Pulmonary Imaging
Upcoming SlideShare
Loading in...5
×
 

Pulmonary Imaging

on

  • 5,355 views

By Prof.Shana

By Prof.Shana

Statistics

Views

Total Views
5,355
Views on SlideShare
5,350
Embed Views
5

Actions

Likes
5
Downloads
718
Comments
1

1 Embed 5

http://www.slideshare.net 5

Accessibility

Upload Details

Uploaded via as Microsoft PowerPoint

Usage Rights

© All Rights Reserved

Report content

Flagged as inappropriate Flag as inappropriate
Flag as inappropriate

Select your reason for flagging this presentation as inappropriate.

Cancel

11 of 1

  • Full Name Full Name Comment goes here.
    Are you sure you want to
    Your message goes here
    Processing…
  • thanks
    Are you sure you want to
    Your message goes here
    Processing…
Post Comment
Edit your comment
  • Self explanatory and goes with next slide
  • Summary of things that will be shown
  • CF

Pulmonary Imaging Pulmonary Imaging Presentation Transcript

  • Chest X-Ray Collection By AMIR B.CHANNA FFARCS,DA (Eng) King Khalid Univ. Hospital Riyadh KSA
  • Most important things when reading a CXR…
    • Have a System
    • Use it consistently
    • Know your anatomy
    • Diff. diagnosis & Pathophysiology
  • Have a System…
  • Step #1: Always, always, always… Confirm the patient’s name & check date on film
  • Step #2: Know a good CXR when you see one… assess the film’s quality HOW ?
  • Assessing Quality: R.I.P.
    • R  Rotation
      • clavicles- symmetric & flush with sternum
    • I  Inspiration
      • want to see at least 8-9 ribs for a good film
    • P  Penetration
      • should see vertebral bodies thru the heart
  • Step #3: Read the film… DO NOT JUMP TO DIAGNOSIS
  • My System: the Short Version: ( Use this for routine films)
    • A  Airways
    • B  Bones & soft tissues
    • C  Cardiac silhouette
    • D  Diaphragm
    • E  Everything else… the lungs
  • The Long Version: Use this system for more complicated films on the wards & at Morning Report
    • R  Rotation (clavicles- symmetric & flush with sternum)
    • I  Inspiration (want to see at least 8-9 ribs for good film)
    • P  Penetration (should see vertebral bodies thru the heart)
    • A  Airways (trachea shifted or irregular, bronchiectasis, ETT)
    • B  Bones (frxs, osteoporosis, lytic lesions, skeletal deform’s)
    • C  Cardiac silhouette (CM, chamber enlargements, aorta, Ca ++ )
    • D  Diaphragm (R higher L?, phrenic nerve palsy, pleural lesions)
    • E  Effusions (pleural/pericardial; effusion size, does it layer out)
    • F  Free air (under diaphragm, in sub-Q tissue, mediastinum)
    • G  GI pathology  gastric bubble (shifted by spleen)
    • H  Hilum (LAD, vascular congestion, calcifications/granulomas)
    • IJ  IJ catheters & other lines (confirm they are in the right place)
    • K  Kerley-B lines, Kypho-scoliosis and skeletal deformities
    • L  And finally… the LUNGS!!!!!!!
  • More Details on the Lungs:
    • Features to look for when characterizing parenchymal lung disease:
    • Over/under inflation (<8 or >9 ribs visible) suggests a restrictive or obstructive process
    • Pneumothorax, atelectasis or volume loss
    • Air bronchograms or bronchiectasis
    • Infiltrates (describe as lobar, multi-lobar, diffuse)
    • Mass/nodule (+/-3cm), shape, cavity?, Ca ++?
    • Interstitial pattern (alveolar, reticular, miliary)
    • Distribution of infiltrates: apical, basilar, pleural
    • Vascular flow: oligemia? cephalization?
  • Know your anatomy…
  •  
  •  
  •  
  •  
  • Investigations
    • Chest Radiograph
    • PA
    • AP
      • Ill patient
    • Lateral
      • Mass localisation, cardiac chambers, hila
    • Expiratory
  •  
  •  
  •  
  •  
  • 1 2 3 4 5 6 7 1 2 3 4 5 6 7 8 9 10
  •  
  • A B C Heart size - Cardiothoracic Ratio (CTR) A+B/C
  •  
  • Investigations
    • CT
      • Focal masses
      • Diffuse lung disease
      • Pulmonary emboli
    • Ultrasound
      • Diaphragm, pleura
    • Magnetic Resonance
      • Mediastinum
      • Lung apex
    • Intervention
      • Biopsy, Drainage
  •  
  •  
  •  
  •  
  •  
  •  
  • Slice width Conventional CT
  • Spiral CT
  • Air Bone Water
  • Normal Anatomy
  • Bone-CT Reconstruction
    • PA View
    Clavicle Rib Intercostal Space Vertebral Column
  • Bone Anatomy Sternum Rib
  • Heart Size
    • Normal is <50% on PA upright radiograph
