Pulmonary Imaging

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  • Pulmonary Imaging

    1. 1. Chest X-Ray Collection By AMIR B.CHANNA FFARCS,DA (Eng) King Khalid Univ. Hospital Riyadh KSA
    2. 2. Most important things when reading a CXR… <ul><li>Have a System </li></ul><ul><li>Use it consistently </li></ul><ul><li>Know your anatomy </li></ul><ul><li>Diff. diagnosis & Pathophysiology </li></ul>
    3. 3. Have a System…
    4. 4. Step #1: Always, always, always… Confirm the patient’s name & check date on film
    5. 5. Step #2: Know a good CXR when you see one… assess the film’s quality HOW ?
    6. 6. Assessing Quality: R.I.P. <ul><li>R  Rotation </li></ul><ul><ul><li>clavicles- symmetric & flush with sternum </li></ul></ul><ul><li>I  Inspiration </li></ul><ul><ul><li>want to see at least 8-9 ribs for a good film </li></ul></ul><ul><li>P  Penetration </li></ul><ul><ul><li>should see vertebral bodies thru the heart </li></ul></ul>
    7. 7. Step #3: Read the film… DO NOT JUMP TO DIAGNOSIS
    8. 8. My System: the Short Version: ( Use this for routine films) <ul><li>A  Airways </li></ul><ul><li>B  Bones & soft tissues </li></ul><ul><li>C  Cardiac silhouette </li></ul><ul><li>D  Diaphragm </li></ul><ul><li>E  Everything else… the lungs </li></ul>
    9. 9. The Long Version: Use this system for more complicated films on the wards & at Morning Report <ul><li>R  Rotation (clavicles- symmetric & flush with sternum) </li></ul><ul><li>I  Inspiration (want to see at least 8-9 ribs for good film) </li></ul><ul><li>P  Penetration (should see vertebral bodies thru the heart) </li></ul><ul><li>A  Airways (trachea shifted or irregular, bronchiectasis, ETT) </li></ul><ul><li>B  Bones (frxs, osteoporosis, lytic lesions, skeletal deform’s) </li></ul><ul><li>C  Cardiac silhouette (CM, chamber enlargements, aorta, Ca ++ ) </li></ul><ul><li>D  Diaphragm (R higher L?, phrenic nerve palsy, pleural lesions) </li></ul><ul><li>E  Effusions (pleural/pericardial; effusion size, does it layer out) </li></ul><ul><li>F  Free air (under diaphragm, in sub-Q tissue, mediastinum) </li></ul><ul><li>G  GI pathology  gastric bubble (shifted by spleen) </li></ul><ul><li>H  Hilum (LAD, vascular congestion, calcifications/granulomas) </li></ul><ul><li>IJ  IJ catheters & other lines (confirm they are in the right place) </li></ul><ul><li>K  Kerley-B lines, Kypho-scoliosis and skeletal deformities </li></ul><ul><li>L  And finally… the LUNGS!!!!!!! </li></ul>
    10. 10. More Details on the Lungs: <ul><li>Features to look for when characterizing parenchymal lung disease: </li></ul><ul><li>Over/under inflation (<8 or >9 ribs visible) suggests a restrictive or obstructive process </li></ul><ul><li>Pneumothorax, atelectasis or volume loss </li></ul><ul><li>Air bronchograms or bronchiectasis </li></ul><ul><li>Infiltrates (describe as lobar, multi-lobar, diffuse) </li></ul><ul><li>Mass/nodule (+/-3cm), shape, cavity?, Ca ++? </li></ul><ul><li>Interstitial pattern (alveolar, reticular, miliary) </li></ul><ul><li>Distribution of infiltrates: apical, basilar, pleural </li></ul><ul><li>Vascular flow: oligemia? cephalization? </li></ul>
    11. 11. Know your anatomy…
    12. 16. Investigations <ul><li>Chest Radiograph </li></ul><ul><li>PA </li></ul><ul><li>AP </li></ul><ul><ul><li>Ill patient </li></ul></ul><ul><li>Lateral </li></ul><ul><ul><li>Mass localisation, cardiac chambers, hila </li></ul></ul><ul><li>Expiratory </li></ul>
    13. 21. 1 2 3 4 5 6 7 1 2 3 4 5 6 7 8 9 10
    14. 23. A B C Heart size - Cardiothoracic Ratio (CTR) A+B/C
    15. 25. Investigations <ul><li>CT </li></ul><ul><ul><li>Focal masses </li></ul></ul><ul><ul><li>Diffuse lung disease </li></ul></ul><ul><ul><li>Pulmonary emboli </li></ul></ul><ul><li>Ultrasound </li></ul><ul><ul><li>Diaphragm, pleura </li></ul></ul><ul><li>Magnetic Resonance </li></ul><ul><ul><li>Mediastinum </li></ul></ul><ul><ul><li>Lung apex </li></ul></ul><ul><li>Intervention </li></ul><ul><ul><li>Biopsy, Drainage </li></ul></ul>
