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Chest imaging in ICU guide
1. Chest imaging in ICU
DR TEKIY ECCMR3
ADVISER DR YEMANE(assistant professor of ECCM)
dr TEKIY 1
11/06/2022
2. Outline
• Objectives
• Introduction
• Overview of chest imaging in ICU
• Rational use of chest imaging in ICU
• Chest imaging in ICU with its clinical point of view
• POCUS in ICU
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11/06/2022
3. Objectives
• Discuss how to approach to CXR reading
• List anatomical land marks for chest imaging
• Identify different clinical use of chest imaging in ICU patients
• Describe common radiographic abnormalities
• Describe the use of POCUS in ICU
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4. Introduction
APPROACH TO CXR
• Documentation
• patient's name,age and gender
• Technical factors-adequacy,AP/PA,supine/erect,side,rotation
• Extra objects-lines,tubes,leads,drains,pacemaker,
• Areas of interest and review areas
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5. Anatomic land marks
1.Tracheal Air Column
2.Carina
3.First Rib
4.Peripheral 1-2cm of lungs with no visible markings
5.Position of Horizontal Fissure (often not seen on normal radiograph)
6.Right Hemi diaphragm (Top usually at 6-7th anterior rib)
7.Left Hemidiaphragm (Slightly lower)
8.Inferior margins of lower ribs are slightly ill defined
9.Anterior mediastinal line (Apposed visceral and parietal pleura)
10.Superior Vena Cava blends into neck soft tissue shadow
11.Region of Azygous Vein
12.Right Pulmonary Artery (less than 16mm in men, 15mm in women is normal)
13.Pulmonary Vessels–the only normal lung markings
14.Border of Right Atrium (Right Heart Border)
15.Inferior Vena Cava
16.Aortic Arch
17.Main Pulmonary Artery
18.Border of Left Ventricl Left Heart Border)
19.Descending Aorta
20.Fat Density and soft tissue density in soft tissues
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7. Cont…
Tissue densities are different on chest radiograph
• Air (lung) absorbs x-rays the least and results in a dark shadow
• Bone (ribs) absorb the most x-ray energy and result in a white shadow
• Fat and water shadows are different degrees of gray
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8. Overview of chest imaging in ICU
Imaging in the ICU are most commonly performed at the bedside
Imaging ICU patients is not easy as any patients
• Are not cooperative with the examiner
• Imaging conditions are more difficult
• Radiographic interpretation is often affected
• Radiographic equipment is frequently limited
• Images are obtained without automatic exposure control
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10. Cont…
• Routine chest films are obtained in a posteroanterior
• PA direction to minimize magnification of the heart
• In ICU AP view can be possible
• Supine patient
• Due to the decreased mobility of patients in the ICU, chest films are
often taken while the patient is supine
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11. Cont…
AP view results in:
• Magnification of anterior structures such as the clavicle, sternum, and
heart, often significantly
• Results up to a 15% difference in mediastinum width
• Medial border of the scapula is projected further into the lung
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12. Cont…
Supine positioning
• Widens the mediastinum and heart due to gravitational effects
• Changes physiology of the pulmonary vasculature
• Putting blood flow more to the upper lobes
• Differentiating between pleural effusion and parenchymal processes
difficult
• Detecting a pneumothorax difficult or impossible due to unusual
distribution
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13. Cont….
