disclosure clinical chest radiography interpretation part ii · clinical chest radiography...

Clinical Chest Radiography Interpretation

Part IIAnthony M. Angelow,

PhD(c), MSN, ACNPC, AGACNP-BC, CENAssociate Lecturer,

Fitzgerald Health Education Associates Clinical practice

Division of Trauma Surgery and Surgical Critical CareCooper University Hospital, Camden, NJ

Assistant Clinical Professor, College of Nursing and Health Professions

Drexel University, Philadelphia, PA

Disclosure

• No real or potential conflict of interest to disclose.

• No off-label, experimental or investigational use of drugs or devices will be presented.

Fitzgerald Health Education Associates 84

ObjectivesPart II

• At the end of this presentation, the participant will be able to:– Apply a systematic approach to the

interpretation of clinical chest radiography.– Identify common abnormalities of the chest

radiograph based on patient case studies.– Describe normal and abnormal findings of

the chest radiograph.


Before We Begin….

Some Reminders!


Chest Radiograph BasicsREMINDER!

• Standard rules of chest radiography– Obtain a thorough history and physical

examination– Always evaluate the entire radiograph– Before confirming a diagnosis re-examine the

patient and the radiograph and be sure the diagnosis fits the clinical picture

– Always confirm the right patient– Develop a systematic approach– Do not get distracted– Why is the plain radiograph appropriate?– Why is a diagnostic study appropriate?


Chest Radiograph InterpretationA Systematic (A-I) Approach

• Adequacy and airway

• Bones and soft tissue

• Cardiac• Diaphragm• Edges (pleura)• Fields (lungs)

• Gastric bubble• Hila and

mediastinum• Impression


Case Study #1


Case Study #1MVC with Chest Pain

• A 35-year-old male presented to the trauma center with a chief complaint of chest pain after being involved in a motor vehicle accident. The patient describes left sided sharp chest pain and also complains of shortness of breath. Physical examination reveals hyperresonance on the right with absent breath sound in the lower right thorax.


Case Study #1MVC with Chest Pain (continued)

Source: https://commons.wikimedia.org/wiki/File:Pneumothorax_CXR.jpg


Case Study #1Step 1 – Adequacy and Airway


AdequacyInspiration?

Penetration?

Rotation?


Case Study #1Step 1 – Adequacy and Airway (continued)


Airway

Is the trachea midline?

Is the tracheal bifurcation at the level of T4‒T5?


Case Study #1Step 2 – Bones and Soft Tissue


Bones

Fractured ribs?

Clavicles?

Scapula, humerus?


Case Study #1Step 2 – Bones and Soft Tissue (continued)


Soft Tissues

Is the soft tissue obscuring any structures?

Is there any subcutaneous air?


Case Study #1Step 3 – Cardiac


Heart

Is the heart positioned appropriately?

Is the heart a normal size?


Case Study #1Step 4 – Diaphragm


Diaphragm

Are there sharp diaphragmatic margins?

Is the contour normal?


Case Study #1Step 5 – Edges (Pleura)


Pleura

Are there any noticeable pleural lines?

Any noticeable fluid or air accumulation?


Case Study #1Step 6 – Field (Lungs)


Lungs

Is there a normal vessel pattern?

Are the lungs air filled?

Any lucencies or shadowing?


Case Study #1Step 7 – Gastric Bubble


Gastric Bubble

Is the bubble round on the left side?

Any suggestion of free air in the abdomen?


Case Study #1Step 8 – Hilum and Mediastinum


Hilum

Is the hilum clearly present?

Any masses or lymphadenopathy?

Similar in size and density?


Case Study #1Step 8 – Hilum and Mediastinum (continued)


Mediastinum

Size and position?

Is the trachea to the right?

Structures identifiable?


Case Study #1Step 9 – Interpretation


Abnormal Findings

• Trachea deviated to right• Heart deviated to right• Clear demarcation of

pleural lines on the left with air in the pleural space

• Lung vasculature not extended to pleural wall on the left

• Mediastinum deviated to the right


Case Study #1Case Review





Diagnosis?

Does this make sense?





Case Study #2


Case Study #2Cough, Chills, and Fever

• A 65-year-old female presents with complaints of cough, chills, and fever for the last three days. She describes her cough as productive with yellow mucus and a fever ranging from 101.5‒102.4°F (38.6‒39.1°C). She describes a feeling of overall fatigue and shortness of breath with activity. Lung sounds produce crackles in the right base.


Case Study #2Cough, Chills, and Fever (continued)

Source: https://commons.wikimedia.org/wiki/File:RLL_pneumoniaM.jpg




Adequacy

Inspiration?

