rady resident symposium: cxr #1 in the worldmsrads.web.unc.edu/files/2020/01/2019radycxrrady...chest...
TRANSCRIPT
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Srinivas Saripalli MDSheryl Jordan MD Katherine Birchard MD
RADY Resident Symposium:CXR #1 in the World
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Module objectives
By the end of this activity, participants will be able to:
1. Describe the utility of chest radiography
2. State chest radiography anatomy
3. Describe a suggested approach to reviewing CXR
4. Understand the CXR basics of pneumonia, pulmonary edema, CHF, cardiomegaly,
atelectasis, aortic aneurysm, lymphadenopathy (NB: in our Critical Values and Radiographic Aunt Minnie sim labs, we will discuss ‘don’t miss’ and iatrogenic
CXR findings)
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Module outline
I. Chest radiography facts and figures
II. Anatomy on CXR
III. Approach to chest film interpretation
IV. Cardiopulmonary diseases
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Chest Radiography Facts
• Chest film is the most commonly performed radiographic examination in the world, but it is also very difficult to interpret expertly
• Low radiation dose (PA film = 0.01-0.02 mSv) inexpensive examination
• First line imaging for cardiopulmonary diseases
PA and lateral series always preferred over single AP/portable
• Limitations do exist
Not for nodules < 1 cm, subtle rib fxs, lung CA screening. Chest radiography is not recommended for rib
fx in uncomplicated setting, or for asymptomatic preop patient
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Chest Radiography Facts
• Routine and emergent diagnoses in critical settings around the world
• WHO recommendations for CXR make it the primary means of diagnosis, triage, as well as screening of TB in resource-poor settings
• In patients receiving mechanical ventilation in the ICU, utilized by about 3/5ths of patients on a daily basis
• In 2019, ongoing research in JAMA about recommendations for CXR utilization in different clinical settings
• Prudent use is important as routine CXR can lead to delays of care, incidental findings, unnecessary radiation, and increased healthcare costs
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Chest Radiography Technique
• PA = Posterior to anterior, pt is standing, xray beam comes from back and pt chest is against the film
• AP = Anterior to posterior, pt is supine or seated, xray beam comes from front and pt back is against the film
• Lat = Lateral, pt is standing or seated, beam comes from right and film is on left against lateral chest wall
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Chest Radiography Technique
• PA = Posterior to anterior, pt is standing, xray beam comes from back and pt chest is against the film
• AP = Anterior to posterior, pt is supine or seated, xray beam comes from front and pt back is against the film
• Lat = Lateral, pt is standing or seated, beam comes from right and film is on left against lateral chest wall
Post →→→→→ →Ant
Ant ↓↓↓↓↓↓
Post
Ant→ →→→→→ Post
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Always view films as if looking at patient !
PA Lateral
Rtside
Lt side
AntChest
PostChest
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Portable versus Lateral Erect CXR
Portable film post-op aortic dissection repair
Lateral film same patient
Rtside
Lt side
AntChest
PostChest
PORTSEMI-UPR
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Portable CXR with large bilateral effusions
Lt side
AntChest
PORTSEMI-UPR
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Chest Radiography: Two vs One
• PA and Lateral series ALWAYS preferred
Two views provide more information
Cardiac size is more accurate, pleural effusions are more readily
seen, and lesion location can be triangulated
• Portable AP films are more limited but are the only option for critically ill patients
Single view
Magnified cardiac silhouette
Unable to triangulate lesions
Pleural effusions may not be detected if small
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Module outline
I. Chest radiography facts and figures
II. Anatomy on CXR
III. Approach to chest film interpretation
IV. Cardiopulmonary diseases
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Normal Anatomy CXR
• Bones
• Lungs
• Pleural space
• Diaphragm
• Heart
• Mediastinum
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Normal Anatomy CXR: RIBS
11
4
2
12
12
3
4
1 234
5
11 1210
5
6
7
9
6
7
8
9
10
11
128
Q: How do you judge lung volumes, and what is normal?
