Submitted on 11 Jan 2010
Figure. CXR of patient (click image to enlarge)
A 85-year-old man, ex-smoker after 30 pack-years, was a known patient with old CVA and hypertension. Since year 2009, he had been repeatedly hospitalized for multiple episodes of wheezy respiratory failure. There was productive cough between each episode, and examination during hospitalization always revealed diffuse rhonchi. He was prescibed long-term inhaled steroid and bronchodilator for his late-onset asthma.
He presented to the surgical ward last week with acute severe abdominal pain. Localized tendernss and rigidty was found at right upper quadrant of abdomen. Ugent laparotomy revealed perforated diverticular abscess, and standard right hemicolectomy was performed. He was doing fine during operation, but an anesthetist noted that there was a lot of sputum deeply seated in the airway associated with diffuse rhonchi. Decision to withold extubation was made, and patient was then sent to ICU after operation.
Bronchoscopy was performed by a respiratory physician who was surprized by an unexpected finding. On retrospective review, the CXRs did illustrate the answer. Could you spot the problem?
Figure 2. Enlarged image