Loculated pneumothorax with a deep sulcus sign
The present case has been reported in the Southwest Respiratory and Critical Care Chronicles.

A 61-year-old man with amyotrophic lateral sclerosis, s/p tracheostomy, and ventilator dependence was admitted for evaluation of respiratory distress, fever, and increased secretions. Broad spectrum antibiotics were started due to bilateral infiltrates on his admission chest x-ray. One day after admission the patient developed severe left shoulder pain and tachycardia.

Chest x-ray showed a pneumothorax with a positive deep sulcus sign in the left hemithorax. A 16 French surgical chest tube was placed with the complication of a persistent air-leak. Eventually, the pneumothorax recurred despite presence of the surgical chest tube, and a second pigtail chest tube was inserted by the Interventional Radiology service.

Key takeaways:-
- Pneumothorax management is usually with chest tube placement ipsilateral to the location of the air. However, a loculated pneumothorax requires direct drainage using imaging guidance to locate the pocket.

- Imaging techniques used to guide pneumothorax drainage include fluoroscopy, chest CT, and chest sonogram. Chest CT and ultrasonography are preferred modalities.

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