Download - Interpreting Chest Films
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Introduction
TechniqueNormal Anatomy
ET tubes
Central Lines
Pneumothorax
Airway occlusion
COPD
MediastinumFree Air
Consolidation
Infiltrates
ARDS
CHF
Systematic approach
Quiz
WebLinker
Interpreting Chest films
Shivani Ahlawat
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Introduction
TechniqueNormal Anatomy
ET tubes
Central Lines
Pneumothorax
Airway occlusion
COPD
MediastinumFree Air
Consolidation
Infiltrates
ARDS
CHF
Systematic approach
Quiz
WebLinker
INTRODUCTION
The basic chest x-ray is part of every physicians diagnostic
armamentarium. This program aims to teach medical
residents a systematic approach to reading the x-rays.
Beginning with finer points of x-ray technique, different views
and normal anatomy, the program will teach pathology with
examplesfocusing on Intensive care unit findings such as
normal and abnormal lines, ET tubes, pulmonary and extra-
pulmonary pathology. The program is also accompanied with
a self-assessment.
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Introduction
TechniqueNormal Anatomy
ET tubes
Central Lines
Pneumothorax
Airway occlusion
COPD
MediastinumFree Air
Consolidation
Infiltrates
ARDS
CHF
Systematic approach
Quiz
WebLinker
PA Images
Posteroanterior (PA) and lateral chestradiographs are the mainstays ofthoracic imaging.
The recognition of proper radiographictechnique on frontal radiographsinvolves assessment of four basicfeatures:
1. Penetration
2. Rotation
3. Inspiration4. Motion
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Introduction
TechniqueNormal Anatomy
ET tubes
Central Lines
Pneumothorax
Airway occlusion
COPD
MediastinumFree Air
Consolidation
Infiltrates
ARDS
CHF
Systematic approach
Quiz
WebLinker
PA Images - Exposure
Proper exposure ispresent when theintervertebral diskspaces of thethoracic spine and
discrete branchingvessels can befaintly identifiedthrough thecardiac shadow
and thediaphragms.
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Introduction
TechniqueNormal Anatomy
ET tubes
Central Lines
Pneumothorax
Airway occlusion
COPD
MediastinumFree Air
Consolidation
Infiltrates
ARDS
CHF
Systematic approach
Quiz
WebLinker
PA ImagesOver-ExposureOverexposure causes the
image to be dark. Underthese circumstances, thethoracic spine,mediastinal structures,retrocardiac areas, and
nasogastric andendotracheal tubes arewell seen, but smallnodules and the finestructures in the lungparenchyma cannot be
seen
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Introduction
TechniqueNormal Anatomy
ET tubes
Central Lines
Pneumothorax
Airway occlusion
COPD
MediastinumFree Air
Consolidation
Infiltrates
ARDS
CHF
Systematic approach
Quiz
WebLinker
PA ImagesUnder-ExposureUnderexposure causes the
image to be white. It willmake the smallpulmonary blood vesselsappear more prominentand may lead to thinking
that there aregeneralized infiltrateswhen none are reallypresent. Underexposurealso makes it impossibleto see the detail of the
mediastinal, retrocardiac,or spinal anatomy
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Introduction
TechniqueNormal Anatomy
ET tubes
Central Lines
Pneumothorax
Airway occlusion
COPD
MediastinumFree Air
Consolidation
Infiltrates
ARDS
CHF
Systematic approach
Quiz
WebLinker
PA Images - RotationRotation is assessed by noting
the relationship between avertical line drawn midwaybetween the medial corticalmargins of the clavicularheads and one drawnvertically through thespinous processes of the
thoracic vertebrae.Superimposition of theselines (the former in themidline anteriorly and thelatter in the midlineposteriorly) indicates aproperly positioned, non-
rotated patient.
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Introduction
TechniqueNormal Anatomy
ET tubes
Central Lines
Pneumothorax
Airway occlusion
COPD
MediastinumFree Air
Consolidation
Infiltrates
ARDS
CHF
Systematic approach
Quiz
WebLinker
PA Images - InspirationWhen standing, most adults can
easily take an inspirationthat brings the domes of thehemidiaphragms down tothe level of the 10thposterior ribs. When thepatient is sitting or lyingdown, often the level isbetween the 8thand 10th
ribs. If the image has thedomes of the diaphragms atthe 7thposterior ribs, thechest should be consideredhypoinflated, and you mustbe very careful beforediagnosing basilarpneumonia or cardiomegaly
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Introduction
TechniqueNormal Anatomy
ET tubes
Central Lines
Pneumothorax
Airway occlusion
COPD
MediastinumFree Air
Consolidation
Infiltrates
ARDS
CHF
Systematic approach
Quiz
WebLinker
Expiration vs. Inspiration
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Introduction
TechniqueNormal Anatomy
ET tubes
Central Lines
Pneumothorax
Airway occlusion
COPD
MediastinumFree Air
Consolidation
Infiltrates
ARDS
CHF
Systematic approach
Quiz
WebLinker
PA Images - Motion
Finally, the cardiac margin,diaphragm, and pulmonary vessels
should be sharply marginated in a
completely still patient who hassuspended respiration during the
radiographic exposure. A small
pneumothorax may be missed due to
motion artifact.
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Introduction
TechniqueNormal Anatomy
ET tubes
Central Lines
Pneumothorax
Airway occlusion
COPD
MediastinumFree Air
Consolidation
Infiltrates
ARDS
CHF
Systematic approach
Quiz
WebLinker
AP ImagesPortable anteroposterior radiographs are obtained when patients cannot be
safely mobilized. There are technical and patient-related compromises as
well as inherent physiologic changes with portable bedside radiography.
The limited maximal kilovoltage potential of portable units requires
longer exposures to penetrate cardiomediastinal structures, which
leads to more motion artifact.
Because critically ill patients are difficult to position, the patient is often
rotated.
The shorter focus-to-film distance and AP technique result in
magnification of intra-thoracic structures.
The supine position elevates the diaphragm, compressing lower lobes
and decreasing lung volumes. The normal gravitational effect evens out
the blood flow between upper and lower zones in supine patients,
which makes assessment of pulmonary venous hypertension difficult.The increase in systemic venous return to the heart produces a
widening of the upper mediastinum.
The gravitational layering of free-flowing fluid may hide small effusions.
