Chest radiograph in septic shock

A CICM imaging viva. The candidate interprets a critically-ill patient's chest radiograph: confirming line and tube positions, distinguishing ARDS from cardiogenic pulmonary oedema, identifying pneumonia, and reading volume state — the core skills for a septic patient in the unit.

Prompt

A portable chest radiograph of an intubated patient on day 1 of septic shock — describe and interpret.

Stimulus

A portable anteroposterior chest radiograph of an intubated patient on day 1 of septic shock from a urinary source. Describe it systematically, then interpret. The relevant findings are:

Endotracheal tube tip approximately 3 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.
Bilateral, predominantly mid- and lower-zone alveolar opacification, confluent, with air bronchograms, no cardiomegaly, no pleural effusions, and no septal (Kerley B) lines.
Normal vascular pedicle width, no upper-lobe venous diversion.^[3]

References3Show

[1]Evans L, Rhodes A, Alhazzani W, et al. Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock 2021. Intensive Care Medicine, 2021.PMID 34599691
[2]Singer M, Deutschman CS, Seymour CW, et al. The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). JAMA, 2016.PMID 26903338
[3]Bersten AD, Soni N (eds) Oh's Intensive Care Manual. 8th edition, Elsevier, 2018.

Chest radiograph in septic shock

Stimulus

A portable anteroposterior chest radiograph of an intubated patient on day 1 of septic shock from a urinary source. Describe it systematically, then interpret. The relevant findings are:

Endotracheal tube tip approximately 3 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.

Bilateral, predominantly mid- and lower-zone alveolar opacification, confluent, with air bronchograms, no cardiomegaly, no pleural effusions, and no septal (Kerley B) lines.

Normal vascular pedicle width, no upper-lobe venous diversion.^[3]

References3Show

[1]Evans L, Rhodes A, Alhazzani W, et al. Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock 2021. Intensive Care Medicine, 2021.PMID 34599691
[2]Singer M, Deutschman CS, Seymour CW, et al. The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). JAMA, 2016.PMID 26903338
[3]Bersten AD, Soni N (eds) Oh's Intensive Care Manual. 8th edition, Elsevier, 2018.