Point of Care Ultrasound Diagnosis of Empyema

Emergency ultrasonography is an efficient and cost effective tool for patients who are in respiratory distress. Chest radiographs can yield limited information for these patients. Computed tomography scans have long been the criterion standard for advanced imaging in patients with respiratory complaints, but point of care ultrasound (POCUS) can be performed at bedside, does not expose the patient to radiation, and at times may provide more information than a computed tomography scan.

A 60-year-old man with a medical history of hypertension presented to the emergency department complaining of a productive cough associated with fever, weakness, and progressively worsening dyspnea on exertion over the previous 1 to 2 weeks. The physical examination was remarkable for rhonchi in the right upper lobe and diminished breath sounds throughout the right lung. POCUS was performed, and the results revealed severe atelectasis and hepatization of the right lung parenchyma with visualized air bronchograms. Complex hypoechoic material with a posterior spine sign was noted, which increased concern for complex consolidation and effusion. The diagnosis of pneumonia with empyema was made. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: POCUS has become a much more commonly used imaging modality within many emergency departments. Ultrasound is more sensitive than chest radiographs for identifying pathologies such as pneumothorax and simple effusions. This case shows how well POCUS can diagnose empyema even in the setting of diagnostic uncertainty of computed tomographic imaging.