Similarly, a pneumothorax may be difficult to detect because free
intrapleural air rises to a nondependent position More
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Introduction
TechniqueNormal Anatomy
ET tubes
Central Lines
Pneumothorax
Airway occlusion
COPD
MediastinumFree Air
Consolidation
Infiltrates
ARDS
CHF
Systematic approach
Quiz
WebLinker
AP versus PA
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Introduction
TechniqueNormal Anatomy
ET tubes
Central Lines
Pneumothorax
Airway occlusion
COPD
MediastinumFree Air
Consolidation
Infiltrates
ARDS
CHF
Systematic approach
Quiz
WebLinker
PA anatomyIDENTIFY A - J
F
E
D
CB
A H
J
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Introduction
TechniqueNormal Anatomy
ET tubes
Central Lines
Pneumothorax
Airway occlusion
COPD
MediastinumFree Air
Consolidation
Infiltrates
ARDS
CHF
Systematic approach
Quiz
WebLinker
PA anatomy
Aright costophrenic angle Bleft diaphragm
C - heart
Daortic knob (arch)
E - trachea
F - hilum
G - carina
Hstomach bubble
Jascending aorta
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Introduction
TechniqueNormal Anatomy
ET tubes
Central Lines
Pneumothorax
Airway occlusion
COPD
MediastinumFree Air
Consolidation
Infiltrates
ARDS
CHF
Systematic approach
Quiz
WebLinker
Lateral Image
More
A
B
C
DE
F
G
I
J
H
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Introduction
TechniqueNormal Anatomy
ET tubes
Central Lines
Pneumothorax
Airway occlusion
COPD
MediastinumFree Air
Consolidation
Infiltrates
ARDS
CHF
Systematic approach
Quiz
WebLinker
Lateral Image - Anatomy Aright costophrenic angle
Bleft diaphragm
C - heart
Daortic knob (arch)
E - trachea
F - hilum G - carina
Hstomach bubble
Ipacer wires
Jascending aorta Also note AICD & sternotomy wires
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Introduction
TechniqueNormal Anatomy
ET tubes
Central Lines
Pneumothorax
Airway occlusion
COPD
MediastinumFree Air
Consolidation
Infiltrates
ARDS
CHF
Systematic approach
Quiz
WebLinker
Lateral decubitus Image
A lateral decubitus radiograph isobtained with a horizontal x-ray beamwhile the patient lies in the decubitusposition. It is used to detect small
effusions, to characterize free-flowingeffusions on the decubitus side, or todetect a small pneumothorax on thecontralateral side. As little as 5 mL offluid or 15 mL of air can bedemonstrated by this view.
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Introduction
TechniqueNormal Anatomy
ET tubes
Central Lines
Pneumothorax
Airway occlusion
COPD
MediastinumFree Air
Consolidation
Infiltrates
ARDS
CHF
Systematic approach
Quiz
WebLinker
Lateral decubitus Image- effusion
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Introduction
TechniqueNormal Anatomy
ET tubes
Central Lines
Pneumothorax
Airway occlusion
COPD
MediastinumFree Air
Consolidation
Infiltrates
ARDS
CHF
Systematic approach
Quiz
WebLinker
27yoM with pleuritic CP & hypoxia
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Introduction
TechniqueNormal Anatomy
ET tubes
Central Lines
Pneumothorax
Airway occlusion
COPD
Mediastinum
Free Air
Consolidation
Infiltrates
ARDS
CHF
Systematic approach
Quiz
WebLinker
Lateral decubitus Image - pneumothorax
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Introduction
TechniqueNormal Anatomy
ET tubes
Central Lines
Pneumothorax
Airway occlusion
COPD
Mediastinum
Free Air
Consolidation
Infiltrates
ARDS
CHF
Systematic approach
Quiz
WebLinker
Different Chest X-ray views
AP - erect
Posteroanterior PALateral (left) Right anterior oblique
Right lateral decubitusAP - supine
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Introduction
TechniqueNormal Anatomy
ET tubes
Central Lines
Pneumothorax
Airway occlusion
COPD
Mediastinum
Free Air
Consolidation
Infiltrates
ARDS
CHF
Systematic approach
Quiz
WebLinker
Normal Anatomy - Heart On the PA view of the heart,
the left border is much moreprominent than the right. As ageneral rule, if the right side ofthe heart is enlarged more thanthe left, a right chamber lesionis present. The same holds truefor the left side.
On an upright PA chest x-ray,
the greatest width of the heartshould be less than half thewidth of the thoracic cavity atits widest point. Sometimespatients have eitherdextrocardia or situs inversus.Before the latter diagnosis ismade, it is important to make
sure that the technician did notmisplace the right or left markeron the image.
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Introduction
Technique
Normal Anatomy
ET tubes
Central Lines
Pneumothorax
Airway occlusion
COPD
Mediastinum
Free Air
Consolidation
Infiltrates
ARDS
CHF
Systematic approach
Quiz
WebLinker
Normal AnatomyMediastinumThe upper mediastinal structures
that are visualized on the rightare the brachiocephalicvessels, azygos vein, andascending aorta. The rightborder of the ascending aortacan be seen beginning belowthe right hilum. The aortic archis most commonly seen to the
left of the trachea. Thedescending thoracic aorta canusually be visualized only alongits left lateral border, where itabuts the left lung. The tracheashould be midline and can befollowed down to the carina.The right and left major bronchiare easily seen. Theesophagus is not normally seenon a standard chest x-ray.
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Introduction
Technique
Normal Anatomy
ET tubes
Central Lines
Pneumothorax
Airway occlusion
COPD
Mediastinum
Free Air
Consolidation
Infiltrates
ARDS
CHF
Systematic approach
Quiz
WebLinker
Normal Anatomy - Hilum The hila are made up of the
main pulmonary arteries andmajor bronchi. The right hilumis usually somewhat lower thanthe left; it should not be at thesame level or higher. Thepulmonary veins usually aremore difficult to see than thearteries. They converge on the
atria at a level 1 to 3 inchesbelow the pulmonary arteries.
The blood vessels in the lungare usually clearly seen out towithin 2 to 3 cm of the chestwall. Some people say thatvisualization of vessels in theouter third of the lung is
abnormal, but this is not true. Itdepends on the quality of thefilm and on how hard you look.Lines located within 2 cm of thechest wall are abnormal andprobably represent edema,fibrosis, or metastatic disease. More
http://bringhamrad.harvard.edu/http://bringhamrad.harvard.edu/ -
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Introduction
Technique
Normal Anatomy
ET tubes
Central Lines
Pneumothorax
Airway occlusion
COPD
Mediastinum
Free Air
Consolidation
Infiltrates
ARDS
CHF
Systematic approach
Quiz
WebLinker
Normal anatomy - Lungs The lungs are composed
mostly of air, and therefore,normally not much is seenother than blood vessels.These should be distinct andremain that way as they aretraced back to the hila. Normalhila are sometimes indistinct onportable x-rays because the
exposure takes longer, and thevessels are blurred by motion.
