interpreting chest films

8/12/2019 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


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


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


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


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

More


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Introduction


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


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


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


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


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.

More


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Introduction


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


ET tubes

Central Lines

Pneumothorax

Airway occlusion

COPD

MediastinumFree Air

Consolidation

Infiltrates

ARDS

CHF

Systematic approach

Quiz

WebLinker

AP versus PA

More


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Introduction


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

More


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Introduction


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

More


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Introduction


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


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


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


ET tubes

Central Lines

Pneumothorax

Airway occlusion

COPD

MediastinumFree Air

Consolidation

Infiltrates

ARDS

CHF

Systematic approach

Quiz

WebLinker

Lateral decubitus Image- effusion

More


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Introduction


ET tubes

Central Lines

Pneumothorax

Airway occlusion

COPD

MediastinumFree Air

Consolidation

Infiltrates

ARDS

CHF

Systematic approach

Quiz

WebLinker

27yoM with pleuritic CP & hypoxia

More


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Introduction


ET tubes

Central Lines

Pneumothorax

Airway occlusion

COPD

Mediastinum

Free Air

Consolidation

Infiltrates

ARDS

CHF

Systematic approach

Quiz

WebLinker

Lateral decubitus Image - pneumothorax

More


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Introduction


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


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

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

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.

More


27/122

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.

More

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

More


29/122

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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30/122

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

More


31/122

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).

More


32/122

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.

More


33/122

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.

More

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

More


35/122

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

More


36/122

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

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

Whats wrong?

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

Tracheostomy is out!

More


39/122

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

More


40/122

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


41/122

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

More


42/122

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

More


43/122

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

More


44/122

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

More

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

More
http://www.emedicine.com.libproxy3.umdnj.edu/CGI-BIN/FOXWEB.EXE/MAKEZOOM@/EM/MAKEZOOM?FZI=1&PICTURE=/WEBSITES/EMEDICINE/RADIO/IMAGES/LARGE/1006SLIDE2.JPG&TEMPLATE=IZOOM2&PIXELS=SQUAREhttp://www.emedicine.com.libproxy3.umdnj.edu/CGI-BIN/FOXWEB.EXE/MAKEZOOM@/EM/MAKEZOOM?FZI=1&PICTURE=/WEBSITES/EMEDICINE/RADIO/IMAGES/LARGE/1006SLIDE2.JPG&TEMPLATE=IZOOM2&PIXELS=SQUAREhttp://www.emedicine.com.libproxy3.umdnj.edu/CGI-BIN/FOXWEB.EXE/MAKEZOOM@/EM/MAKEZOOM?FZI=1&PICTURE=/WEBSITES/EMEDICINE/RADIO/IMAGES/LARGE/1006SLIDE2.JPG&TEMPLATE=IZOOM2&PIXELS=SQUARE


46/122

Introduction

Technique

Normal Anatomy

ET tubes

Central Lines

Pneumothorax

Airway occlusion

COPD

Mediastinum

Free Air

Consolidation

Infiltrates

ARDS

CHF

Systematic approach

Quiz

WebLinker

Pneumothorax

More

Deepsu lcuss ign


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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

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.

More


48/122

Introduction

Technique

Normal Anatomy

ET tubes

Central Lines

Pneumothorax

Airway occlusion

COPD

Mediastinum

Free Air

Consolidation

Infiltrates

ARDS

CHF

Systematic approach

Quiz

WebLinker

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


49/122

Introduction

Technique

Normal Anatomy

ET tubes

Central Lines

Pneumothorax

Airway occlusion

COPD

Mediastinum

Free Air

Consolidation

Infiltrates

ARDS

CHF

Systematic approach

Quiz

WebLinker

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.

More


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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

More
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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.

More
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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

More


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Anterior mediastium

Terriblelymphoma

Thymoma

Teratoma

Thoracic aorta

Thyroid

More


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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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Middle mediastinum Any middle mediastinal

lesion associated with theaorta should be

considered an aneurysm

until proven otherwise

More


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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.

More


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Air under the diaphragm

More


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Perforated Viscus

More


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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.

More


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RUL consolidation

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RML Pneumonia

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RLL Pneumonia

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LUL Pneumonia

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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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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

More

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

More

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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Atelectasis

More

Free air

atelectasis


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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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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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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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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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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.

More
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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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Pleural Effusions

More

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

More

R f


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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

This is the end of ChestXray teaching module, dont forget to take the quiz.

- Quiz button . . . to take the quiz

- Clerkship tab . . to select a new topic

- End . . . . . . . to quit programCLICK:

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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

More

Q i


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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

Quiz

CB DA E

Key

More

Q i


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Quiz

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

CB DA E

Key

More

Quiz


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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

QuizKey

CB DA E More

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Quiz

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

Key

CB DA E More

Q


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Quiz

6. which of the following is not acommon cause of abscess

formation?

A. post-obstructive PNA

B. viral PNA

C. septic emboli

D. aspiration

Key

A B C D More

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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

Key

A B C D E More

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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

Key

A B C D E More

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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:


B. Anticoagulation


D. Thoracentesis


F. High Flow Nebulized treatmentsand IV steroids

Key

A B C D E More

Q i


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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:


B. Anticoagulation


D. Thoracentesis


F. High Flow Nebulized treatmentsand IV steroids

Key

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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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Systematic approach

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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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Systematic approach

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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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CHF

Systematic approach

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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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Systematic approach

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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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http://www.emedicine.com.libproxy3.umdnj.edu/RADIO/IMAGES/LARGE/593959391.JPG


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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.

Correct!

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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.

Correct!


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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.

Correct!


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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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Systematic approach

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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.

Correct!


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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.

Correct!

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COPD

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Q

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.

Correct!


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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".

Correct!


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interpreting chest films

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