HOW READ CHEST XR -11

ANAS SAHLE ,MD

Brief review

PATCHY

INFILTIRATION

NODULE

MASS

CAVITARY

OPACITY

Consolidation

Infection causes

Pneumonia

Non-infection causes

Lymphoma

Broncho-

alveolar

carcinoma

COP

WEGNER disease

Sarcoi

d

Cardiac failu

re

Solitary Pulmonary Nodule(SPN)

Comparison with a previous x-ray toAssess growth over time.

Cavitary lesion

Air + tissue

Air-fluid level

StraightAbscess

Wavy ruptured

Hydatid cyst

Air only

ThickIrregular

inner wall

Cavitating

neoplasm

Regular

inner wall

Chronic

abscess

ThinPeriph

eral Emphesemato

us bulla

Centralpneu

matocele

Wall thickness

site1. Fungal ball.2. Rupture hydatid cyct3. Necrotic tumor4. Blood glot

LINEAR PATTERN

LINEAR PATTERNPerihilar and peripheral basal septal lines,changes acutely and resolves with diuretics

LEFT VENTRICULAR FAILURE

Coarsening of lung markings in lower zones, nochange on review of recent films

Normal ageing

Coarse nodular and linear thickening ofmarkings, known malignancy, often associatedwith pleural effusion, rapid clinicaldeterioration of patient

Lymphangitis

LINEAR PATTERNLINEAR PATTERN

Short thin lines, often basal, new on review ofprevious films

Atelectasis

Longer thicker bands, often perihilar or basal,suggest recent infection or infarction

Subsegmentalcollapse

Any length, persist over time unchanged

Volume loss is key, persists over time

Scarring

Fibrosis

Causes of fibrosisMid zone lung Lower zone lung Upper zone lung

tuberculosis Drug indused fibrosis(most common)

sarcoidosis

Chronic extrinsic allergic alveolitis

UIP

Radio-therapy Asbestose-related fibrosis

Ankylosing spondylitis

Progressive massive fibrosis

histoplasmosis

CASE-1• A 50-year-old male smoker is evaluated for chronic shortness of breath. • On physical examination his vital signs are:

– pulse 110 bpm; – Temperature normal; – respirations 30/min with use of accessory muscles and pursed-lip breathing; – blood pressure 110/78 mm Hg.

• Other pertinent findings are: – heart exam: apex beat (impulse) is medial to the mid-clavicular line– generalized decreased breath sounds on lung exam;

• ABGs (FiO2 0.21):– pH 7.38; PCO2 47 mm Hg; PO2 67 mm Hg.

• PFTs/spirometry: – FVC 2.80 L (67% of predicted); – FEV1 1.56 (50% of predicted); – FEV1/FVC% 56%;– TLC 134% of predicted; – RV 170% of predicted; – DLCO 43% of predicted.– There is no reversibility with bronchodilators.

CASE-1

POSITION •PA CXR

QUALITY •Good Technical Quality

LESION •Bilateral linar (vascular)infitration .•Laminar opacity from right hilum.•Hyper-lucency area at lower right zone.

MEDIASTINAL\Hilum

•Central trachea and mediasteinal.•Dangle heart.

ANGELS •Hazy left angle\irregular diaphragm(flat)

OTHER •No

CASE-1• 1. What is the most likely diagnosis?• a. Bronchial asthma with status asthmaticus• b. Emphysema• c. Chronic bronchitis• d. Tuberous sclerosis• 2. Associated with the above condition is• a. Obstructive sleep apnea• b. Increased IgE levels• c. Respiratory failure with increased A-aDO2

gradient• d. Clubbing

CASE-2• A 38-year-old man is admitted with progressive shortness of breath• and cough. • He denies any fever, chills, or purulent sputum production. • He wants to be evaluated to determine the reasons for his

symptoms. • On exam, he is afebrile and has decreased breath sounds with

hyper-resonant upper lung field more obvious on the right. • ABGs on RA: pH 7.35; PCO2 38mm Hg; PO2 78 mm Hg. • Spirometry:

– (FVC) 1.72 (70% of predicted); – (FEV1)1.34 L (60% of predicted); – FEV1/FVC% 76%; – TLC 4.1 L (100% of predicted);– TLC by helium dilution method 3.4 (71%); – DLCO 70% of predicted.– There is no bronchodilator response.

CASE-2

POSITION •PA CXR

QUALITY •Poor Technical Quality

LESION•Large bulla extend at right upper and middle zone.•Vascular marking crowded at lower zone.•Hyperlucensy area at left upper zone.