Remember that on chest x-ray,the lungs go behind the heart,behind and below the dome ofthe hemidiaphragms, andbehind and in front ofmediastinal structures. 40% of
the lung area and 25% of thelung volume will be obscuredby these other structures
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Introduction
Technique
Normal Anatomy
ET tubes
Central Lines
Pneumothorax
Airway occlusion
COPD
Mediastinum
Free Air
Consolidation
Infiltrates
ARDS
CHF
Systematic approach
Quiz
WebLinker
Normal anatomy - Diaphragms The diaphragms are
typically dome-shaped;The right hemidiaphragmis usually higher than theleft, The diaphragms areat different levelsbecause the heart is
pushing the lefthemidiaphragm down.The edges of bothhemidiaphragms formacute angles with thechest wall, and bluntingof these angles should
raise the suspicion ofpleural fluid.
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Introduction
Technique
Normal Anatomy
ET tubes
Central Lines
Pneumothorax
Airway occlusion
COPD
Mediastinum
Free Air
Consolidation
Infiltrates
ARDS
CHF
Systematic approach
Quiz
WebLinker
Diaphragms on Lateral XR Most people have trouble
telling the right from the lefthemidiaphragm on the lateralview, but several ways exist totell them apart. The righthemidiaphragm is usuallyhigher than the left and can beseen extending from theanterior chest wall to the
posterior ribs. The left sideusually can be seen only fromthe posterior aspect of theheart to the posterior ribs. Italso is the hemidiaphragmmost likely to have a gasbubble (stomach or colon)immediately beneath it.
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Left Right
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Introduction
Technique
Normal Anatomy
ET tubes
Central Lines
Pneumothorax
Airway occlusion
COPD
Mediastinum
Free Air
Consolidation
Infiltrates
ARDS
CHF
Systematic approach
Quiz
WebLinker
Normal anatomy - Bones The upper margin of the ribs is
usually well seen, because the rib isrounded here. The lower edge of theribs is usually very thin, and theinferior cortical margin can bedifficult to appreciate. Look forsymmetry between the right and leftribs at the same level. If they aresymmetrical, they are usuallynormal. At the anterior ends of theribs, cartilage connects to the
sternum. In older individuals,significant calcification of thiscartilage may occur; this is a normalfinding
The medial aspect of the scapulaprojects over the upper lateralaspect of the lungs and sometimescan be mistaken for a pathologicline, such as a pneumothorax.
Note the cervical ribs
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Introduction
Technique
Normal Anatomy
ET tubes
Central Lines
Pneumothorax
Airway occlusion
COPD
Mediastinum
Free Air
Consolidation
Infiltrates
ARDS
CHF
Systematic approach
Quiz
WebLinker
Normal anatomy - Bones The thoracic spine is seen only
incompletely on a standardchest x-ray because, on thefrontal view, it is obscured bythe heart and mediastinalstructures. In older people,substantial degenerativechanges or bone spurs mayextend laterally from the
vertebral bodies. These canoften be seen on the PA view,and on the lateral view, thespurs can look like pulmonarynodules. A key to differentiatingbony spurs from nodules is thatspurs project over the vertebraldisks on the lateral view and donot look like round nodules onthe frontal chest x-ray.
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Introduction
Technique
Normal Anatomy
ET tubes
Central Lines
Pneumothorax
Airway occlusion
COPD
Mediastinum
Free Air
Consolidation
Infiltrates
ARDS
CHF
Systematic approach
Quiz
WebLinker
Pathology on CXR - outline1. Position of lines, ETT & NGT
2. Pneumothorax3. COPD
4. Airway occlusion
5. Pneumo-mediastinum
6. Subcutaneous emphesyma
7. Widened mediastinum8. Air under the diaphragm
9. Infiltratesalveolar & interstitial
10. Atelectasis
11. ARDS
12. Pulmonary edema13. Pleural effusion
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Introduction
Technique
Normal Anatomy
ET tubes
Central Lines
Pneumothorax
Airway occlusion
COPD
Mediastinum
Free Air
Consolidation
Infiltrates
ARDS
CHF
Systematic approach
Quiz
WebLinker
Position of endotracheal tube
The ET tip shouldbe at least 1 cm
above the carina.
The highest that an
ET tube tip should
be is at the level ofthe suprasternal
notch (which is
midway between
the proximalclavicles).
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Introduction
Technique
Normal Anatomy
ET tubes
Central Lines
Pneumothorax
Airway occlusion
COPD
Mediastinum
Free Air
Consolidation
Infiltrates
ARDS
CHF
Systematic approach
Quiz
WebLinker
Position of Endotracheal tube A tube in a lower
position can obstructair flow to one sideand causeatelectasis (collapse)of a lung or a portion
of a lung. An ET tubein low positionusually will go intothe right main-stembronchus because itis more verticallyoriented than the leftmain-stem bronchus.
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Introduction
Technique
Normal Anatomy
ET tubes
Central Lines
Pneumothorax
Airway occlusion
COPD
Mediastinum
Free Air
Consolidation
Infiltrates
ARDS
CHF
Systematic approach
Quiz
WebLinker
Position of Naso-gastric tube
NG tube shouldfollow the course of
the esophagus on
the frontal chest x-
ray, and on the
lateral view, itshould pass behind
the trachea and
then along the
posterior aspect ofthe heart.
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NG in RLL bronchus
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Introduction
Technique
Normal Anatomy
ET tubes
Central Lines
Pneumothorax
Airway occlusion
COPD
Mediastinum
Free Air
Consolidation
Infiltrates
ARDS
CHF
Systematic approach
Quiz
WebLinker
Position of Nasogastric tubes During insertion, the
NGT may be coiled inthe esophagus. Lesscommonly, the NG tubescan pass into the tracheainstead of going into theesophagus and go down
the right main-stembronchus. Because NGtubes can be stiff andhave a rigid end, ifpushed hard enough,they can perforate thelung and go out into the
pleural space
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Introduction
Technique
Normal Anatomy
ET tubes
Central Lines
Pneumothorax
Airway occlusion
COPD
Mediastinum
Free Air
Consolidation
Infiltrates
ARDS
CHF
Systematic approach
Quiz
WebLinker
Identify the hardware
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Introduction
Technique
Normal Anatomy
ET tubes
Central Lines
Pneumothorax
Airway occlusion
COPD
Mediastinum
Free Air
Consolidation
Infiltrates
ARDS
CHF
Systematic approach
Quiz
WebLinker
NGT & ETT in place
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Introduction
Technique
Normal Anatomy
ET tubes
Central Lines
Pneumothorax
Airway occlusion
COPD
Mediastinum
Free Air
Consolidation
Infiltrates
ARDS
CHF
Systematic approach
Quiz
WebLinker
Whats wrong?