Penetration?

Rotation?



Airway






Bones

Fractured ribs?

Clavicles?

Scapula, humerus?



Case Study #2Step 2 – Bones and Soft Tissue (continued)

Soft Tissues






Heart






Diaphragm






Pleura






Lungs







Gastric Bubble






Hilum







(continued)Mediastinum

Size and position?






Abnormal Findings

• Slight under-penetration of the radiograph

• Consolidation noted in the RLL







Diagnosis?







Case Study #3


Case Study #3Cough with Hemoptysis

• A 60-year-old male with a 40-pack-year smoking history presented with a complaint of cough with noted blood in his sputum and breathlessness. He states he has been short of breath for the last few months, but contributes that to his smoking. He also admits to a 10 lb (4.5 Kg) unprovoked weight loss over the last “few weeks.”


Case Study #3Cough, Chills, and Fever

Source: https://en.wikipedia.org/wiki/File:Chest_Xray.jpg




Adequacy

Inspiration?

Penetration?

Rotation?



Airway






Bones

Fractured ribs?

Clavicles?

Scapula, humerus?




(continued)Soft Tissues






Heart






Diaphragm






Pleura






Lungs







Gastric Bubble






Hilum








Size and position?






Abnormal Findings

• Singular mass/lesion located in the left lung

• Left hilum is obstructed by the presence of a singular mass







Diagnosis?







Case Study #4


Case Study #4Chest Pain After Being Hit with a Bat

• An 11-year-old male with a chief complaint of left sided chest pain presented to the ED after sustaining a blow to the chest with a bat during a baseball game. He states the pain is sharp in nature and worsens with inspiration. On physical examination there is noted chest tenderness to palpation in the left upper chest.


Case Study #4Chest Pain After Being Hit with a Bat

(continued)

Source: https://commons.wikimedia.org/wiki/File:PfracturedribX.png




Adequacy

Inspiration?

Penetration?

Rotation?



Airway






Bones

Fractured ribs?

Clavicles?

Scapula, humerus?










Heart






Diaphragm






Pleura






Lungs







Gastric Bubble






Hilum






Case Study #4Step 8 – Hilum and Mediastinum (continued)

Mediastinum

Size and position?






Abnormal Findings

• Slightly displaced fracture of the left 3rd rib







Diagnosis?







Case Study #5


Case Study #5Hospitalized Patient Sudden Onset SOB

• An 47-year-old male who was admitted to the TICU after sustaining multiple traumatic injuries requiring numerous blood product transfusions complains this morning of severe onset of shortness of breath. He denies chest pain, cough, and no fever is documented. On physical examination his lung sounds are decreased with diffuse crackles.


Case Study #5Hospitalized Patient Sudden Onset SOB

(continued)

Source: https://commons.wikimedia.org/wiki/File:ARDS_X-Ray.jpg




AdequacyInspiration?

Penetration?

Rotation?



(continued)Airway






Bones

Fractured ribs?

Clavicles?

Scapula, humerus?










Heart






Diaphragm






Pleura






Lungs







Gastric Bubble






Hilum



Similar in size and density?Source: https://commons.wikimedia.org/wiki/File:ARDS_X-Ray.jpg




Size and position?






Abnormal Findings

• Costovertebral angles not clear

• Bilateral, diffuse patchy infiltrates







Diagnosis?







Case Study #6


Case Study #6Cough

• An 25-year-old female presents with complaints of cough for two days and is demanding a chest x-ray for evaluation. The cough is non-productive, she denies SOB, and denies fever. There are no other symptoms reported by the patient, although she states she does have a history of well-controlled asthma. Her physical examination is unremarkable.


Case Study #6Cough (continued)

Source: https://pixabay.com/en/diagnosis-xray-chest-lungs-ribs-1476620/




Adequacy

Inspiration?

Penetration?

Rotation?



(continued)Airway






Bones

Fractured ribs?

Clavicles?

Scapula, humerus?










Heart






Diaphragm






Pleura






Lungs







Gastric Bubble






Hilum



Similar in size and density?Source: https://pixabay.com/en/diagnosis-xray-chest-lungs-ribs-1476620/




Size and position?






Abnormal Findings

• None identified







Diagnosis?



? ?





