0
ONLINE EXCLUSIVES
Ultrasound Corner |

A 73-Year-Old Man With Left Lung “White Out”A 73-Year-Old Man With Left Lung “White Out” FREE TO VIEW

Jarrod D. Frizzell, MD; Lucie S. Griffin, DO; Michel A. Boivin, MD, FCCP; Ali I. Saeed, MD, FCCP
Author and Funding Information

From the University of New Mexico School of Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, Albuquerque, NM.

CORRESPONDENCE TO: Michel A. Boivin, MD, FCCP, MSC10-5550, University of New Mexico, Albuquerque, NM 87131; e-mail: mboivin@salud.unm.edu


Drs Frizzell and Griffin contributed equally to the manuscript.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.


Chest. 2015;148(2):e38-e41. doi:10.1378/chest.14-1621
Text Size: A A A
Published online

A 73-year-old man presented to the ED with confusion. He had a history of atrial fibrillation complicated by ischemic stroke and a history of DVT with placement of an inferior vena caval filter. His primary care physician had discontinued anticoagulants because of repeated falls. On presentation, his admission chest radiograph revealed opacity of the left lower lobe. He received antibiotics for suspected community-acquired pneumonia.

On hospital day 2, the patient developed increased respiratory distress and was transferred to the medical ICU (MICU) for impending respiratory failure. Upon arrival to the MICU, the resident attempted to place a central venous catheter in the left internal jugular vein under ultrasound guidance, but this was malpositioned and removed. As part of the workup for progressive respiratory failure, CT angiography of the chest confirmed the presence of a pulmonary embolism in the anterior segment of the left upper lobe. The MICU team began treatment with unfractionated heparin. On hospital day 4, the patient’s hemoglobin level decreased from 13.6 g/dL to 7.9 g/dL and chest radiograph showed near complete opacification of the left hemithorax (Fig 1).

Figure Jump LinkFigure 1 –  Chest radiography obtained with near-complete opacification of the left hemithorax.Grahic Jump Location
Question: Which ultrasound examination should be performed to further determine the etiology of the patient’s new radiologic finding?
Answer: Ultrasonography of the left lung, pleura, and hemidiaphragm, which led to a presumptive diagnosis of hemothorax with associated left lower-lobe atelectasis (Video 1)

Video 1

A bedside pleural ultrasound done by the critical care medicine fellow revealed a complex pleural space with stranding and an area of increased echogenicity located centrally and not obviously contiguous with lung parenchyma (Video 2). This ultrasound finding, along with the recent drop in hemoglobin level, suggested a hemothorax. Ultrasound-guided thoracentesis returned a bloody aspirate. A large-bore chest tube was placed, which returned 700 mL of blood. Anticoagulation treatment with heparin was discontinued. The chest tube was clamped, as the patient became hemodynamically unstable after drainage. The patient was fluid resuscitated, and thoracic surgery was consulted. The patient was taken to the operating room for emergent video-assisted thoracoscopic surgery evacuation of the hemothorax. Intraoperative exploration revealed several blood clots but did not identify an active source of bleeding. Although unproven, it was felt the likely source of the hemothorax was the misplaced central venous catheter and that bleeding from that site did not become significant until heparin was begun. The patient recovered uneventfully and was transferred to a skilled nursing facility 2 weeks postoperatively.

Video 2

Running Time: 3:23

Ultrasonography is sensitive and specific for the diagnosis of hemothorax.1,2 The most common application of ultrasound in the diagnosis of hemothorax is in the initial evaluation of the trauma patient. The focused assessment with sonography for trauma examination is now considered the preferred initial test in trauma patients for the rapid diagnosis of visceral hemorrhage.3 The extended focused assessment with sonography for trauma includes examination of the pleura for pneumothorax and hemothorax,1,3 for which it has high sensitivity and specificity.1,2

Identification of landmarks, including the diaphragm and lung, is very important as the initial step in pleural ultrasound.4 It is important to note, and may be under-recognized, that acute free-flowing blood in the pleural space appears anechoic. Next, the “hematocrit sign” may appear, which represents a separation of erythrocytes from the plasma as they settle in the most dependent portion of the pleural space. With time, clotted blood may appear; it is hyperechoic,5 appearing somewhat like a jellyfish (Fig 2, Video 1). Fibrin strands can be present after enough time has elapsed for the blood to coagulate. All of these signs were present together in this case (Fig 2).

Figure Jump LinkFigure 2 –  Ultrasound image of left hemithorax showing blood clot and fibrin strands (arrows).Grahic Jump Location

Alternative diagnoses to consider in the setting of opacification of the hemithorax on chest radiograph include pleural effusion, atelectasis, and consolidation. Consolidation has a typical ultrasonographic appearance with isoechoic-appearing lung and hyperechoic bronchi (Video 3). Atelectasis has a similar appearance to consolidation on ultrasound but may have signs of volume loss (such as raised hemidiaphragm) or compressive effects from a pleural effusion. Clinical correlation and the absence of dynamic air bronchograms (in atelectasis) can help distinguish the two (Fig 3). Other causes of pleural effusion could have a similar ultrasonographic appearance; the sensitivity and specificity of the “jellyfish sign,” hematocrit sign, or fibrin strands have not been well determined. Thoracentesis or tube thoracostomy provides definitive diagnosis for hemothorax in this setting.

