PMC5932523_01
Preintubation CXR shortly after ICU admission.
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fig1
A preintubation CXR is shown (Figure 1).
Repeat CXR on ICU day 11; ongoing hypoxia despite successful diuresis.
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fig2
Despite radiological and clinical resolution of pulmonary oedema the oxygen requirements were largely static; one week after admission he was still requiring FiO2 0.6 to maintain PaO2 9-10 kPa; a later CXR is shown (Figure 2).
Transverse section of upper abdominal viscera; images acquired during CTPA.
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Incidental imaging of the upper abdominal viscera showed a nodular and cirrhotic liver with ascites around both the liver and spleen (Figure 3).
Screenshot of sequential FiO2 and SpO2 values at one-minute intervals upon moving the patient from a semirecumbent to supine position.
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fig4
Marked orthodeoxia was demonstrated; the FiO2 required to achieve fixed SpO2 rapidly fell from 0.66 to 0.46 upon moving from a semirecumbent to supine posture (Figure 4); however, a test-dose of methylene blue did not improve oxygenation.
(a) Contrast/"bubble" TTE at time of injection. (b) Contrast/"bubble" TTE showing extensive opacification of the left heart in 4-5 cardiac cycles.
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fig5
This showed extensive opacification of the left heart within four to five cardiac cycles, consistent with an intrapulmonary shunt (Figure 5 & supplementary material (available here)); this confirmed the diagnosis.