The Case of the Floating Lung

54 M with pmhx of HTN and previous right-sided empyema in 2014 presenting from Big Bear with left sided chest pain for possible NSTEMI. EKG was negative and first cardiac enzymes were negative. The patient complained of 3 weeks of cough with yellow sputum and 2 days of worsening, sharp chest pain on his left chest, which was worse with movement, cough, and deep breath. He denied fever. His vitals on presentation were significant for a fever to 101.4 and tachycardia from 110s-120s with normal sats. His labs showed a white count of 14.56. CXR showed small left pleural effusion with possible consolidation.

On ultrasound of his left lung (L PLAPS), the above image was found along with diffuse B-lines in the anterior lung views. The image above is concerning for empyema versus complicated pleural effusion. In the image, the lung is surrounded by fluid and there is an obvious “spine sign” below, which provides further evidence for fluid in the pleural space. The lung itself also appears “hepatized” which points towards consolidation of the lung. Septations in the fluid collection are also noted.

The findings on ultrasound for empyema depend on the stage of the empyema. In the first stage, the empyema will appear as an anechoic fluid collection and can sometimes be differentiated from pleural effusion by hyperechoic free floating debris. In the second stage, septations can be seen within the free fluid as thin hyperechoic lines. Finally, the empyema will form loculations, which will appear more structured than the hyperechoic lines seen in the second stage. In all three stages, the spine sign will be present as the pus in the lung will act as a medium through which the ultrasound beams will travel.

The patient was admitted and had a chest tube placed, which confirmed the diagnosis of empyema.

Nelson M, Stankard B, Greco J, Okumura Y. Point of Care Ultrasound Diagnosis of Empyema. The Journal of Emergency Medicine. 2016;51(2):140-143


Bryant Khoo PGY1 Emergency Medicine

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