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Introduction
Technique
Normal Anatomy
ET tubes
Central Lines
Pneumothorax
Airway occlusion
COPD
Mediastinum
Free Air
Consolidation
Infiltrates
ARDS
CHF
Systematic approach
Quiz
WebLinker
Tracheostomy is out!
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Introduction
Technique
Normal Anatomy
ET tubes
Central Lines
Pneumothorax
Airway occlusion
COPD
Mediastinum
Free Air
Consolidation
Infiltrates
ARDS
CHF
Systematic approach
Quiz
WebLinker
PositionsCentral lines
The tip of the cathetershould optimally be
placed in the
superior vena cava
(SVC). On the
frontal chest x-ray,the catheter tip
should be about 1
to 4 cm below the
medial aspect ofthe right clavicle
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Introduction
Technique
Normal Anatomy
ET tubes
Central Lines
Pneumothorax
Airway occlusion
COPD
Mediastinum
Free Air
Consolidation
Infiltrates
ARDS
CHF
Systematic approach
Quiz
WebLinker
Positioncentral lines
More
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Introduction
Technique
Normal Anatomy
ET tubes
Central Lines
Pneumothorax
Airway occlusion
COPD
Mediastinum
Free Air
Consolidation
Infiltrates
ARDS
CHF
Systematic approach
Quiz
WebLinker
Position of central linesThe abnormal positions
of subclaviancatheter tips arethose that haveturned up into the
jugular vein rather
than down into theSVC, and those thathave crossed themidline andextended into theopposite subclavianvein
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Introduction
Technique
Normal Anatomy
ET tubes
Central Lines
Pneumothorax
Airway occlusion
COPD
Mediastinum
Free Air
Consolidation
Infiltrates
ARDS
CHF
Systematic approach
Quiz
WebLinker
Position of Swan Ganz catheterThe normal course is almost
circular: down the SVC,through the right atrium andright ventricle, and out intothe main pulmonary andperipheral pulmonaryarteries. The tip of a centralvenous pressure (CVP) line
should not extend morethan halfway between thehilum and the lungperiphery, or lung infarctioncan occur. Another problemencountered can be thepassage of such a catheterfrom the SVC into the IVCinstead of into the rightheart
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Introduction
Technique
Normal Anatomy
ET tubes
Central Lines
Pneumothorax
Airway occlusion
COPD
Mediastinum
Free Air
Consolidation
Infiltrates
ARDS
CHF
Systematic approach
Quiz
WebLinker
Identify the Hardware
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Introduction
Technique
Normal Anatomy
ET tubes
Central Lines
Pneumothorax
Airway occlusion
COPD
Mediastinum
Free Air
Consolidation
Infiltrates
ARDS
CHF
Systematic approach
Quiz
WebLinker
Swan Ganz & IABP
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Intra-Aortic Balloon Pump
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Introduction
Technique
Normal Anatomy
ET tubes
Central Lines
Pneumothorax
Airway occlusion
COPD
Mediastinum
Free Air
Consolidation
Infiltrates
ARDS
CHF
Systematic approach
Quiz
WebLinker
PneumothoraxBecause the pleural space is continuous around each lung, if the patient is
in an upright or semi-upright position, air in the pleural space willtypically go toward the apex. Thus, the first place to look for a PTXis in the upper hemithorax. The most common appearance is anarea adjacent to the ribs where no lung vascularity is seen andwhere a very thin white line represents the visceral pleura that hasbeen separated from the parietal pleura by air. It may be useful toobtain an expiration chest x-ray in addition to the usual inspirationchest x-ray if the PTX is small. On an expiration view, the lungbecomes somewhat denser and smaller as expiration occurs. Theamount of air in the pleural space will not change in size or density,and thus the pneumothorax will appear relatively larger duringexpiration
1cm of space lateral to the lung constitutes about a 10%pneumothorax.
1 inch of space between the lateral chest wall and the lung margin isabout a 30% pneumothorax.
When a chest tube is properly placed, connected to a vacuum, andunobstructed, if there is persistence of the PTX, consider thepossibility of a bronchopleural fistula. This usually is a result ofblunt trauma with a tear in the region of a major bronchus.Other possibilities are a loculated PTX or an anterior PTX with aposteriorly placed chest tube
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Pneumothorax
More
Deepsu lcuss ign
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Systematic approach
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Tension pneumothoraxIf mediastinal shift occurs or if
there is depression of thehemi- diaphragm withdisplacement of the heartand trachea away fromthe side with thepneumothorax, yourpatient has a tension
pneumothorax
Deepsu lcuss ign. Normally,the lateral costophrenic
angles are sharp. Thepleural space, however,goes much farther downalong the edge of thelateral aspect of the liverand spleen than most
people think. If air is inthe pleural space, it caneasily track down,
making the costophrenicangle or su lcusmuchdeeperand the anglemuch more acute than isnormally seen.
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ET tubes
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Systematic approach
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Airway occlusionIf a tumor or mucous plug obstructs
an airway, resorption of airdistally will be accompaniedby volume loss. If theobstruction is of a majorbronchus, rapid opacification(whiteness) of the lung maybe found with tracheal andmediastinal shift toward theaffected side as a result ofvolume loss.
in cases in which a nonmetallicobstructing foreign body issuspected, you should orderinspiration and expiration PAchest views.
In uncooperative patient, right and
left decubitus chest views aresometimes used. The sidethat does not decrease involume during expiration orwhen placed dependently isabnormal. More
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Systematic approach
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COPDobvious signs of hyperinflation such
as the superior portions ofthe hemidiaphragms may bedown to the level of theposterior twelfth ribs, andoften blunting of thecostophrenic angles is seen.
With COPD, an increase in the APdiameter of the chest on the
lateral view, a large anteriorclear space between thesternum and ascendingaorta, and marked flatteningor even inversion of thehemidiaphragms are seen.
