Non-cardiogenic pulmonary edema (NCPE) is a rare but serious complication of heroin overdose, more frequently observed in fatal cases. This report discusses a 33-year-old male patient with a history of hypertension and heroin use disorder who presented with dyspnea and hypoxia. Upon examination, his vital signs indicated an SpO2 of 82% on room air, along with tachycardia and tachypnea. The patient disclosed heroin use the day before admission, and urine toxicology screening confirmed the presence of opioids and methadone. Pulmonary auscultation revealed bilateral crackles, while chest imaging, including chest X-ray (CXR) and computed tomography angiography (CTA) of the chest, revealed diffuse bilateral airspace opacities consistent with pulmonary edema, effectively ruling out pulmonary embolism. Arterial blood gas analysis indicated acute respiratory acidosis, which improved with oxygen therapy. A prior echocardiogram had shown normal cardiac function. Notably, diuretics were not administered, and the patient's oxygen requirements decreased within two days. NCPE is a diagnosis of exclusion, often characterized by persistent hypoxia following the resolution of opioid-induced respiratory depression, with radiographic evidence of pulmonary edema. The condition typically resolves within 24-48 hours with supportive care, as observed in this case. While NCPE is frequently identified during autopsy in heroin-related fatalities, its underlying pathophysiology remains poorly understood. NCPE should be considered in the differential diagnosis of respiratory failure in patients with heroin overdose. Given its potentially fatal consequences and the limited understanding of its pathophysiology, further research is warranted to optimize management strategies.

The British Society of Thoracic Imaging (BSTI) has published clear guidance on the classification of chest X-ray (CXR) findings in coronavirus disease 2019 (COVID-19) patients, which are summarised in four main categories: COVID-classical, COVID-indeterminate, COVID-normal, or non-COVID. We report the case of a 34-year-old lady who is otherwise fit and well. She presented with typical COVID-19 symptoms requiring supplemental oxygen, with normal CXR and COVID-19 reverse transcriptase-polymerase chain reaction (RT-PCR) swab on admission. Her condition deteriorated after 24 hours with severe hypoxia requiring up to 60% oxygen. Repeat CXR was normal, which was followed by computed tomography pulmonary angiogram (CTPA) that ruled out pulmonary embolism; however, CTPA confirmed multi-lobar pneumonia consistent with COVID-19. The patient was admitted to the intensive care unit for non-invasive ventilation (NIV) and ongoing care. Extended respiratory screening confirmed positive COVID-19 antibodies and positive adenovirus swabs. The patient also developed COVID-19 related hepatocellular injury and myocarditis in the absence of other causes. These were treated by a multidisciplinary team, and the patient achieved full recovery after three weeks. This case highlights the fact that normal CXR does not rule out COVID-19 pneumonia even in the severely hypoxic patient requiring NIV. Also, it is important to investigate for other potential causes of hypoxia in a deteriorating patient, such as pulmonary embolism and non-COVID causes of pneumonia.

Computed tomography (CT) of the chest plays an important role in the diagnosis and management of coronavirus disease 2019 (COVID-19), but it should not be used indiscriminately. This review provides indications of CT chest in COVID-19 suspect, positive and recovered patients based on the current scientific evidence and our personal experience. CT chest is not indicated as a routine screening modality due to its poor sensitivity and specificity. However, it is useful in a small subset of COVID-19 suspects who test negative on reverse transcription-polymerase chain reaction (RT-PCR) with normal/indeterminate chest X-ray (CXR) but have moderate-to-severe respiratory symptoms and high index of clinical suspicion. CT chest is not indicated in every RT-PCR-positive patient and should be done only in specific clinical scenarios, where it is expected to significantly contribute in the clinical management such as COVID-19 patients showing unexplained clinical deterioration and/or where other concurrent lung pathology or pulmonary thromboembolism needs exclusion. Serial CXR and point-of-care ultrasound are usually sufficient to evaluate the progression of COVID-19 pneumonia. CT chest is also indicated in COVID-19-positive patients with associated co-morbidities (age >65 yr, diabetes, hypertension, obesity, cardiovascular disease, chronic respiratory disease, immune-compromise, etc.) who, despite having mild symptoms and normal/indeterminate CXR, record oxygen saturation of <93 per cent at rest while breathing room air or de-saturate on six-minute walk test. Finally, CT chest plays a crucial role to rule out lung fibrosis in patients recovered from COVID-19 infection who present with hypoxia/impaired lung function on follow up. In conclusion, though CT chest is an indispensable diagnostic tool in COVID-19, it should be used judiciously and only when specifically indicated.

BACKGROUND Radiotherapy is often used as an adjuvant therapy in breast cancer following surgical resection of the primary malignant tumor. It has multiple respiratory side effects, but acute respiratory distress syndrome (ARDS) is a rare complication. We describe here the case of a woman with breast cancer who developed ARDS 1 week after her final radiotherapy session. CASE REPORT A 69-year-old female with breast cancer presented 1 week after her final session of radiotherapy. She had developed a sudden onset of hypotension unresponsive to fluids, oxygen desaturation unresponsive to high flow oxygen, and new bilateral infiltrates had appeared on chest x-ray (CXR) predominant in the left upper lobe, which was interestingly the main area affected by the radiotherapy beams. A diagnosis of atypical ARDS secondary to radiotherapy was established. She was intubated and a low tidal volume/high positive end-expiratory pressure (PEEP) strategy was utilized to manage her condition. After 48 hours, the infiltrates diminished remarkably, and she was extubated the following day. On discharge, she had a completely normal CXR; a computed tomography (CT) chest performed 1 month later showed complete resolution of the alveolar opacities. CONCLUSIONS ARDS remains an extremely rare complication of thoracic radiotherapy. However, physicians must be wary of its development in order to diagnose it quickly and treat accordingly.

Despite recommendations against routine imaging, chest radiography (CXR) is frequently performed on infants hospitalized for bronchiolitis. We conducted a review of 811 infants hospitalized for bronchiolitis to identify clinical factors associated with imaging findings. CXR was performed on 553 (68%) infants either on presentation or during hospitalization; 466 readings (84%) were normal or consistent with viral illness. Clinical factors significantly associated with normal/viral imaging were normal temperature (odds ratio = 1.66; 95% CI = 1.03-2.67) and normal oxygen saturation (odds ratio = 1.77; 95% CI = 1.1-2.83) on presentation. Afebrile patients with normal oxygen saturations were nearly 3 times as likely to have a normal/viral CXR as patients with both fever and hypoxia. Our findings support the limited role of radiography in the evaluation of hospitalized infants with bronchiolitis, especially patients without fever or hypoxia.

The current study evaluates the need for trauma bay chest radiographs (CXR) in stable blunt-trauma patients who are scheduled for chest computed tomography (CCT). A retrospective review of 157 randomly selected, stable, adult blunt-trauma patients who were admitted to a level I trauma center between 2000 and 2002, who underwent both CXR and CCT (GE Light-Speed Scanner), was performed. Stable patients were defined as unintubated, normotensive (SBP > 100 mm Hg), and without hypoxia (O2 saturation > 90%). No interventions were conducted in the trauma bay based on chest radiograph findings. Among 95 patients with a "normal" CXR, 38 patients (40%) were found on CCT to have traumatic injuries. Among 62 patients with an "abnormal" CXR, 18 (29%) were found to be normal on CCT. Of the remaining 44 patients, 34 had additional findings on CCT. In 32 patients, CCT led to changes in management. CCT was more sensitive in diagnosing thoracic injuries and led to significant changes in management. We feel that CXR could be safely eliminated in favor of CCT in stable blunt-trauma patients.