A: Count POSTERIOR ribs: 9-10 posteriorribs seen above hemidiaphragm on frontal film is normal
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Normal Anatomy CXR: LUNG LOBES
RUL
RML
RLL
LUL
LLL
LULRUL
RLL LLL
RML
RIGHT:Upper lobeLower lobeMiddle lobe
LEFT:Upper lobeLower lobe
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Normal Anatomy CXR: DIAPHRAGMS
I
A
AE
I E
DIAPHRAGMATICHIATUS:
IVCAortaEsophagus
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Normal Anatomy CXR: CARDIAC BORDERS
LT VENT
RT ATRIUM
PA CXR
CARDIAC CT
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Normal Anatomy CXR: CARDIAC BORDERSCARDIAC CT LAT CXR
LT ATRIUM
RT VENT
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Normal Anatomy CXR: MEDIASTINAL LINES
FRONTAL PA or APCHECKLIST:
TracheaCarina, RMB, LMBHila/hilar vessels
(right hilum lower than than left, hila = densityand size)
RA borderLV borderAortic arch & desc
aorta
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Normal Anatomy CXR: MEDIASTINAL LINES
FRONTAL PA or APCHECKLIST:
TracheaCarina, RMB, LMBHila/hilar vessels
(right hilum lower than than left, hila = densityand size)
Aortic arch & descaorta
RA borderLV border
TracheaCarina
Hilum
Hilum
RA LV
Ao
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Normal Anatomy CXR: MEDIASTINAL LINES
LATERALCHECKLIST:
TracheaRV and RVOTHila/hilar vessels
(LMB and LPARPA confluence)
LA contourIVC
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Normal Anatomy CXR: MEDIASTINAL LINES
Trachea
RV
RVOT
IVC
LA
Hila LPALMB
LATERALCHECKLIST:
TracheaRV and RVOTHila/hilar vessels
(LMB and LPARPA confluence)
LA contourIVC
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Module outline
I. Chest radiography facts and figures
II. Anatomy on CXR
III. Approach to chest film interpretation
IV. Cardiopulmonary diseases
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APPROACH TO CHEST FILM INTERPRETATION
CHECKLIST:1 Technique2 Rotation3 Lung Volumes4 Lung Parenchyma5 CP Angles6 Heart Size7 Bones & Soft
Tissues
123
4
5
6
7
8
9
10
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CHECKLIST:1 Technique2 Rotation3 Lung Volumes4 Lung Parenchyma5 CP Angles6 Heart Size7 Bones & Soft
Tissues
APPROACH TO CHEST FILM INTERPRETATION
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Module outline
I. Chest radiography facts and figures
II. Anatomy on CXR
III. Approach to chest film interpretation
IV. Cardiopulmonary diseases
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RECALL: Normal CXR Appearance
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Pneumonia very common disease and one of the most common causes of death worldwide. Causative organisms may be bacterial, viral, or fungal. In pneumonia (particularly bacterial), alveolar spaces are filled with organisms, inflammatory cells, and pus. Lobar pattern of consolidation containing air bronchograms.Peripheral ground-glass opacities are present.
Case 1: Pneumonia
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Lobar consolidation containing air bronchograms is the classic appearance seen in bacterial pneumonia. Interstitial disease seen as reticular (mesh‐like or netlike), nodular (small round opacities), or reticulonodular (mixed reticular and nodular patterns) with infecting organisms ‘atypical’. These patterns may be found in viral, mycoplasma, or fungal pneumonias.
Case 2: Pneumonia
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Increased pulmonary venous pressure causes early dilation of superior zone veins.
Increased prominence of the vasculature superiorly is cephalization.
Typical for early CHF with approx 15-25 mm HG
Case 3: Interstitial Pulmonary Edema
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Kerley lines are present, consistent with a wedge pressure of approx 25-30 mmHg
Due to thickened interlobular septa
Horizontal lines typically found in periphery
Case 3: Interstitial Pulmonary Edema
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As pulmonary pressure progresses above 30 mm Hg or higher ‘Batwing’ edema appears.
Perihilar opacities
With a high enough wedge pressure, the fluid spills into the alveoli yielding air bronchograms and air alveolograms.
Case 4: Alveolar Pulmonary Edema
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As pulmonary pressure progresses above 30 mm Hg or higher ‘Batwing’ edema appears.
With a high enough wedge pressure, the fluid spills into the alveoli yielding air bronchograms and air alveolograms.
Case 5: Alveolar Pulmonary Edema
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As pulmonary pressure progresses above 30 mm Hg or higher ‘Batwing’ edema appears.
With a high enough wedge pressure, the fluid spills into the alveoli yielding air bronchograms and air alveolograms.