Reference Slides

Other Common Abnormalities


Atelectasis• Condition of volume loss in some

portion of lung• May involve sub-segment, segment,

lobe or entire lung• Increased density usually linear• Collapse or incomplete expansion of

the lung or part of the lung • Segmental and sub-segmental collapse

may show linear, curvilinear, wedge shaped opacities


Atelectasis Causes

• Obstructive– Most common– Bronchus obstructed by mucous plug,

neoplasm, or foreign body

• Compressive– Normal lung compressed by tumor,

emphysematous bulla or heart enlargement


Atelectasis Causes (continued)

• Cicatrization– Organizing scar tissue– Most often after healing granulomatous

disease (i.e., TB), pulmonary infarct or trauma

• Adhesive– Inactivation of surfactant (i.e., hyaline

membrane disease)


Atelectasis Causes (continued)

• Passive– Normal compliance of the lung with

pneumothorax or pleural effusion– Airway remains patent


Linear Atelectasis

Source: https://commons.wikimedia.org/wiki/File:Thorax_mit_bds_Unterlappen-Atelektase_mit_Voraufnahme.jpg


Pulmonary Edema• Cardiogenic

– Increased hydrostatic pulmonary capillary pressure

• Non-cardiogenic– Altered capillary

membrane permeability or decreased plasma oncotic pressure

• NOT CARDIAC (pneumonic)– Near-drowning, Oxygen

therapy, Transfusion or Trauma, CNS disorder, ARDS, Aspiration, or Altitude sickness, Renal disorder or Resuscitation, Drugs, Inhaled toxins, Allergic Alveolitis, Contrast or Contusion


Cardiogenic Pulmonary Edema

• Cephalization of the pulmonary vessels• Kerley A lines

– Thin linear opacities in mid and upper zones radiating to hila

• Kerley B lines – Linear opacities 1‒2 cm long and 1‒2 mm

thick perpendicular to pleural surface caused by interstitial fluid (septal lines)


Cardiogenic Pulmonary Edema (continued)

• Peribronchial cuffing• “Bat wing" pattern

– Perihilar and medullary consolidation of both lungs

• Patchy shadowing with air bronchograms

• Heart enlargement • Pleural effusions


Pulmonary EdemaCephalization of Vessels

Source: Anthony Angelow


Bat Wing Pattern

Source: Anthony Angelow and Theresa Campo (used with permission)


Pulmonary Edema



Heart Failure



Pleural Effusion

• Causes– CHF– Infection (parapneumonic)– Trauma– PE– Tumor– Autoimmune disease– Renal failure


Pleural Effusion (continued)



Pulmonary Nodules



Pulmonary Nodules (continued)


References

• Campo, T.M. (2017). Clinical Chest Radiography Podium Presentation at National Conference of Nurse Practitioners.

• Campo, T.M. (2016). Medical Imaging for Health Care Providers: Practical Radiograph Interpretation. Springer Publishing: New York, NY.


References(continued)

• Collins and Stern. (2008). Chest Radiology: The Essentials. Wolters Kluwer/LWW: Philadelphia, PA.

• Daffner and Hartman (2014). Clinical Radiology: The Essentials 4th ed. Wolters Kluwer/LWW: Philadelphia, PA.


References(continued)

• Hermann et al. (2012). Best practices in digital radiography: White paper. American Society of Radiologic Technologies accessed from http://www.asrt.org/docs/whitepapers/asrt12_bstpracdigradwhp_final.pdf

• Wallace, J.E. (2015). Radiographic exposure: Principles and practice. FA Davis: Philadelphia, PA.


• Images/Illustrations: Unless otherwise noted, all images/illustrations are from open sources, such as the CDC or Wikipedia or property of FHEA or author.

• All websites listed active at the time of publication.


Copyright Notice

Copyright by Fitzgerald Health Education AssociatesAll rights reserved. No part of this publication may be reproduced or transmitted

in any form or by any means, electronic or mechanical, including photocopy, recording or any information storage and retrieval system, without permission

from Fitzgerald Health Education Associates

Requests for permission to make copies of any part of the work should be mailed to:

Fitzgerald Health Education Associates85 Flagship Drive

North Andover, MA 01845-6184


Statement of Liability

• The information in this program has been thoroughly researched and checked for accuracy. However, clinical practice and techniques are a dynamic process and new information becomes available daily. Prudent practice dictates that the clinician consult further sources prior to applying information obtained from this program, whether in printed, visual or verbal form.

• Fitzgerald Health Education Associates disclaims any liability, loss, injury or damage incurred as a consequence, directly or indirectly, of the use and application of any of the contents of this presentation.


Fitzgerald Health Education Associates

85 Flagship Drive

North Andover, MA 01845-6154978.794.8366 Fax-978.794.2455

Website: fhea.com

Learning and Testing Center: fhea.com/npexpert

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