Answer

Tension pneumothorax

There is a large left-sided tension pneumothorax with mediastinal shift to the right side and depression of the left hemidiaphragm. A chest drain needs to be inserted urgently.

In supine patients, beware of skin folds which can simulate pneumothorax - these can sometimes be followed beyond the chest wall. In normal lung, the vasculature cannot be seen in the peripheral 1-2 cm and the absence of pulmonary vasculature is only a secondary sign of pneumothorax. In a supine patient, air collects anteriorly often adjacent to the cardiac silhouette causing it to appear sharper than usual (see Fig. 1.12). Supine pneumothorax is commonly seen in the intensive care setting because patients are X-rayed supine and if there is co-existent respiratory distress, then the lungs are 'stiffer' and fail to collapse.

Fig. 1.12 Supine pneumothorax. The patient is on intensive care, has a tracheostomy and various lines. The right heart border is 'too' clearly seen because it is outlined by air.

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