Case 5: Alveolar Pulmonary Edema
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CHFCardiomegaly Pulmonary edemaPleural effusions are also common
Case 6: Congestive Heart Failure
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SG catheter monitors hemodynamic status
Aids in differentiating cardiogenic from noncardiogenic edema via use of a pressure balloon
Position 2 cm distal to hilum in proximal R or L pulm art
SG risks pulm hemorrhage & infarct if overwedged
Case 7: Pulmonary Artery Catheter
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Pacemaker leads should have gentle curves and be continuous without breaks or kinks:
1 lead: RV2 leads: RV, RA3 leads: RV, RA,
coronary sinus
Case 8: Pacemaker
RA
RV
CS
RA
RV
CS
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Cardiomegaly defined as widest transverse heart diameter greater than half the transverse thoracic diameter on PA film in full inspiration
False positivesLow lung volChest wall abnlPericardial effusionAP view
Case 9: Cardiomegaly
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Cardiomegaly defined as widest transverse heart diameter greater than half the transverse thoracic diameter on PA film in full inspiration
False positivesLow lung volChest wall abnlPericardial effusion
Case 9: Cardiomegaly
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Increased lung opacity with evidence of volume loss Direct signs: Vascular crowding, displacement of fissuresIndirect signs: Elevation of the hemi diaphragm of the affected lung, mediastinal shift to side of volume loss, rib crowding, obscuration of heart or diaphragm border. Silhouette sign: RUL (mediastinum), RML (rtheart), RLL LLL (hemidiaphragms), LUL (mediastinum)
Case 10: Atelectasis
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Case 11 (Schematic): Atelectasis
Patterns of collapse
**Directly from Core Radiology textbook
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• Can be difficult to detect on frontal radiograph
• Silhouetting of R heart border by collapsed lobar segment
• Lateral radiograph demonstrates wedge-shaped opacity
Case 12: Atelectasis RML
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Left upper lobe atelectasis demonstrates the ‘luftsichel’ or ‘air sickle’ sign
Abnormal air crescent present when aorta is illuminated against the backdrop of hyperexpanded superior segment of left lower lobe
Case 13: Atelectasis LUL
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Thoracic aorta can be dilated tortuous (ectatic) or aneurysmal. Aneurysm defined as maximal transverse diameter > 50% larger than normal vessel. Upper limit normal ascending aorta = 40 mm, and descending aorta = 30 mm.
Case 14: Aortic Aneurysm
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Deceleration injury of thoracic aorta aka aortic transectionHigh mortalityWidened mediastinum, >8cm level arch), obscured or irregular aortic arch, deviation of the trachea to the right of T4 spinous process, deviation of NGT to right of T4 spinous process, left apical cap
Case 15: Aortic Injury
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Case 16: Lymphadenopathy
Bilateral hilar LAN: manifested as enlarged lobular hila Mediastinal LAN: thickening of the right paratracheal stripe and the left paratracheal stripe.DDx of thoracic lymphadenopathy includes granulomatous disease, HIV, other infection, metastatic disease.
Sarcoidosis
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CXR findings are bronchial thickening, bronchiectasis, atelectasis, focal consolidation, hilar lymphadenopathy, enlarged pulmonary arteries, hyperinflation due to chronic airway obstruction. Severe disease can lead to mucus plugging, pneumothorax, pneumomediastinum, hemoptysis, and pulmonary hypertension.
Case 17: Cystic Fibrosis
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SC Disease cardiopulmonary and bone changes namely CM, pulmopacities, atelectasis and peripheral pulmonary infarcts, pleural effusion, bone infarcts in humeral heads and spine (H shaped vertebra), upper abdominal findings (RUQ cholecystectomy clips and auto-splenectomy)
Case 18: Sickle Cell Disease
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CXR RECAP
• Relatively cheap and widely used
• May demonstrate very subtle findings in a variety of settings and diseases
• May be better than cross sectional imaging depending on indication
• Adopt an organized approach to chest radiograph interpretation and stick with it!
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References
• Mandell J. (2013). Core radiology: A visual approach to diagnostic imaging.
• Gershengorn HB, Wunsch H, Scales DC, Rubenfeld GD. Trends in Use of Daily Chest Radiographs Among US Adults Receiving Mechanical Ventilation. JAMA NetwOpen. 2018;1(4):e181119.
• Mettler, FA Jr. et al. Radiologic and nuclear medicine studies in the United States and worldwide: frequency, radiation dose, and comparison with other radiation sources--1950-2007. Radiology. 253 2;520-31. Published 2009 Nov.
• Introduction to chest radiology. Available at: https://www.med-ed.virginia.edu/courses/rad/cxr/. Accessed March 25, 2019.
• Right middle lobe collapse. Available at: https://radiopaedia.org/articles/right-middle-lobe-collapse?lang=us. Accessed March 31, 2019.