A liver in the lung

65-yo female with COPD presents to the ED severely distressed and dyspneic. Oxygen saturation 70%. Breathing frequency 45/min. Obstructive breath sounds with spread rhonchi. The patient is heavily dependent on accessory respiratory muscles. 120BPM. BP 100/70. Afebrile. COPD with acute exacerbation is suspected. Corticosteroids, bronchodilators and oxygen are administered. A bloodgas shows PCO2 retention and respiratory acidosis. Vitals slightly improved but oxygen saturation is not adequate. Higher levels of oxygen therapy will cause carbon dioxid narcosis. BIPAP is started with progressive improvement. Bedside ultrasound:

Left lateral thoracic- and upper abdominal view plus zoom. Significant for consolidations and hence a high suspicion of severe pneumonia/pneumosepsis. Fluids and antibiotics are administered. Bloodpanel returns showing Lactate 4,5, CRP 200 and WBC 18 with a left shift. A central venous catheter is placed.

The patient is taken to the ICU where a new bedside ultrasound is done. Consolidations are again visualized. In addition the following is seen.

What do you think? Please comment below. All intercostal spaces look the same. The pleura is statically prolapsed intercostally. My guess:the intercostal muscles have been through a marathon of strain. Currently flaccid and off-loaded by a well-deserved non-invasive ventilation. Additionally we see a flattened diaphragm which signifies severe COPD/emphysema.

Three days into treatment inflammatory parameters and oxygen saturation have been improved and NIV discontinued.

Left lateralt thoracic- and upper abdominal view. Interestingly enough the consolidation has changed. What we see now is an air bronchogram/hepatization of the lung which simply means that the lung takes on the appearance of a liver. The bronchi appear white. Causes may vary, but in short it implies lung consolidation or atelectasis. In contrast to chest x-ray, ultrasound can divided air bronchograms into either static with no movement in the bronchi or to dynamic with movement in the bronchi (see youtube). The dynamic form has a very high specificity and positiv predictive value for pneumonia. In our case the air bronchogram is static but the clinical scenario implies an infectious process.

Furthermore the intercostal space and pleura seem to have normalized.

1. The dynamic air bronchogram. A lung ultrasound sign of alveolar consolidation ruling out atelectasis. 2009. Lichtenstein D, Mezière G, Seitz J.
2. Radiopaedia.orgAir bronchogram
3. Introduction to Bedside Ultrasound: Volume 1 by Matthew Dawson och Mike Mallin (free at Itunes)

Focus on the snake & miss the scorpion

47-year-old woman seeking due to acute / subacute onset dyspnea.
Past medical history significant for rectal cancer with metastasis to liver, lungs and brain. Previously hospitalized due to severe left sided pleural fluid.
Current vitalsigns: Sat 91% on 2L oxygen, p.90, BP 115/70. The journal shows a habitual BP of 140/70. Clinical examination reveals absent leftsided breath sounds and dull percussion.

Spine-sign, well-defined diaphragm and the absence of curtain-effect indicates a large amount of pleural fluid. A fluid gap is also seen apically. But was this the entire truth? One would expect a gradual onset dyspnea in this setting.

The right ventricle, located adjacent to the liver, seems overloaded basally. Inferior vena cava (IVC) seems plethoric (dilated with poor respiratory variation) signifying increased central venous pressure (CVP). What happens to the right ventricle if preload / returnvolume is increased? Ask the patient to take a deep breath. This generally also improves the subcostal image quality. Alternatively, try passive leg raise.

The basal part of the right ventricle is considerably dilated while the apex is hyperdynamic. Known as McConnell’s sign, it may indicate massive or submassive pulmonary embolism. But the question is if large amounts of unilateralt pleural fluid can induce respiratory variations in right ventricular load. A quick review of the literature comes back empty.
A left-sided pleural chest tube was set up and 1000cc of clear-red liquid drain after which the drainage was stopped. This was followed up by 500cc / 4hrs to avoid complications such as reexpansion-related pulmonary edema. The patient experienced immediate symptomatic relief and was admitted for further treatment. Sat 94%, p.80 and BP 120/70.
After a total of 2.5L fluid was drained, the patient noted a swelling of the lower extremities. Ultrasound showed bilateral DVT in common femoral veins. Pending thoracic CT according to LE protocol, a new cardiac echo was performed.

McConnell’s sign is accentuated by inspiration.
Central right-sided pulmonary embolism. In view of the brain metastasis, a reduced dose low molecular weight heparin was instituted BID.

One may ask if the CT is really necessary in this case. Bilateral DVT was already diagnosed and thus the indication for LMWH present. However, it was still deemed reasonable to perform the CT since the diagnosis was not quite clear and it may affect duration of treatment with anticoagulation.