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Systematic approach
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Pneumo-mediastinum air collections that are
typically vertical arefound within the upperportion of themediastinum and lowerneck. On the lateral view,you can sometimes seeair in front of or behindthe trachea. Apneumomediastinum canbe the result of atracheobronchial tear.This entity carries up to a50% mortality rate if not
treated
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Systematic approach
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Subcutaneous emphesymaAir in the soft tissues is seen as
dark linear or ovoid areas,which can extend into thesupraclavicular and lowercervical regions. Whensubcutaneousemphysema is extensive,it can dissect into the
pectoral muscles,producing a bizarre fan-shaped appearance of theair as it outlines themuscle fibers; it can beconfirmed with crepitationon physical exam.
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Widened mediastinum
Most mediastinal masses cause afocal widening
Most mediastinal infiltrations (blood
or infection) cause a generalizedwidening
In both cases, the interface with the
lung is usually sharp and convex
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Systematic approach
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Anterior mediastium
Terriblelymphoma
Thymoma
Teratoma
Thoracic aorta
Thyroid
More
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Systematic approach
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Middle mediastinum thoracic aortic
aneurysms, hematomas,neoplasms, adenopathy,esophageal lesions,diaphragmatic hernias(hiatal or Morgagni type),and duplication cysts.Morgagni hernias tend tobe on the right side. Anymiddle mediastinal lesionassociated with the aortashould be considered ananeurysm until proven
otherwise
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ET tubes
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Systematic approach
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Middle mediastinum Any middle mediastinal
lesion associated with theaorta should be
considered an aneurysm
until proven otherwise
More
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Systematic approach
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Posterior mediastinum Most (90%) posterior
mediastinal lesions areneurogenic. They mayrepresent neuroblastomasin young children, but inadults are more likely to beneurofibromas,schwannomas, organglioneuromas. Otherposterior mediastinallesions include hernias(hiatal or Bochdalek type),neoplasms, hematomas,or extra-medullaryhematopoiesis. Bochdalekhernias are most often onthe left side.
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ET tubes
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COPD
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Systematic approach
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Air under the diaphragm
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ET tubes
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Systematic approach
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Perforated Viscus
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ET tubes
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Systematic approach
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Alveolar air space disease Alveolar air space disease
suggest that the alveoli are filledwith pus, blood, or fluid. As fillingof the alveoli progresses, theonly things left with air in themare the bronchi, and thus airbronchograms can be seen.
Most bacterial pneumoniasproduce lobar, segmental, orpatchy infiltrates. Accuratelocalization requires both PA &lateral films.
Lobar pneumonias areassociated with streptococcal,staphylococcal, and gram-negative organisms. Lobarenlargement with an infiltrate ischaracteristically associated withKlebsiella. Cavitation in an acutepneumonia is associated withstaphylococci and virulentstreptococci. Chronic cavitation
is associated with tuberculosis(TB), histoplasmosis, and fungallesions.
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ET tubes
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Systematic approach
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RUL consolidation
More
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ET tubes
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RML Pneumonia
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RLL Pneumonia
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LUL Pneumonia
More
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LLL pneumonia
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The opaque hemithorax
Atelectasis Lobar PNA EffusionIpsilateral volume loss
Ipsilateral tracheal,
hemi-diaphragm and
mediastinal shift
Visceral and parietal
pleura do not separate
from each other
No shift of the
mediastinum
Air bronchograms
Mass effect
Pushing the
mediastinum to the
contra-lateral side
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Systematic approach
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Interstitial disease Interstitial patterns are caused by disease processes
that affect tissues outside the alveoli. Interstitialprocesses are usually diffuse and are seen as thinwhite lines. Occasionally they may be somewhathoneycombed in appearance, and the differentialdiagnosis of these processes often depends onwhether the interstitial infiltrate is acute or chronic
Intersitial PNA are atypical and include Mycoplasma,viruses, and Pneumocystis. Severe acute respiratorysyndrome (SARS) is an atypical pneumonia. Theimaging findings in SARS are nonspecific and includefocal and patchy interstitial opacities as well asunilateral or bilateral areas of consolidation.
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Interstitial Pattern
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27yoF with suabcute cough and fever
CXR with subtle interstitial pattern
For further elucidationCt chest obtained
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Alveolar versus interstitial
More
Normal lobule
Interstitial
Alveolar
With interstitial pattern, the lungs
appear well aerated but lung markings
are thick. With alveolar pattern, the
lung markings are invisible, because
the surrounding lung is consolidated.
Goodman: Felsons Principles of Chest Roentgenology A programmed text, Saunders, 2nd ed., 1999
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Reticular versus nodular
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NodularReticular
Reticulo-nodular
If the interstitial thickening is
generalized, the pattern is linear
(reticular); if the thickening is discrete,
it forms many small nodules. Thesepatterns may be further characterized
as focal or diffuse and acute or
chronic.
Goodman: Felsons Principles of Chest Roentgenology A programmed text, Saunders, 2nd ed., 1999
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Atelectasis
Atelectasis refers to collapse of a lung or portion of the lung
with resorption of air from the alveoli. Causes include anobstructing bronchial lesion, extrinsic compression (frompleural effusions or bullae), fibrosis, or a loss of surfacetension in the alveoli (as in hyaline membrane disease).
Linear (discoid or platelike) atelectasis is almost always seen inthe middle or lower lung zones as a horizontal or near-horizontalline of increased density (whiteness). This minimal form ofsubsegmental collapse is most commonly seen in patients whohave difficulty breathing, such as after recent surgery or ribfractures.
Atelectasis of entire lung segments occurs typically as a result ofa mucous plug, tumor, or low ET tubes. Signs of atelectasisinclude ipsilateral volume loss and tracheal deviation.
The most severe form of volume loss occurs after after apneumonectomy, empty space fills with fluid over several weeks.
