Abstract: INTRODUCTION:Physiotherapy can aid the removal of secretions following a whole lung collapse, presenting as an opaque hemithorax or “whiteout” on chest radiograph (CXR). Identifying the cause of an opaque hemithorax can prove difficult due to low sensitivity of chest radiography (CXR). Thoracic ultrasound (TUS) is a diagnostic technique able to differentiate between pathologies. The aim of this report is to highlight the impact of TUS on physiotherapy practice. CASE PRESENTATION:A 63-year-old patient underwent elective cardiac surgery. Post-operatively he sustained a cerebral artery infarct with a dense hemiplegia and an ineffective cough. He required nasal pharyngeal suction and use of a cough-assist machine. Increased oxygen requirements prompted a CXR showing an opaque hemithorax. Physiotherapy was requested to aid sputum removal and lung recruitment. Prior to initiating physiotherapy treatment TUS showed a large pleural effusion. Despite this new information a bronchoscopy elicited no significant sputum plug. A second TUS scan showed no change in the effusion. A chest drain was inserted which elicited 3500 mls within an hour. A third TUS showed an absence of any pleural effusion. Following physiotherapy treatment a final TUS scan showed normal aeration. DISCUSSION:An opaque hemithorax can be caused by a significant pleural effusion even when sputum retention is suspected. When patients are referred to physiotherapy TUS can highlight pathologies not amenable to physiotherapy treatment. It seems reasonable to address the pleural effusion first and then implement physiotherapy treatment. TUS will also allow rapid repeated imaging to assess whether treatments have been successful immediately after being administered.
Keywords: Opaque hemithorax, whiteout, thoracic ultrasound, physiotherapy, case report