu-mothorax. AJR Am J Roentgenol 1984;142:1283–6.

10. Tocino I, Miller M, Fairfax W, Distribution of pneumothorax inthe supine and semirecumbent critically ill adult. AJR Am JRoentgenol 1985;144:901–5.

e UPPER AIRWAY MASS MIMICKINGNEAR-FATAL ASTHMA

e To the Editor:

We read with interest the article by Kokturk et al. (1) onsubglottic mass mimicking near-fatal asthma. We wouldlike to share our experience by describing a case of upperairway mass mimicking near-fatal asthma.

A 62-year-old woman went to a hospital with wheez-ing, shortness of breath, and dry cough. She was diag-nosed with bronchial asthma and her symptoms seemedto improve slightly after use of bronchodilators. One yearlater, however, she developed acute onset of severe re-spiratory distress and bloody sputum. A computed to-mography (CT) scan of the neck and chest showed atumor at the isthmus of the thyroid gland and an intra-tracheal mass having the same density as the tumor andobstructing almost the entire lumen at the level of thefifth cervical vertebra. The patient was referred to ourhospital. On admission, she was critically ill, frightened,and tachypneic, using accessory respiratory muscles and

104 Letters to the Editor