Pneumothorax POCUS

YOUR PATIENT WITH COPD PRESENTS TO THE ED WITH DYSPNEA. YOU SHOW OFF YOUR FANCY NEW POCUS SKILLS AND OBTAIN THE ABOVE IMAGE. WHAT IT THE ETIOLOGY OF THE PATIENT'S DYSPNEA? WHY MIGHT THIS HAVE OCCURRED?

Bar Code or Stratosphere Sign

We had a fantastic faculty session last week with Dr. Jessica Baez on Point of Care Ultrasound for the lungs. Check that out here if you missed it!

Our patient with pmh of COPD presented with dyspnea. Our general differential includes: COPD exacerbation, decompensated heart failure, acute valvulopathies, pHTN, cardiac tamponade, arrhythmias, pulmonary embolism, pneumonia, pleural effusion, pneumothorax, anemia.

Clinical Problem Solvers has a great diagnostic schema for your review:

https://clinicalproblemsolving.com/dx-schema-dyspnea/

As we learned from Dr. Baez, you can rapidly uncover the etiology at the bedside with POCUS. B-lines, Z-lines - the lungs have an alphabet of information ready for your interpretation.

The ultrasound image above is achieved with the linear probe in M-mode.

HTTP://WWW.TAMINGTHESRU.COM/BLOG/DIAGNOSTICS/LUNG-ULTRASOUND

First, let’s check out normal lung in M-mode:

Normal lung should give the appearance of a “sandy beach” given the granular appearance of the foreground (sand) and a linear bar code in the background (ocean).

HTTP://WWW.ICMTEACHING.COM/ULTRASOUND/LUNG%20ULTRASOUND/STYLED-125/

In our patient’s ultrasound, we only see the linear “bar code” of the ocean. No sandy beach! This is “bar code sign” (also known as “stratosphere sign”) which represents pneumothorax.

The second part of the question was getting at the etiology of the pneumothorax. Without a clinical history of trauma, the most likely etiology in a patient with COPD is rupture of emphysematous bleb.

-Natalie Hood