UOTW #84

55 yo male presents with acute onset of back pain at the level of T2-T5 approximately 3 hrs prior to arrival. He denies any obvious inciting factors, although he does say that deep respirations make the pain worse and he feels slightly short of breath. Movement very slightly worsens pain. Past medical/surgical history is negative, social history is positive for 20 pack/year history of smoking. Pertinent negatives on review of systems include: No urinary symptoms, no recent travel, no leg swelling. Vitals stable.  Physical exam: Pain located posteriorly on the right side at the level of T5-T2. Auscultation reveals equal breath sounds.

An ultrasound transducer is placed on the anterior lung fields at the level of T2-T3 anteriorly bilaterally with the patient supine and demonstrates the following:

Answer

 

Answer and Pearl: Pneumothorax

The above clips show adequate lung sliding on the left and the absence of lung sliding on the right.  The presence of lung sliding rules out a pneumothorax in the area being evaluated.1  In the right clinical setting, the absence of lung sliding rules in a pneumothorax, but there are other things besides pneumothorax that can cause the absence of lung sliding, such as massive atelectasis,  apnea, main-stem intubation and adhesions, among other causes.2  The sonographic confirmatory test for a pneumothorax is the lung point.2  The lung point represents the limit or border of the pneumothorax.  This finding is thought to be highly specific for a pneumothorax. In a lung point, you will see lung sliding on part of the image, with the absence of lung sliding on the other side. See the clip below:

 

References:

  1. Staub LJ, Biscaro RRM, Kaszubowski E, Maurici R. Chest ultrasonography for the emergency diagnosis of traumatic pneumothorax and haemothorax: A systematic review and meta-analysis. Injury. 2018; 49(3):457-466. [PMID: 29433802]
  2. Volpicelli G. Sonographic diagnosis of pneumothorax. Intensive care medicine. 2011; 37(2):224-32. [PMID: 21103861]


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