Pneumothorax and atelectasis post CABG surgery

Case contributed by Dr Balint Botz

Presentation

CABG operation on the day before, dyspnea, reduced oxygenation and absent respiratory sounds upon auscultation on the left.

Patient Data

Age: 75
Gender: Female
X-ray

Supine AP CXR (mobile unit)

  • A left sided pneumothorax is visible with an apparent distance of the visceral pleura form the chest wall varying between 10-18 mm (see magnified key image).
  • There is a marked decrease of bronchovascular markings on the left.
  • There is an oddly sharply defined consolidation adjacent to the left hilum with marked aerobronchograms (see key image). 
  • Other: right jugular CVC and mediastinal drain in correct position, sternotomy wires, annular calcification in the right upper mediastinum possibly due to thyroid nodule. 

Due to the unusual appearance of the left-sided consolidation and the left hemithorax in general - not fully explained by the apparent extent of the pneumothorax - a chest CT was recommended. 

CT

Noncontrast chest CT

  • Partial collapse of the left upper and lower lobes with aerobronchograms, with a focal region of reduced density suggesting simultaneous presence of atelectasis, pneumonia, and necrosis.
  • Small pleural effusion on the right. 
  • A large pneumothorax is visible on the left measuring a maximum AP diameter of 85 mm (see annotated image).
  • Other: CVC line, mediastinal drain in correct position, calcified granulomas in the spleen, calcified thyroid nodule. 
Annotated image

Annotated images

As the pneumothorax is located mostly anteriorly, its extent is grossly underestimated by the CXR.

X-ray

Supine AP CXR a few hours later (mobile unit)

After successful drainage of the pneumothorax, the transparency of the two hemithoraces becomes similar, and the left-sided consolidation is immediately less well-defined. 

Case Discussion

In this case the severity of the pneumothorax is easily underestimated by the supine CXR alone, though the decrease of bronchovascular markings on the left and the unusually sharp appearence of the consolidation suggests a more extensive pathology. 

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Case information

rID: 63254
Published: 23rd Sep 2018
Last edited: 14th Aug 2019
System: Chest
Inclusion in quiz mode: Included
Institution: University of Pécs

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