As this progresses, the hemidiaphragm will elevate, themediastinum will move toward the affected side, and theremaining lung will hyperinflate and often will herniate across themidline. If the mediastinal structures are displaced away from theresected lung, you should be suspicious of a postoperativemalignant effusion or an empyema. More
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Systematic approach
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Atelectasis
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Free air
atelectasis
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Systematic approach
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Atelectasis versus Consolidation
Atelectasis ConsolidationDisplaced fissure Fissure is in place
Crowded broncho-vascular
markings
Vessels are less visible in the
area of consolidation
Volume loss - Shift of a markerstructure towards the collapsed
lung; ex.nodule, trachea,
mediastinum
No volume lossNo anatomical shift
Atelectatic lung is more radio-
opaque & adjacent lobes may
hyperinflatemore radiolucent
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COPD
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CHF
Systematic approach
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Pulmonary edema - earlyMinimal cardiomegaly and
redistribution of thepulmonary vascularity maybe seen on an upright film,with almost equal flow toupper and lower lung zones(with mean PCWP of 15 to25 mm Hg). At this time, thediameter of upper lobevessels will be equal to or
greater than that of lowerlobe vessels at the samedistance from the hilum.
Another way to tell is by thepresence in the firstintercostal space ofpulmonary vessels that aregreater than 3 mm in
diameter. Remember thatyou cannot use these signson a supine chest x-ray
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Congestive Heart Failure
The films demonstrate cardiomegaly, pleural effusions (greater on the right than
the left, an accentuated pattern of interstitial lines (reticular opacities), and
peribronchial cuffing (seen best on the lateral view). The opacity at the right base
is associated with a meniscus tracking up along the lateral chest wall; this
suggests pleural effusion.More
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Systematic approach
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Progressive pulmonary edema As CHF increases, fluid
may be seen in theinterlobular septa at thelateral basal aspects of thelung (25 to 30 mm Hg).These are referred to asKerley B lines. They arealways located just insidethe ribs and are horizontalin orientation. Remember,these cannot be bloodvessels, because youshould not normally seelung markings in theperipheral one fourth of thelungs
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Systematic approach
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Fulminant failureVessels near the hila become indistinct
because of fluid accumulating in
the interstitium. Symmetrical andbilateral hilar indistinctnessshould immediately raise thepossibility of CHF. Pleuraleffusions may be present, asevidenced by blunting of thelateral or posterior costophrenicangles. With pronounced CHF,fluid accumulates in the alveolar
spaces, and frank pulmonaryedema becomes apparent. This isseen as bilateral, predominantlybasilar and perihilar alveolarinfiltrates (>30 mm Hg).
A note of caution is inserted here,because the changes of minimalcardiomegaly and theequalization of the pulmonaryvasculature are essentiallynormal findings on a supine APchest x-ray
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Systematic approach
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Acute Respiratory Distress SyndromeThe damage results from leakage
of fluid from the alveolar
capillary bed. The usualpattern is that of diffuse orpatchy alveolar infiltratesthroughout both lungs. Themajor difficulty in evaluatingthese patients is theexclusion of a concurrentbacterial PNA or CHF. If analveolar infiltrate changesrapidly (within several hoursor within 1 day), theinfiltrates most likelyrepresent fluid overload. Inpatients with CHF, usuallyKerley B lines, pleuraleffusions, increased heartsize, and peribronchial
cuffing occur. With ARDS,Kerley B lines should not bepresent, pleural effusionsoccur only late, heart size isoften normal, and alveolarinfiltrates often extend to thelung periphery.
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Systematic approach
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Pleural effusion Pleural effusions usually are at
least 100 cc if they are seen on a
routine upright chest x-ray. Empyema is pus filled pocket in
the pleural space. An empyemamay look very much like a pleuraleffusion or pleural thickening, butit does not move freely and willnot layer on a decubitus chest x-ray. The process is often elliptical,with the long axis along the lateral
chest wall, and the lung iscompressed or displaced.Empyemas often are loculatedand have septae
Occasionally a pneumothoraxoccurs when pleural fluid ispresent. This gives a rathercharacteristic, straight horizontalline as a result of the air/fluid level
in the pleural space. This istermed a hydropneumothorax
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ET tubes
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Airway occlusion
COPD
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Systematic approach
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Pleural Effusions
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P tti it ll t th
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Putting it all together
First look at the patients name, date andtime of the image taken and the viewif allsatisfactory then proceed in a systematicway to analyze the film and generate adifferential diagnosis
Are there any prior films for comparison?
This may determine the acuity of disease Always try to look at the area of interest last.
For example, most chest x-rays are orderedto look at the lung parenchymaso try andexamine the lungs last, this way other things
of interest are not missed.
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S t ti h
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Systematic approach
Patient Data (name history #, age, sex, old films)
Routine Technique: AP/PA, supine or erect Adequate exposurevertebral detail visible through the cardiac
shadow
Inspiratory filmcount the # of ribs
Rotationexamine the clavicular heads relative to the spinous process
Abdomenidentify stomach bubble, hepatic & splenic flexure. Is there anyfree air?
Thoracic cage
Look at soft tissues of the chest wallMastectomy? Subcutaneousemphesyma? Calcification
The ribsnote that the posterior ribs descend from medial to lateral,and the anterior ribs descend from lateral to medialfractures?
The shoulder girdlescapula & clavicle (fractures)
Mediastinal contour: widthfocal or diffuse? mass?
Trachea: midline or deviated, caliber, mass
Aorta & heart - heart width > 2:1 ? Cardiac configuration?
Hila: masses, lymphadenopathy; Pulmonary vessels: artery or veinenlargement
Lungs: abnormal shadowing or lucency
Examine each lung separately first and then side by side to compare forsymmetry
Pleura: effusion, thickening, calcification
ICU Films: identify tubes first and look for pneumothorax
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Systematic approach
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References
Mettler: Essentials of Radiology, 2nd ed., 2005
Brant: Fundamentals of Diagnostic Radiology, 3rd ed., 2007Goodman: Felsons Principles of Chest Roentgenology A
programmed text, Saunders, 2nded., 1999
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1. Which of the following will be an
ideal study to better visualize a
questionable right sided effusion in
an ICU patient?
A. Posteroanterior filmB. Anteroposterior film
C. Left lateral decubitus film
D. Right lateral decubitus film
E. Lateral film
Quiz
CB DA E
Key
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2. After placing a left subclavian triple lumen catheter
in an ICU patient, the patient becomes dyspneic andhypoxic. The AP film to confirm line placementdoes not demonstrate a pneumothorax. Which ofthe following films would be best suited todemonstrate a small pneumothorax in an ICUpatient?A. Posteroanterior film
B. Anteroposterior filmC. Left lateral decubitus film
D. Right lateral decubitus film
E. Lateral film
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3. All of the following XR findings confirm
the presence of atelectasis except:
a. Shift of anatomy towards area of volume
loss
b. Displaced fissuresc. Crowded broncho-vascular markings
d. Adjacent non-atelectatic lung is more radio-
opaque
e. Tracheal deviation towards atelectasis
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4. All of the following radiographicfindings are consistent withcongestive heart failure except:a. Air bronchograms
b. Kerley b lines
c. cardiomegaly
d. Wedge shaped density
e. Bilateral hilar haziness
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5. all of the following are true except:
A. In an ICU patient left lower lobe is subject toatelectasis most often
B. Most patients with pulmonary embolism do nothave cxr findings
C. ARDS is usually characterized by normal PCWPD. In a supine patient who has aspirated - the mostcommon location of pneumona is posterior segmentof upper lobe and superior segment of lower lobe
E. In a supine patient who has aspirated - the mostcommon location of pneumona is basilar segment of
the lower lobes and the apex
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6. which of the following is not acommon cause of abscess
formation?
