Nov 2006 Kishore P.Critical Care Conference

Imaging in the ICU

Nov 2006 Kishore P.Critical Care Conference

Modalities

• X-Ray

• CT scans

• MRI

• Ultrasound examinations

• Angiography

• Flouroscopy

Nov 2006 Kishore P.Critical Care Conference

X-Ray

• Most common

• AP view

• Centering difficult

• Exposure equalization difficult

• X-Rays other than chest difficult

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Nov 2006 Kishore P.Critical Care Conference

Case 1

• 70 year old diabetic reverend admitted to the ICU for Urosepsis. Intubated for poor sensorium and labored breathing. On treatment gradually getting better.

On day 5, being weaned from ventilation when he desaturates with no hemodynamic instability.

On examination has decreased breath sounds on right side and crackles bilaterally

876308A

876308A

918121C

Nov 2006 Kishore P.Critical Care Conference

Collapse

• Humidification

• Suction

• Chest physiotherapy

• Position

• PEEP

• Bronchoscopy

Nov 2006 Kishore P.Critical Care Conference

Case 2

• 30 yr old man with AML on chemotherapy develops bilateral fungal pneumonia. He is intubated for persistent hypoxia in spite of CPAP. His lung infiltrates worsen on Amphotericin and antibiotics and he requires high peep, low tidal volumes and prone position ventilation to maintain saturations of 88-92%. He is also on high inotropes. On Day 15, he develops a sudden deterioration of oxygenation and hemodynamics.

864620C

864620C

864620C

864620C

864620C

898326C• 20 yr old primi with scrub typhus

898326C

898326C

Nov 2006 Kishore P.Critical Care Conference

Pneumothorax

• Deep sulcus sign

Nov 2006 Kishore P.Critical Care Conference

Hemodynamic compromiseSuspected tension

Hemodynamically stable

Needle aspiration and chest tube

placement

FiO2 100%Reduce PEEP to 3

FiO2 100%Reduce PEEP to 3

Chest X-Ray

Clinically suspected pneumothorax

Chest X-Ray

Mechanical ventilationSymptomatic

Self ventilatingasymptomatic

Chest tube/pigtailConservative management

Nov 2006 Kishore P.Critical Care Conference

Case 3

• Patient with Multiple Myeloma on mechanical ventilation for respiratory failure due to bilateral pneumonia.

• FiO2 100%, PEEP 15cm H2O, TV 360ml

Rate 35/min.

A

B

A

16 year old girl with ITP,autoimmune thyroiditis and medium vessel vasculitis on mechanical ventilation with high PEEP for ARDS due to viral pneumonia

A

B

Nov 2006 Kishore P.Critical Care Conference

Causes of pneumomediastinum in mechanical ventilation

• High tidal volumes

• High PEEP

• “fighting” the ventilator

• Auto PEEP

Nov 2006 Kishore P.Critical Care Conference

Case 4

• 35 yr old lady with SLE and lupus nephritis and mild CRF on steroids is intubated for severe hypoxia when she presents to the emergency department with breathlessness.

Examination reveals bilateral crackles. She is started on cover for bacterial, fungal and PCP etiologies.

890403C

Nov 2006 Kishore P.Critical Care Conference

Ely, E. W. et al. Chest 2002;121:942-950

The VPW is measured by (1) dropping a perpendicular line from the point at which the left subclavian artery exits the aortic arch and (2) measuring across to the point at which the superior vena cava crosses the right mainstem bronchus

Vascular Pedicle Width

890403C

278680A

832720C-malaria

839892C

801557C-scrub

Nov 2006 Kishore P.Critical Care Conference

• Patients with a VPW > 70mm coupled with a cardiothoracic ratio >0.55 are more than three times likely to have a Pulmonary Artery Occlusion Pressure > 18mm Hg compared to those without these findings.

Wayward Lines

Nov 2006 Kishore P.Critical Care Conference

Review

• Collapse

• Deep sulcus sign for pneumothorax

• Pneumomediastinum

• Fluid overload-VPW

• Pleural effusion

• Wayward lines