Kishore P.

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Imaging in the ICU
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Modalities

• X-Ray
• CT scans
• MRI
• Ultrasound examinations
• Angiography
• Flouroscopy

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X-Ray

• Most common
• AP view
• Centering difficult
• Exposure equalization difficult
• X-Rays other than chest difficult

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Case 1

• 70 year old diabetic reverend admitted to the ICU
  for Urosepsis. Intubated for poor sensorium and
  labored breathing. On treatment gradually getting
  better.
• On day 5, being weaned from ventilation when
  he desaturates with no hemodynamic instability.
• On examination has decreased breath sounds on
  right side and crackles bilaterally

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876308A
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876308A
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918121C
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Collapse

• Humidification
• Suction
• Chest physiotherapy
• Position
• PEEP
• Bronchoscopy

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Case 2

• 30 yr old man with AML on chemotherapy develops
  bilateral fungal pneumonia. He is intubated for
  persistent hypoxia in spite of CPAP. His lung
  infiltrates worsen on Amphotericin and
  antibiotics and he requires high peep, low tidal
  volumes and prone position ventilation to
  maintain saturations of 88-92. He is also on
  high inotropes.
• On Day 15, he develops a sudden deterioration
  of oxygenation and hemodynamics.

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864620C
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864620C
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864620C
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864620C
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898326C

• 20 yr old primi with scrub typhus

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898326C
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898326C
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Pneumothorax

• Deep sulcus sign

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Clinically suspected pneumothorax
Hemodynamic compromise Suspected tension
Hemodynamically stable
FiO2 100 Reduce PEEP to 3
FiO2 100 Reduce PEEP to 3
Chest X-Ray
Needle aspiration and chest tube placement
Mechanical ventilation Symptomatic
Self ventilating asymptomatic
Conservative management
Chest X-Ray
Chest tube/pigtail
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Case 3

• Patient with Multiple Myeloma on mechanical
  ventilation for respiratory failure due to
  bilateral pneumonia.
• FiO2 100, PEEP 15cm H2O, TV 360ml
• Rate 35/min.

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A
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A
B
16 year old girl with ITP,autoimmune thyroiditis
and medium vessel vasculitis on mechanical
ventilation with high PEEP for ARDS due to viral
pneumonia
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A
B
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Causes of pneumomediastinum in mechanical
ventilation

• High tidal volumes
• High PEEP
• fighting the ventilator
• Auto PEEP

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Case 4

• 35 yr old lady with SLE and lupus nephritis and
  mild CRF on steroids is intubated for severe
  hypoxia when she presents to the emergency
  department with breathlessness.
• Examination reveals bilateral crackles. She is
  started on cover for bacterial, fungal and PCP
  etiologies.

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890403C
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The VPW is measured by (1) dropping a
perpendicular line from the point at which the
left subclavian artery exits the aortic arch and
(2) measuring across to the point at which the
superior vena cava crosses the right mainstem
bronchus
Ely, E. W. et al. Chest 2002121942-950
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Vascular Pedicle Width
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890403C
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278680A
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832720C-malaria
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839892C
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801557C-scrub
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• Patients with a VPW gt 70mm coupled with a
  cardiothoracic ratio gt0.55 are more than three
  times likely to have a Pulmonary Artery Occlusion
  Pressure gt 18mm Hg compared to those without
  these findings.

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Wayward Lines
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Review

• Collapse
• Deep sulcus sign for pneumothorax
• Pneumomediastinum
• Fluid overload-VPW
• Pleural effusion
• Wayward lines