    16. 32. Slice width Conventional CT
    17. 33. Spiral CT
    18. 34. Air Bone Water
    19. 35. Normal Anatomy
    20. 36. Bone-CT Reconstruction <ul><li>PA View </li></ul>Clavicle Rib Intercostal Space Vertebral Column
    21. 37. Bone Anatomy Sternum Rib
    22. 38. Heart Size <ul><li>Normal is <50% on PA upright radiograph </li></ul>
    23. 39. Lateral view
    24. 40. Cardiac Anatomy: Right Sided Chambers
    25. 41. Cardiac Anatomy: Left Sided Chambers
    26. 42. isnpexp SVC Aortic Arch Right Descending Pulmonary Artery Left Descending Pulmonary Atery
    27. 43. inspexp <ul><li>Lungs posteriorly should get darker as you go down more inferiorly </li></ul>Retrosternal Airspace Scapula IVC Pulmonary Vessels Hilum
    28. 44. Airway Anatomy <ul><li>Trachea </li></ul><ul><ul><li>Cartilage </li></ul></ul><ul><ul><li>Membranous posteriorly </li></ul></ul><ul><li>Carina </li></ul><ul><ul><li>Bifurcation </li></ul></ul><ul><li>Bronchus </li></ul><ul><ul><li>Left and right </li></ul></ul><ul><ul><li>Lobar (RUL,RML,LUL,LLL) </li></ul></ul><ul><ul><li>Segmental (8 left, 10 right) </li></ul></ul>
    29. 45. Trachea Carina R + L Main Bronchi
    30. 46. Lung Anatomy <ul><li>Lobes are separated by fissures </li></ul><ul><li>Right </li></ul><ul><ul><li>Upper Lobe </li></ul></ul><ul><ul><li>Middle Lobe </li></ul></ul><ul><ul><li>Lower Lobe </li></ul></ul><ul><li>Left </li></ul><ul><ul><li>Upper Lobe (includes lingula) </li></ul></ul><ul><ul><li>Lower Lobe </li></ul></ul>
    31. 52. Pleura and Fissures <ul><li>Pleura </li></ul><ul><ul><li>Lubricates and prevents friction during respiration </li></ul></ul><ul><ul><li>Potential Space – Don’t see unless abnormal </li></ul></ul><ul><li>Parietal pleura: Lines chest wall, mediastinal and diaphragmatic surfaces </li></ul><ul><li>Visceral pleura: Lines lungs, fissures </li></ul>
    32. 53. Parietal Pleura Visceral pleura
    33. 54. normaldiag Diaphragms Normal: Sharp costophrenic sulcus
    34. 55. normaldiag
    35. 56. Which is right and left diaphragm?
    36. 58. Approach to Chest Radiograph: Technical Factors <ul><li>Patient Identification (name and date) </li></ul><ul><li>Markers (Left vs right) </li></ul><ul><li>Assess for rotation (clavicles vs spinous process) </li></ul><ul><li>Penetration (thoracic spine should be visible) </li></ul><ul><li>Degree of Inpiration: 6 th anterior or 10 th posterior </li></ul>
    37. 59. isnpexp Clavicles Spinous Process Vertebral Body Visible 6 7 Counting anterior ribs 10 11 Counting posterior ribs
    38. 60. Inspiration/Expiration Images <ul><li>Expiration </li></ul><ul><ul><li>Heart size appear larger </li></ul></ul><ul><ul><li>Mediastinum is wider </li></ul></ul><ul><ul><li>Pulmonary vasculature indistinct </li></ul></ul>
    39. 61. 4 th Anterior 8 th Posterior Expiration Image
    40. 62. Inspiration: Same Patient Expiration
    41. 63. Abnormal Cases <ul><li>Bone </li></ul><ul><li>Cardiovascular </li></ul><ul><li>Airspace Disease including Silhouette Sign </li></ul><ul><li>Interstitial Disease and Pulmonary Edema </li></ul><ul><li>Atelectasis </li></ul><ul><li>Pulmonary Nodule </li></ul><ul><li>Pleura and Diaphragm </li></ul><ul><li>Mediastinal Mass </li></ul>
    42. 64. Bone and Soft Tissues
    43. 65. productive1stribs Productive 1 st rib changes: Can simulate nodule
    44. 66. Lordotic View Better assess apices without bone overlap
    45. 67. Rib Fracture
    46. 69. Presenting CXR
    47. 71. MRI Computed Tomography Pancoast Tumour
    48. 72. Cardiovascular
    49. 73. Increased Cardiac Size: Can be Cardiac or Pericardial Pericardial Effusion Dilated Cardiomyopathy What imaging would you use to differentiate between the two ?