  • Lateral view
  • Cardiac Anatomy: Right Sided Chambers
  • Cardiac Anatomy: Left Sided Chambers
  • isnpexp SVC Aortic Arch Right Descending Pulmonary Artery Left Descending Pulmonary Atery
  • inspexp
    • Lungs posteriorly should get darker as you go down more inferiorly
    Retrosternal Airspace Scapula IVC Pulmonary Vessels Hilum
  • Airway Anatomy
    • Trachea
      • Cartilage
      • Membranous posteriorly
    • Carina
      • Bifurcation
    • Bronchus
      • Left and right
      • Lobar (RUL,RML,LUL,LLL)
      • Segmental (8 left, 10 right)
  • Trachea Carina R + L Main Bronchi
  • Lung Anatomy
    • Lobes are separated by fissures
    • Right
      • Upper Lobe
      • Middle Lobe
      • Lower Lobe
    • Left
      • Upper Lobe (includes lingula)
      • Lower Lobe
  •  
  •  
  •  
  •  
  •  
  • Pleura and Fissures
    • Pleura
      • Lubricates and prevents friction during respiration
      • Potential Space – Don’t see unless abnormal
    • Parietal pleura: Lines chest wall, mediastinal and diaphragmatic surfaces
    • Visceral pleura: Lines lungs, fissures
  • Parietal Pleura Visceral pleura
  • normaldiag Diaphragms Normal: Sharp costophrenic sulcus
  • normaldiag
  • Which is right and left diaphragm?
  •  
  • Approach to Chest Radiograph: Technical Factors
    • Patient Identification (name and date)
    • Markers (Left vs right)
    • Assess for rotation (clavicles vs spinous process)
    • Penetration (thoracic spine should be visible)
    • Degree of Inpiration: 6 th anterior or 10 th posterior
  • isnpexp Clavicles Spinous Process Vertebral Body Visible 6 7 Counting anterior ribs 10 11 Counting posterior ribs
  • Inspiration/Expiration Images
    • Expiration
      • Heart size appear larger
      • Mediastinum is wider
      • Pulmonary vasculature indistinct
  • 4 th Anterior 8 th Posterior Expiration Image
  • Inspiration: Same Patient Expiration
  • Abnormal Cases
    • Bone
    • Cardiovascular
    • Airspace Disease including Silhouette Sign
    • Interstitial Disease and Pulmonary Edema
    • Atelectasis
    • Pulmonary Nodule
    • Pleura and Diaphragm
    • Mediastinal Mass
  • Bone and Soft Tissues
  • productive1stribs Productive 1 st rib changes: Can simulate nodule
  • Lordotic View Better assess apices without bone overlap
  • Rib Fracture
  •  
  • Presenting CXR
  •  
  • MRI Computed Tomography Pancoast Tumour
  • Cardiovascular
  • Increased Cardiac Size: Can be Cardiac or Pericardial Pericardial Effusion Dilated Cardiomyopathy What imaging would you use to differentiate between the two ?
  • Left Ventricular Enlargement Enlargement of Left Ventricle Left Ventricle IVC
  • Airspace Disease and Silhouette Sign
  • Airspace Disease
    • Filling in of acini (air space)
    • Air space (acinar) nodules
    • Coalesce to consolidation
    • Air bronchograms
    • Silhouette Sign
  • Air Space Disease: Etiology
    • Water -Pulmonary Edema
    • Pus -Infections, Non-infectious inflammatory process
    • Blood-Pulmonary Hemmorhage
    • Protein-Alveolar Proteinosis
    • Tumour-BAC, Lymphoma
  • Bronchopneumonia Pattern: Airspace Nodules
  • Acinar Nodules Computed Tomography
  • Air Bronchogram
    • Airways are not normally seen in a normal chest radiograph because they are an air structure within an aerated lung
    • When the aerated lung opacify, the bronchii become visualized because of the surrounding contrast effect.
  • airbronch
  •  
  • CT Consolidation: Air Bronchograms
  • Silhouette Sign
    • Definition: The effacement of a normal structure
    • Example: Airspace disease may silhouette:
      • right heart margin with right middle lobe pneumonia
      • diaphragm with lower lobe pneumonia
  • Where is the Pneumonia?
  •  
  •  
  •  
  •  
  •  
  •  
  •  
  •  
  • What Types of CXRs Are Available?
  • Different CXR Views:
    • Posterior-Anterior (PA)
    • Anterior-Posterior (AP)
    • Lateral
    • Supine
    • Oblique
    • Expiratory
    • Lateral Decubitus
    • Lordotic
  • Routine CXR Views:
    • Erect or Posterior-Anterior (PA):
        • Standard view & most reliable technique
        • Erect films detect air under the diaphragm
    • Lateral view:
        • Done at the same time as the PA film
        • Helps localize infiltrates
        • Also helps with CM, effusions & LAD
    • Anterior-posterior (AP):
