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July 2013 Critical Care Case of the Month: The Fortuitous Critical Care Consult

Clement U. Singarajah, M.D.

Elijah Poulos, M.D.


Phoenix VA Medical Center

Phoenix, AZ


History of Present Illness

A 70 year old male with squamous cell cancer of the hypopharynx had undergone a laser ablation and debridement as an outpatient. The ENT surgeon placed a # 6 Shiley DCT tracheostomy tube and the patient did well after the procedure. His chest x-ray after the procedure revealed right lower lobe atelectasis but was interpreted as otherwise normal (Figure 1).

Figure 1. Portable chest-ray after laser ablation and tracheostomy placement.

Due to aspiration and feeding issues, he was scheduled 2 weeks later for percutaneous endoscopic gastrostomy (PEG) tube placement as an outpatient. However, the gastroenterologist cancelled the procedure due to copious secretions from tracheal site, described as purulent and some mild respiratory distress. He was admitted to the general medicine service at the Phoenix VA Medical Center.  

Physical Examination

On examination of the patient, was non-toxic, talking, and alert. Vital signs were within normal limits, but with he had mild dyspnea and moderately thick secretions. A tracheostomy tube was in place in the neck. There were no areas of tenderness over his neck. The remainder of his physical examination was normal.


A chest x-ray was performed (Figure 2). 


Figure 2. Admission PA (Panel A) and lateral (Panel B) chest x-ray.

Which of the follow are abnormal findings of the chest radiography?

  1. The distal tip of the tracheostomy tube is not aligned with the tracheal stripe
  2. There is a right pleural effusion
  3. There is an air-fluid level in the right lower lung
  4. There is right lower lobe atelectasis and/or consolidation
  5. All of the above 

Reference as: Singarajah CU, Poulos E. July 2013 critical care case of the month: the fortuitous critical care consult. Southwest J Pulm Crit Care. 2013;7(1):10-16. doi: PDF 

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