Pneumothorax and barotrauma on the ICU chest radiograph

A CICM imaging viva on the chest radiograph of a ventilated patient. The candidate reads the film systematically, identifies a pneumothorax with subcutaneous emphysema as a manifestation of barotrauma (radiographic VILI), confirms tube and line positions, and frames the finding against the lung-protective strategy.

Prompt

A portable chest radiograph of a ventilated patient with severe ARDS who has just become hypotensive with high airway pressures — describe and interpret.

Stimulus

A portable anteroposterior chest radiograph of an intubated patient on day 4 of severe ARDS, taken moments after the nurse reports a rising airway pressure, falling oxygen saturation, and new hypotension. Describe it systematically, then interpret. The relevant findings are:^[1]

Endotracheal tube tip approximately 4 cm above the carina, mid-trachea.
Right internal jugular central venous catheter tip at the cavoatrial junction.
Nasogastric tube descending below the diaphragm, tip in the stomach.
A visceral pleural edge parallel to the right chest wall with absent lung markings peripheral to it — a right pneumothorax — with lateral displacement of the right heart border and depression of the right hemidiaphragm.
Streaky lucencies in the soft tissues of the neck and chest wall — subcutaneous (surgical) emphysema.
Bilateral, diffuse alveolar opacification with air bronchograms, a normal heart size, and no large pleural effusions — the underlying ARDS pattern.
The left lung fields show no pneumothorax.^[1]

References3Show

[1]Bersten AD, Soni N (eds). Oh's Intensive Care Manual. 8th edition, Elsevier, 2018.
[2]Dreyfuss D, et al. High Inflation Pressure Pulmonary Edema. Respective Effects of High Airway Pressure, High Tidal Volume, and Positive End-Expiratory Pressure. American Review of Respiratory Disease, 1988.PMID 3057957
[3]Marino PL. The ICU Book. 4th edition, Lippincott Williams & Wilkins, 2014.

Pneumothorax and barotrauma on the ICU chest radiograph

Stimulus

Endotracheal tube tip approximately 4 cm above the carina, mid-trachea.

Right internal jugular central venous catheter tip at the cavoatrial junction.

Nasogastric tube descending below the diaphragm, tip in the stomach.

A visceral pleural edge parallel to the right chest wall with absent lung markings peripheral to it — a right pneumothorax — with lateral displacement of the right heart border and depression of the right hemidiaphragm.

Streaky lucencies in the soft tissues of the neck and chest wall — subcutaneous (surgical) emphysema.

Bilateral, diffuse alveolar opacification with air bronchograms, a normal heart size, and no large pleural effusions — the underlying ARDS pattern.

The left lung fields show no pneumothorax.^[1]

References3Show

[1]Bersten AD, Soni N (eds). Oh's Intensive Care Manual. 8th edition, Elsevier, 2018.
[2]Dreyfuss D, et al. High Inflation Pressure Pulmonary Edema. Respective Effects of High Airway Pressure, High Tidal Volume, and Positive End-Expiratory Pressure. American Review of Respiratory Disease, 1988.PMID 3057957
[3]Marino PL. The ICU Book. 4th edition, Lippincott Williams & Wilkins, 2014.