A 38 yo presents with acute respiratory failure

what is wrong on the CXR?

Our patient had left lower lobe collapse which can be seen on cxr. It is of course much easier to see on the CT scan. 

Some of the features which can be seen are:

A triangular opacity in the posterior aspect of the L lung referred to as the ‘sail sign’

A ‘double cardiac contour’

Depression of the L hilum

Loss of the L hemidiaphragm

Loss of the outline of the descending aorta

Treatment of a mucous plug which our patient had is chest physiotherapy, nebulized dornase alfa(DNase) and sometimes bronchoscopy.  Our patient was admitted 11/11/16 and has been unable to be weaned off the ventilator.  He had a trach placed 11/24 to help clear secretions.  11/25he became febrile and grew E. coli out of his secretions.  He is again on antibiotics. Our patient had a previous gsw to the neck and may have had some difficulty moving his diaphragm because of that.

Teaching point:  there is another sail sign; the thymic sail sign which occurs in children when a pneumomediastinum elevates the thymus and it appears in the R chest.  

1.       Clarke C, Dux A. Chest X-Rays for Medical Students. 2011.  Wiley

2.       Coche EE, Ghaye B, Mey JD. Comparative Interpretation of CT and Standard Radiography of the Chest. Springer Verlag. 2010.

3.       Bejvan S, Godwin J 1996. Pneumomediastinum: old signs and new signs. AJR Am J Toentgenol 166(5)  1041-8.