Video 3

Figure Jump LinkFigure 3 –  Ultrasound image of lung consolidation seen with findings labeled (arrows).Grahic Jump Location

In hemothoraces, the presence of > 1,500 mL of blood in the pleural space or chest tube drainage of > 200 mL/h requires surgical intervention.6 Video-assisted thoracoscopic surgery is the mainstay of management, and conversion to open thoracotomy is seldom required.7 Drainage of hemothoraces should occur within 7 days. After this time, the clotted blood becomes organized and is much more difficult to remove. This appearance of increasing loculation and of fibrin strands is readily appreciated with pleural ultrasonography. Characterization of pleural effusions by ultrasonography represents an important initial step toward determining the etiology. Ultrasound machines are now readily available in most hospitals, and clinicians may reliably learn thoracic ultrasound techniques.8 In this case, we have illustrated ultrasonographic signs that favor a diagnosis of hemothorax in the setting of unilateral lung opacification.

  • 1. Pleural ultrasonography examinations can be suggestive of a diagnosis of hemothorax and should always start with identification of landmarks. Free-flowing blood will be anechoic, and a hematocrit sign reflects the separation of erythrocytes from plasma.

  • 2. Ultrasound can help differentiate the common etiologies of an opacified hemithorax on chest radiography (consolidation, atelectasis, and pleural effusion) and is the appropriate next imaging modality.

  • 3. Thoracentesis often provides definitive diagnosis of the etiology of an anechoic pleural fluid collection and can diagnose or exclude hemothorax.

Financial/nonfinancial disclosures: The authors have reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Other contributions: CHEST worked with the authors to ensure that the Journal policies on patient consent to report information were met.

Additional information: To analyze this case with the videos, see the online version of this article.

Brooks A, Davies B, Smethhurst M, Connolly J. Emergency ultrasound in the acute assessment of haemothorax. Emerg Med J. 2004;21(1):44-46. [CrossRef] [PubMed]
 
Ma OJ, Mateer JR. Trauma ultrasound examination versus chest radiography in the detection of hemothorax. Ann Emerg Med. 1997;29(3):312-315. [CrossRef] [PubMed]
 
Moore CL, Copel JA. Point-of-care ultrasonography. N Engl J Med. 2011;364(8):749-757. [CrossRef] [PubMed]
 
Bouhemad B, Zhang M, Lu Q, Rouby JJ. Clinical review: bedside lung ultrasound in critical care practice. Crit Care. 2007;11(1):205. [CrossRef] [PubMed]
 
Meyer DM. Hemothorax related to trauma. Thorac Surg Clin. 2007;17(1):47-55. [CrossRef] [PubMed]
 
Murray J. Murray and Nadel’s Textbook of Respiratory Medicine. Philadelphia, PA: Elsevier/Saunders; 2010.
 
Carrillo EH, Richardson JD. Thoracoscopy in the management of hemothorax and retained blood after trauma. Curr Opin Pulm Med. 1998;4(4):243-246. [CrossRef] [PubMed]
 
Lichtenstein DA. Ultrasound in the management of thoracic disease. Crit Care Med. 2007;35(suppl 5):S250-S261. [CrossRef] [PubMed]
 

Figures

Figure Jump LinkFigure 1 –  Chest radiography obtained with near-complete opacification of the left hemithorax.Grahic Jump Location
Figure Jump LinkFigure 2 –  Ultrasound image of left hemithorax showing blood clot and fibrin strands (arrows).Grahic Jump Location
Figure Jump LinkFigure 3 –  Ultrasound image of lung consolidation seen with findings labeled (arrows).Grahic Jump Location

Tables

Video 1

Video 2

Running Time: 3:23

Video 3

References

Brooks A, Davies B, Smethhurst M, Connolly J. Emergency ultrasound in the acute assessment of haemothorax. Emerg Med J. 2004;21(1):44-46. [CrossRef] [PubMed]
 
Ma OJ, Mateer JR. Trauma ultrasound examination versus chest radiography in the detection of hemothorax. Ann Emerg Med. 1997;29(3):312-315. [CrossRef] [PubMed]
 
Moore CL, Copel JA. Point-of-care ultrasonography. N Engl J Med. 2011;364(8):749-757. [CrossRef] [PubMed]
 
Bouhemad B, Zhang M, Lu Q, Rouby JJ. Clinical review: bedside lung ultrasound in critical care practice. Crit Care. 2007;11(1):205. [CrossRef] [PubMed]
 
Meyer DM. Hemothorax related to trauma. Thorac Surg Clin. 2007;17(1):47-55. [CrossRef] [PubMed]
 
Murray J. Murray and Nadel’s Textbook of Respiratory Medicine. Philadelphia, PA: Elsevier/Saunders; 2010.
 
Carrillo EH, Richardson JD. Thoracoscopy in the management of hemothorax and retained blood after trauma. Curr Opin Pulm Med. 1998;4(4):243-246. [CrossRef] [PubMed]
 
Lichtenstein DA. Ultrasound in the management of thoracic disease. Crit Care Med. 2007;35(suppl 5):S250-S261. [CrossRef] [PubMed]
 
NOTE:
Citing articles are presented as examples only. In non-demo SCM6 implementation, integration with CrossRef’s "Cited By" API will populate this tab (http://www.crossref.org/citedby.html).

Some tools below are only available to our subscribers or users with an online account.

Related Content

Customize your page view by dragging & repositioning the boxes below.

Find Similar Articles
CHEST Journal Articles
  • CHEST Journal
    Print ISSN: 0012-3692
    Online ISSN: 1931-3543