    50. 74. Left Ventricular Enlargement Enlargement of Left Ventricle Left Ventricle IVC
    51. 75. Airspace Disease and Silhouette Sign
    52. 76. Airspace Disease <ul><li>Filling in of acini (air space) </li></ul><ul><li>Air space (acinar) nodules </li></ul><ul><li>Coalesce to consolidation </li></ul><ul><li>Air bronchograms </li></ul><ul><li>Silhouette Sign </li></ul>
    53. 77. Air Space Disease: Etiology <ul><li>Water -Pulmonary Edema </li></ul><ul><li>Pus -Infections, Non-infectious inflammatory process </li></ul><ul><li>Blood-Pulmonary Hemmorhage </li></ul><ul><li>Protein-Alveolar Proteinosis </li></ul><ul><li>Tumour-BAC, Lymphoma </li></ul>
    54. 78. Bronchopneumonia Pattern: Airspace Nodules
    55. 79. Acinar Nodules Computed Tomography
    56. 80. Air Bronchogram <ul><li>Airways are not normally seen in a normal chest radiograph because they are an air structure within an aerated lung </li></ul><ul><li>When the aerated lung opacify, the bronchii become visualized because of the surrounding contrast effect. </li></ul>
    57. 81. airbronch
    58. 83. CT Consolidation: Air Bronchograms
    59. 84. Silhouette Sign <ul><li>Definition: The effacement of a normal structure </li></ul><ul><li>Example: Airspace disease may silhouette: </li></ul><ul><ul><li>right heart margin with right middle lobe pneumonia </li></ul></ul><ul><ul><li>diaphragm with lower lobe pneumonia </li></ul></ul>
    60. 85. Where is the Pneumonia?
    61. 94. What Types of CXRs Are Available?
    62. 95. Different CXR Views: <ul><li>Posterior-Anterior (PA) </li></ul><ul><li>Anterior-Posterior (AP) </li></ul><ul><li>Lateral </li></ul><ul><li>Supine </li></ul><ul><li>Oblique </li></ul><ul><li>Expiratory </li></ul><ul><li>Lateral Decubitus </li></ul><ul><li>Lordotic </li></ul>
    63. 96. Routine CXR Views: <ul><li>Erect or Posterior-Anterior (PA): </li></ul><ul><ul><ul><li>Standard view & most reliable technique </li></ul></ul></ul><ul><ul><ul><li>Erect films detect air under the diaphragm </li></ul></ul></ul><ul><li>Lateral view: </li></ul><ul><ul><ul><li>Done at the same time as the PA film </li></ul></ul></ul><ul><ul><ul><li>Helps localize infiltrates </li></ul></ul></ul><ul><ul><ul><li>Also helps with CM, effusions & LAD </li></ul></ul></ul><ul><li>Anterior-posterior (AP): </li></ul><ul><ul><ul><li>Portable- patient is too ill to go to X-ray, usually patient is sitting upright in bed </li></ul></ul></ul><ul><ul><ul><li>Poor quality but may be the best you can do </li></ul></ul></ul><ul><ul><ul><li>Remember- AP films may cause the mediastinum & heart to appear larger than they are </li></ul></ul></ul>
    64. 97. When to get special views… <ul><ul><li>- Decubitus: </li></ul></ul><ul><ul><ul><li>Excellent to assess effusions before thora’s </li></ul></ul></ul><ul><ul><ul><li>Want to see >10mm (1cm) fluid that layers freely </li></ul></ul></ul><ul><ul><li>Supine: </li></ul></ul><ul><ul><ul><li>Patient is vent’ed or too ill to go to X-ray </li></ul></ul></ul><ul><ul><li>Oblique: </li></ul></ul><ul><ul><ul><li>Good for rib views to r/o frxs </li></ul></ul></ul><ul><ul><li>Lordotic: </li></ul></ul><ul><ul><ul><li>Used to look at the lung apices (TB infection) </li></ul></ul></ul><ul><ul><li>Expiratory: </li></ul></ul><ul><ul><ul><li>Used to exclude small PTX (after thora’s) </li></ul></ul></ul>
    65. 98. Enough Basics… Lets read some films! **Don’t feel bad if you miss some things… these are not easy films**
    66. 99. Case #201
    67. 100. Patient is brought to the ED after a restrained MVA…he complains of CP and abd pain… A Portable film was obtained in the ER…
    68. 101. CXR 201
    69. 102. Case #202
    70. 103. Patient presents to the WSVA emergency room with severe abd pain, nausea & vomiting… the lab calls and says their machine is broken… A Portable film was obtained in the ER… you have only this CXR with which to make your Dx…
    71. 104. CXR 202
    72. 105. CXR 202 (lat)
    73. 106. Case #203
    74. 107. 35 yo with chronic cough, new onset oligoarthritis & painful nodules on his BLE’s… A Portable film was obtained in the ER…