MEDIASTINAL\Hilum

•Central trachea and mediasteinal.

ANGELS •Free

OTHER •No

CASE-2• 1. What is the most likely diagnosis?• a. Severe emphysema• b. Bulla• c. Pneumothorax• d. Bronchiectasis• 2. What is the next management option?• a. Place a chest tube urgently• b. Increase bronchodilator dosage and frequency• c. Start chest physical therapy• d. Perform CT scan of chest

CASE-3• A 39-year-old man, a smoker since age 16, is seen in

the clinic with complaints of fever, cough, and production of yellowish sputum.

• He has been chronically short of breath, but these symptoms have increased over the last week after he developed a flulike illness.

• On exam, he is febrile and looks ill. • Lung exam reveals diffuse wheezing with egophony

and whispering pectoriloquy on the right side. • ABGs show PO2 of 55 mm Hg on room air, • sputum is negative for TB.

CASE-3

POSITION •PA CXR

QUALITY •Poor Technical Quality

LESION •Multiple air-fluid level at right middle zone.•Area of hyperlucensy at right and left upper zone.

MEDIASTINAL\Hilum

•Central trachea and mediasteinal.

ANGELS •Free

OTHER •No

CASE-3• 1. The next step in the management of this patient

would be• a. Arrange with intervention radiology to do a needle aspiration• b. Consult thoracic surgery for lung reduction surgery• c. Start antibiotic and O2 therapy• d. Admit patient in an isolation room• 2. Appropriate measures at the first follow-up should

include• a. Pneumococcal and influenza vaccine• b. Allergy testing• c. Detailed occupational history• d. Genetic counseling

CASE-4• A 31-year-old African American man is admitted

with increasing cough, fever, and sputum production.

• He gives a history of repeated infections and “pneumonias” since childhood.

• Lung exam reveals:– diffuse rhonchi– bilateral crackles, more so in the left lung field.

• Routine labs are normal except for a poly-morphonuclear leuko-cytosis.

CASE-4

POSITION •PA CXR

QUALITY •Poor Technical Quality

LESION •Bilateral nodulo-reticular pattern crowded at lower,middle zone and cyct-like apperance.

MEDIASTINAL\Hilum

•Central trachea and mediasteinal.

ANGELS •Free

OTHER •No

CASE-4• 1. What is the most likely diagnosis?• a. Bronchiectasis• b. Cystic fibrosis• c. Sarcoidosis• d. Allergic bronchopulmonary aspergillosis• 2. What is the next management option?• a. Bronchoscopy• b. Steroid Rx• c. Antibiotics and postural drainage• d. Surgical consult

DISCUSSION• The history is suggestive of bronchiectasis, and

the bilateral cystic-appearing lesions on the CXR are consistent with that diagnosis.

• Cystic fibrosis is generally predominant in the upper zone.

• Sarcoidosis rarely presents with this history, and the fibrotic changes in sarcoidosis are usually in the upper lobes.

• Allergic bronchopulmonary aspergillosis is seen with an underlying asthmatic condition.

CASE-5• A 24-year-old male law student presents with

a 3-wk history of increasing dyspnea. • He has a history of chronic sputum production

of about 100 cc of purulent material each day for many years.

• In the past, he was hospitalized for a left pneumothorax.

• He is on inhaled bronchodilator as an outpatient.

CASE-5

POSITION •PA CXR

QUALITY •Good Technical Quality

LESION •Bilateral cyct-like opacity apperance.•At middle zone near hilum and extend to left upper zone (fibrosis).

MEDIASTINAL\Hilum

•Central trachea and mediasteinal.

ANGELS •Free\flated diaphragm.

OTHER •No

CASE-5• 1. Physical exam will most likely show• a. Clubbing• b. Koilonychia• c. Oncholysis• d. Pectus excavatum

• 2. Spirometry will most likely show• a. FVC 60%; FEV1 40%; ratio 66%• b. FVC 60%; FEV1 62%; ratio 90%• c. Normal• d. Normal except mild decrease in FEF25–75

• 3. The most helpful treatment option would be• a. Increase bronchodilator therapy• b. Start broad-spectrum antibiotic therapy• c. Initiate anti-pseudomonas antibiotic regimen• d. Start oral steroids

DISCUSSION

• The history and chest x-ray are consistent with cystic fibrosis with bilateral cystic upper zone predominance.

• Physical exam would reveal clubbing; spirometry would show a mixed obstructive with restrictive picture.

• The best option would be to initiate anti-pseudomonas antibiotics.