A. post-obstructive PNA
B. viral PNA
C. septic emboli
D. aspiration
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Quiz7. All of the following should be included in the
differential diagnosis of anterior mediastinal massexcept:
A. Thymoma
B. T cell lymphoma
C. Thyroid cancer
D. Teratoma
E. Neuroblastoma
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Quiz8. 56 yo M with h/o COPD, CHF,
HTN, hyperlipidemia c/osubacute onset of dyspnea andthis CXR. Of the followinganswer choice, which is themost appropriate course ofaction:
A. Aggressive diuresis
B. Anticoagulation
C. IV ceftriaxone & azithromycin
D. Thoracentesis
E. Non-steroidal anti-inflammatory
F. High Flow Nebulized treatments
and IV steroids
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Quiz9. 56 yo M with h/o COPD, CHF,
HTN, hyperlipidemia c/o subacuteonset of dyspnea and this CXR.Of the following answer choice,which is the most appropriatecourse of action:
A. Aggressive diuresis
B. Anticoagulation
C. IV ceftriaxone & azithromycin
D. Thoracentesis
E. Non-steroidal anti-inflammatory
F. High Flow Nebulized treatmentsand IV steroids
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Quiz10.56 yo M with h/o COPD, CHF,
HTN, hyperlipidemia c/o subacuteonset of dyspnea and this CXR.Of the following answer choice,which is the most appropriatecourse of action:
A. Aggressive diuresis
B. Anticoagulation
C. IV ceftriaxone & azithromycin
D. Thoracentesis
E. Non-steroidal anti-inflammatory
F. High Flow Nebulized treatmentsand IV steroids
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Quiz11. Radiologic signs of diffuse interstitial lung disease include all of the
following except:
a. Pulmonary markings are not visible
b. The lung appears aerated
c. An air bronchogram is seldom visible
d. Acute disease causes no distortion of lung pattern
e. Most diffuse interstitial lung disease is chronic and usually due tofibrosis
f. Acute diffuse interstitial disease is usually due to pulmonary edemaand viral or mycoplasma pneumonia
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Quiz12. Radiographic signs of alveolar lung disease or airspace consolidation
include all of the following except:
a. Vessels are less visible in the area of disease
b. The disease lung appears aerated
c. An air bronchogram is visible
d. The most frequent cause of diffuse alveolar disease are bacterialpneumonia and severe pulmonary edema
e. The most frequent cause of focal alveolar disease is bacterialpneumonia
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Quiz13. A 57yo man c/o dyspnea and
lower leg swelling. On exam,VS are stable and PE issignificant for JVD, bilateralcrackles, edema, and thisCXR. All of the followingshould be considered indifferential diagnosis except:
A. Mitral regurgitation
B. Ischemic cardiomyopathy
C. Aortic regurgitation
D. Tricuspid regurgitation
E. Aortic stenosis
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Quiz14. All of the following are true of the limitations posed by anteroposterior
film except:
a. The limited maximal kilovoltage potential of portable units requireslonger exposures to penetrate cardiomediastinal structures, whichleads to more motion artifact.
b. Because critically ill patients are difficult to position, the patient is oftenrotated.
c. The shorter focus-to-film distance and AP technique result in
magnification of intra-thoracic structures.d. The normal gravitational effect evens out the blood flow between upper
and lower zones in supine patients, which makes assessment ofpulmonary venous hypertension difficult. The increase in systemicvenous return to the heart produces a widening of the uppermediastinum.
e. The hydrostatic pressures associated with the supine position allows
small effusions and pneumothoraces to become more visible
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Quiz15. All of the following techniques masquerades presence of
disease when there is none except:
a. An expiration film causes small pulmonary blood vessels toappear more prominent
b. An AP film demonstrates mediastinal widening due toincreased systemic venous return
c. Underexposure causes the image to be white. It will make
the small pulmonary blood vessels appear more prominentand may lead to thinking that there are generalized infiltrateswhen none are really present.
d. Overexposure causes the image to be white. It will make thesmall pulmonary blood vessels appear more prominent andmay lead to thinking that there are generalized infiltrateswhen none are really present.
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Quiz16. All of the following statements are true except:
a. Supine film decreases lung volume; so the infiltrates andinterstitium appears more pominent
b. Fluid and air migrate; such that small pnuemothoraces andeffusions may be missed
c. A supine film decreases venous return to heart; thepulmonary vein and azygous vein are less distended.Diaphragm rises and intracardiac pressure decrease;
therefore the heart and mediastinal structures are smallerd. Pneumothorax signs on supine film include deep sulcus
sign, costophrenic sharply outlined by air, diaphragm-mediastinal junction is sharply outlined and a hyperlucencymay be superimposed over the liver shadow
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17. What is the predominantbasic mechanism
responsible for hypoxemia
in
this patient with the chest
x-ray on right?
a. Ventilation-perfusion
mismatch
b. Venous admixture (shunt)
c. Hypoventilation
d. Asphyxia
e. Diffusion block
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Quiz18. Which of the following
causes best explainsthe opaquehemithorax?
a. Right pleural effusion
b. Right sided pneumonia
c. Atelectasis
d. Tension pneumothorax
e. None of the above
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1. The correct answer is D. Free fluid in the pleural cavityis affected by gravity, fluid will gravitate toward thediaphragm when the patient is erect and toward theback when patient is supine and toward the lateralaspect of the dependent thorax when the patient lies
on his or her side in the lateral decubitus position.When a patient with a right sided effusion lies with theright side down (right lateral decubitus), the fluid layersagainst the dependent thoracic wall.
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2. The correct answer is D. While intra-pleural
fluid falls with gravity, intra-pleural air rises.