    75. 108. CXR 203
    76. 109. Case #204
    77. 110. 44 yo alcoholic presents with new onset SOB… PA & lat from the ED…
    78. 111. CXR 204
    79. 112. CXR 204 (lat)
    80. 113. CXR 204 (decub)
    81. 114. These are the two CXRs of the same patient taken few seconds apart, what is evident from it
    82. 116. Identify the problem with this patient having this CXR, what are its anesthetic implications
    83. 117. Identify the problem with this patient having this CXR, what are its anesthetic implications
    84. 118. Identify the problems with this patient having this CXR, what are its anesthetic implications
    85. 119. Identify the problems with this patient having this CXR, what other investigations would you do for this patient who is scheduled for chest surgery
    86. 121. Identify the problems with this patient having this CXR, what are its anesthetic implications
    87. 122. Identify the problem with this patient having this CXR, what are its anesthetic implications & how will you manage this patient
    88. 123. Identify the problem with this patient having this VQ scan, what are its anesthetic implications & how will you manage this patient
    89. 124. Identify the problem with this patient having this CXR, what are its anesthetic implications & how will you manage this patient
    90. 125. Identify the problems with this child having this CXR, what are its anesthetic implications
    91. 126. Identify the problem with this patient having this CXR, what do the arrows point toward & what are its anesthetic implications
    92. 127. Identify the problems with this patient having this CXR, what are its anesthetic implications
    93. 185. Case #205
    94. 186. Same 44 yo alcoholic presents 1 week later with fevers & chills… PA/lat CXR performed in the ED…
    95. 187. CXR 205
    96. 188. CXR 205 (lat)
    97. 189. Case #206
    98. 190. 50 yo male with sinusitis, fever & progressive cough/DOE for 8 weeks… An AP film was obtained in the ED…
    99. 191. CXR 206
    100. 192. Case #207
    101. 193. 25 yo female presents with acute L sided chest pain… AP & lateral films were obtained in the ED…
    102. 194. CXR 207
    103. 195. CXR 207 (lat)
    104. 196. Case #208
    105. 197. 40 yo with HIV (refused HAART), presents with new SSCP… A portable film was obtained in the ED…
    106. 198. CXR 208
    107. 199. Case #209
    108. 200. 40 yo with HIV on HAART x 10 years (cd4 count 250) presents with new onset fever & night sweats… Portable film obtained in the ED…
    109. 201. CXR 209
    110. 202. Case #210
    111. 203. 60 yo with 1 week of progressive DOE followed by SOB at rest… AP film was obtained in the ED…
    112. 204. CXR 210
    113. 205. <ul><li>CXR from 3 months prior… </li></ul>
    114. 206. Case #211
    115. 207. 70 yo presents with 6 weeks of progressive DOE, chronic n-p cough and now SOB at rest… PA & lateral films were obtained in the ED…
    116. 208. CXR 211
    117. 209. CXR 211 (lat)
    118. 210. Case #212
    119. 211. 55 yo with severe epigastric pain x 2 days followed by 4 hours of new onset SSCP and worsing abd pain… Portable film obtained in the ED…
    120. 212. CXR 212
    121. 213. Case #213
    122. 214. 45 yo smoker gets this pre-op CXR before an elective Nissen fundapplication… He’s been having a lingering non-productive cough x 6 weeks This PA film was obtained…
    123. 215. CXR 213
    124. 216. Case #214
    125. 217. 40 yo previously healthy immigrant presents with new onset massive (>400cc) hemoptysis… A portable CXR was obtained in the ED…
    126. 218. CXR 214
    127. 219. Case #215
    128. 220. 40 yo previously healthy female presents with 1 day fever, cough & SOB She is admitted to the floor for dehydration but then develops hypoxemia requiring increasing O2… Serial CXR’s over the next 12 hours were obtained…
    129. 221. CXR 215A
    130. 222. CXR 215B
    131. 223. CXR 215C
    132. 224. End CXR 201 Happy CXR reading!

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