Critical Care Medicine

Answer 3 Deep sulcus sign. When a patient is in the supine position, the classic radiographic findings of a pneumothorax may not be present. In this position, the most superior (ie, the highest) portion of the thorax is near the lung bases. Because pneumothorax air rises to the highest location in the chest, the lung bases should be closely scrutinized for the following signs: (1) clear visualization of the diaphragm anteriorly creating a “double” appearance of the diaphragm; (2) a deep costophrenic angle (deep sulcus sign); (3) an unusually distinct cardiac apex and pericardial fat tags; and (4) increased radiolucency of the upper abdominal quadrants. SUGGESTED READING 1. Bonten MJ, Gaillard CA, Wouters EF, et al. Problems in diagnosing nosocomial pneumonia in mechanically ventilated patients: a review. Crit Care Med 1994;22:1683-91. 2. Chiles C, Ravin CE. Radiographic recognition of pneumothorax in the intensive care unit. Crit Care Med 1986;14:677-80. 3. Lamm WJ, Graham MM, Albert RK. Mechanism by which the prone position improves oxygenation in acute lung injury. Am J Respir Crit Care Med 1994;150:184-93. 4. Pappert D, Rossaint R, Slama K, et al. Influence of positioning on ventilation-perfusion relationships in severe adult respiratory distress syndrome. Chest 1994;106:1511-6. 5. Tuxen DV. Detrimental effects of positive end-expiratory pressure during controlled mechanical ventilation of patients with severe airflow obstruction. Am Rev Respir Dis 1989;140:5-9. 6. Tuxen DV, Williams TJ, Scheinkestel CD, et al. Use of a measurement of pulmonary hyperinflation to control the level of mechanical ventilation in patients with acute severe asthma. Am Rev Respir Dis 1992;146(5 Pt 1):1136-42. Click here to return to the questions

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