        • Portable- patient is too ill to go to X-ray, usually patient is sitting upright in bed
        • Poor quality but may be the best you can do
        • Remember- AP films may cause the mediastinum & heart to appear larger than they are
  • When to get special views…
      • - Decubitus:
        • Excellent to assess effusions before thora’s
        • Want to see >10mm (1cm) fluid that layers freely
      • Supine:
        • Patient is vent’ed or too ill to go to X-ray
      • Oblique:
        • Good for rib views to r/o frxs
      • Lordotic:
        • Used to look at the lung apices (TB infection)
      • Expiratory:
        • Used to exclude small PTX (after thora’s)
  • Enough Basics… Lets read some films! **Don’t feel bad if you miss some things… these are not easy films**
  • Case #201
  • 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…
  • CXR 201
  • Case #202
  • 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…
  • CXR 202
  • CXR 202 (lat)
  • Case #203
  • 35 yo with chronic cough, new onset oligoarthritis & painful nodules on his BLE’s… A Portable film was obtained in the ER…
  • CXR 203
  • Case #204
  • 44 yo alcoholic presents with new onset SOB… PA & lat from the ED…
  • CXR 204
  • CXR 204 (lat)
  • CXR 204 (decub)
  • These are the two CXRs of the same patient taken few seconds apart, what is evident from it
  •  
  • Identify the problem with this patient having this CXR, what are its anesthetic implications
  • Identify the problem with this patient having this CXR, what are its anesthetic implications
  • Identify the problems with this patient having this CXR, what are its anesthetic implications
  • Identify the problems with this patient having this CXR, what other investigations would you do for this patient who is scheduled for chest surgery
  •  
  • Identify the problems with this patient having this CXR, what are its anesthetic implications
  • Identify the problem with this patient having this CXR, what are its anesthetic implications & how will you manage this patient
  • Identify the problem with this patient having this VQ scan, what are its anesthetic implications & how will you manage this patient
  • Identify the problem with this patient having this CXR, what are its anesthetic implications & how will you manage this patient
  • Identify the problems with this child having this CXR, what are its anesthetic implications
  • Identify the problem with this patient having this CXR, what do the arrows point toward & what are its anesthetic implications
  • Identify the problems with this patient having this CXR, what are its anesthetic implications
  •  
  •  
  •  
  •  
  •  
  •  
  •  
  •  
  •  
  •  
  •  
  •  
  •  
  •  
  •  
  •  
  •  
  •  
  •  
  •  
  •  
  •  
  •  
  •  
  •  
  •  
  •  
  •  
  •  
  •  
  •  
  •  
  •  
  •  
  •  
  •  
  •  
  •  
  •  
  •  
  •  
  •  
  •  
  •  
  •  
  •  
  •  
  •  
  •  
  •  
  •  
  •  
  •  
  •  
  •  
  •  
  •  
  • Case #205
  • Same 44 yo alcoholic presents 1 week later with fevers & chills… PA/lat CXR performed in the ED…
  • CXR 205
  • CXR 205 (lat)
  • Case #206
  • 50 yo male with sinusitis, fever & progressive cough/DOE for 8 weeks… An AP film was obtained in the ED…
  • CXR 206
  • Case #207
  • 25 yo female presents with acute L sided chest pain… AP & lateral films were obtained in the ED…
  • CXR 207
  • CXR 207 (lat)
  • Case #208
  • 40 yo with HIV (refused HAART), presents with new SSCP… A portable film was obtained in the ED…
  • CXR 208
  • Case #209
  • 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…
  • CXR 209
  • Case #210
  • 60 yo with 1 week of progressive DOE followed by SOB at rest… AP film was obtained in the ED…
  • CXR 210
    • CXR from 3 months prior…
  • Case #211
  • 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…
  • CXR 211
  • CXR 211 (lat)
  • Case #212
  • 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…
  • CXR 212
  • Case #213
  • 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…
  • CXR 213
  • Case #214
  • 40 yo previously healthy immigrant presents with new onset massive (>400cc) hemoptysis… A portable CXR was obtained in the ED…
  • CXR 214
  • Case #215
  • 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…
  • CXR 215A
  • CXR 215B
  • CXR 215C
  • End CXR 201 Happy CXR reading!