Therefore, the best position to diagnose a
pneumothorax in a patient who cannot sit orstand is a lateral decubitus film. If you
suspect a left sided PTX, the right side is
downwhich is called the right lateral
decubitus film.
Correct!
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3. The correct answer is D. Atelactatic lung is more radio-
opaque and adjacent lobes may hyperinflate and become
more radiolucent. Atelectasis usually leads to volume loss
with crowding of broncho-vascular structures and
anatomical shifts of marker structures towards areas ofvolume loss such as tracheal and mediastinal shifts as well
as raised and prominent fissures.
Correct!
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4. The correct answer is D. Congestive heart failure is usuallyaccompanied with cardiomegaly (although in patients with early
diastolic dysfunction, this finding may not be present); kerley b lines
interlobular septal prominence, air bronchograms; pleural
effusions, bilateral hilar haziness and cephalization. Because CHF isa diffuse process, it is not manifested as wedge shaped density.
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5. The correct answer is E. In an ICU patient left lower lobe is subject toatelectasis most often because of its dependent location. Mostpatients with pulmonary embolism do not have cxr findingsa rareCXR may demonstrate hamptons hump. ARDS is usuallycharacterized by normal PCWP because the edema is non-cardiogenic in etiology. In a supine patient who has aspirated - the
most common location of pneumona is posterior segment of upperlobe and superior segment of lower lobe. In a supine patient whohas aspirated - the most common location of pneumona is notbasilar segment of the lower lobes and the apex.
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6. The correct answer is b. Post-obstructive PNA,septic emboli and aspirtion are commoncauses of abscess. Viral PNA usually doesnot cause abscess.
Correct!
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7. The correct answer is e. The anterior mediastinal compartment
sits between the sternum and a line drawn anterior to the trachea
and posterior to the heartin the retro-sternal clear space on the
lateral x-ray. The contents of the anterior mediastinum include
thymus, thyroid, teratoma, lymphoma, ascending thoracic aorta
and the heart. The middle mediastinum includes esophagus,trachea, aortic arch and lymph nodes. The posterior mediastinum
include the descending aorta, nerves (neurofibroma, meningocele)
and vertebral column.
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8. The correct answer is A. The CXRdemonstrates cardiomegaly, bilateral hilarhaziness, bilateral pleural effusions L>>R,cephalization; all these findings are consistentwith congestive heart failure and so the nextbest step in treatment should be aggressivediuresis. IV antibiotics would be ideal forpneumonia. Thoracentesis would be ideal forpleural effusion. This patient had effusions buttheir likely cause is fluid overload.
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9. The correct anser is C. The CXR demonstrates aRight Upper Lobe, focal, alveolar consolidationconsistent with a lobar pnuemonia with most commoncauses include Strep pneumonia, Haemophilusinfluenza, and moraxella catarrhalis. Of the choices,
the most appropriate therapeutic option is antibiotics.
Correct!
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10. The correct answer is D. The CXR demonstrates a
large right sided pleural effusion. A thoracentesis will
provide diagnostic information separating an exudate
from transudate. It will also provide therapeutic relief in
patients complaints of dyspnea.
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11. The correct answer is A. Radiologic signs of diffuse interstitiallung disease include aerated lungs (a feature that separatesinterstitial disease from alveolar disease); seldom visible airbronchogram; no distortion of lung pattern. Pulmonarymarkings are more visible. Most diffuse interstitial lung
disease is chronic and usually due to fibrosis. Acute diffuseinterstitial disease is usually due to pulmonary edema andviral or mycoplasma pneumonia
Correct!
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12. The correct answer is B. Radiographic signs of alveolar lungdisease or airspace consolidation include less visiblepulmonary vessels, air bronchograms, and non-aeratedlungs. The most frequent cause of diffuse alveolar diseaseare bacterial pneumonia and severe pulmonary edema. Themost frequent cause of focal alveolar disease is bacterialpneumonia
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13. The correct answer is D. The clinical scenario and Chest X-ray demonstrate pulmonary edema and signs and symptomsof left sided heart failure. Mitral regurgitatoin, ischemiccardiomyopathy, aortic regurgitation and aortic stenosiscause left sided failure due to systolic or diastolicdysfunction. Tricuspid insufficiency causes right sided heartfailure only which would produce lower extremity edema butno complaints of dyspnea.
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14. The correct answer is E. The potential of portable units requireslonger exposures to penetrate cardiomediastinal structures, whichleads to more motion artifact. Because critically ill patients aredifficult to position, the patient is often rotated. The shorter focus-
to-film distance and AP technique result in magnification of intra-thoracic structures. The normal gravitational effect evens out theblood flow between upper and lower zones in supine patients, whichmakes assessment of pulmonary venous hypertension difficult. Theincrease in systemic venous return to the heart produces a wideningof the upper mediastinum. The hydrostatic pressures associatedwith the supine position allows small effusions and pneumothoracesto become less visible.
Correct!
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15. The correct answer is D. An expiration film causes small pulmonaryblood vessels to appear more prominent. An AP film demonstratesmediastinal widening due to increased systemic venous return.Underexposure causes the image to be white. It will make the smallpulmonary blood vessels appear more prominent and may lead tothinking that there are generalized infiltrates when none are really
present. Overexposure causes the image to be dark. Under thesecircumstances, the thoracic spine, mediastinal structures,retrocardiac areas, and nasogastric and endotracheal tubes arewell seen, but small nodules and the fine structures in the lungparenchyma cannot be seen.
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16. The correct answer is C. The supine position elevates thediaphragm, compressing lower lobes and decreasing lung volumes.The normal gravitational effect evens out the blood flow betweenupper and lower zones in supine patients, which makes assessmentof pulmonary venous hypertension difficult. The increase in systemic
venous return to the heart produces a widening of the uppermediastinum. The gravitational layering of free-flowing fluid may hidesmall effusions. Similarly, a pneumothorax may be difficult to detectbecause free intrapleural air rises to a nondependent position.
Correct!
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17. The correct answer is B. The chest x-ray is consistent withAcute respiratory distress syndrome. In ARDS, many of the
alveoli are filled with protein-rich exudative edema fluid.
Since these alveolar units do not have any gas within them,
the pulmonary capillary blood which traverses them does notbecome oxygenated. Thus blood with the low oxygen content
characteristic of mixed venous blood, admixes with
oxygenated blood traversing more normal alveoli, causing
shunt and severe hypoxemia which does not respond well to
100% oxygen and is sometimes referred to as "shunt-like
hypoxemia".
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Nor