The authors describe a patient with a unilateral total lung opacification that was later resolved by bronchial lavage. Either a mechanical obstruction to the bronchus caused by endotracheal tube or mucous plug may be responsible for this chest x-ray image.
A 38-year-old man with a history of primary pulmonary hypertension and right heart failure presented to the emergency room because of progressive dyspnea, somnolence, central cyanosis, and diffuse peripheral edema. Because of progressive respiratory acidosis, he was intubated and placed on a mechanical ventilator. A day later, while he was still on respiratory support, we realized that the right side of his chest was not moving. A subsequent chest x-ray (Fig. 1A) showed total opacification of the right hemithorax, mediastinal shift toward the right, and overexpansion of the left hemithorax, suggesting right lung volume loss. The lower end of the endotracheal tube was above the carina, thus eliminating single (left) lung intubation as a cause of the abnormality. An alternative explanation would be intrinsic obstruction from a mucous plug or foreign body. An urgent bronchoscopy detected obstructing mucous plugs in the right main stem bronchus. After removal of these plugs by aspiration and 2 days of intensive medical and chest physiotherapy, another chest x-ray (Fig. 1B) demonstrated that the total opacification of the right hemithorax and mediastinal shift had resolved.
Unilateral lung “white-out” should suggest mechanical obstruction for which prompt diagnosis and therapy are required.