Respiration
• Make differentiating basilar atelectasis and lung oedema more
difficult
• May cause significant changes in the apparent size of the heart and
mediastinum
• Diameter of a patient's mediastinum may differ by up to 50%
between an expiratory supine AP and a erect inspiratory PA
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14. Cont…
Other views
• Cross-table views
• Right lateral decubitus views
• Tangential views
Causes of Poor Image Quality
• Incomplete visualization of the lungs,devices
• Inadequate depth of inspiration
• Undesired oblique projection
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15. Cont…
CT scan
• CT is the main advanced imaging of the lung
• primary imaging in certain indication
• Less accessible than CXR, more accessible than MRI
• Main negative is radiation ( iatrogenic radiation in radiology)
• Some studies need contrast so need to be aware of renal function and
allergies
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16. Cont…
Different terminologies for CT
• CAT scan
• HRCT (high resolution CT)
• CTA (CT angiography)
• CTPE (CT pulmonary embolism)
• “spiral CT” (outdated term for CTA or CT PE)
• LDCT (Low dose CT)
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17. Catheters and Monitoring Devices
Chest radiograph is first choice:
• Evaluate the placement of monitoring and therapeutic devices
• Device malposition
• Complications
• Providing a document for medicolegal purposes
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21. Cont….
Intrathoracic tubes and lines
should be completely visualized
on radiographs
• Chest X-ray
• CT
• U/S
• Fluoroscopy
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22. Cont…
Endotracheal Tube
• Tip of the ETT is marked with a radiopaque strip
• Tip position is usually described in relation to the carina, which is at
the level of the T5±1 vertebra in 95% of patients
• In the neutral position, the tip of the ETT should be 5–7cm above the
carina
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23. Cont….
Show malposition of the ETT in 12–15% of intubated patients
• Unilateral endobronchial intubation
• Too low or too high
• Esophageal intubation
• Rupture of the larynx
• Trachea (usually the membranous part), or main bronchi
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11/06/2022
24. Cont…
Tracheostomy Tube
• The tracheostomy tube should run down the tracheal air column,
parallel to its longitudinal axis
• The tip of the tube should be located above the carina
• At least two-thirds of the straight portion of the tube should be
intratracheal
• The tracheostomy tube should occupy one-half to two-thirds of the
tracheal lumen to minimize airway resistance
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25. Cont…
• The tip of the tube may be pressed or jammed against the anterior or
posterior tracheal wall, leading to pressure necrosis or perforation of
the tracheal wall
• Erosion of the left brachiocephalic artery in front of the trachea or
give rise to a tracheobronchial fistula
• look for Superimposition on the chest radiograph
• Tube is not passing normally down the trachea
• Clinical examination is sufficient in most cases
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26. Central Venous Catheter
• Should be visualized in the superior vena cava
• Catheter tip should lie close to the level of the azygos vein
• Post interventional malposition of the central venous catheter (CVC)
in up to 33% of patients
• Intrathoracic course of the catheter
• Possible complications
• Contrast instillation
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27. Cont…
• Catheters introduced via the subclavian vein and internal jugular vein
should appear to cross each other on the AP radiograph
• If they do not, the possibility of an extravascular or intra-arterial
catheterization should be considered
• Intracardiac malposition
• Intramural malposition
• Ipsilateral internal jugular artery
• Contralateral brachiocephalic vein
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28. PAC
PAC
Placement of the pulmonary artery catheter assured by
• Characteristic pressure waveforms
• Chest radiograph to confirm the catheter position and exclude
complications
Others like:
• IABP
• Feeding Tubes
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29. Chest imaging in ICU with its clinical point of view
Pulmonary edema:
• an extravascular accumulation of intrapulmonary fluid
• Initially the fluid is confined to the interstitium
• May spread to the alveolar spaces
Radiographic signs of interstitial edema
• Blurring of vessel margins
• Subpleural thickening
• Thickened interlobar septa
• Peribronchial cuffing
• Septal lines
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30. Cont…
Pulmonary edema
• Indistinct vasculature
• Perihilar opacities
• Peripheral interstitial reticular opacities
• Although this is an anteroposterior film making cardiac size more
difficult to assess, the cardiac silhouette still appears enlarged
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31. Cont…
Bronchial wall thickening (bronchial cuffing) (arrows),
Kerley lines (arrowhead), and
blurring of vascular margins due to interstitial fluid
accumulation
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32. Cont….
Radiographic signs of alveolar edema
• Increased density, which is often uniform and diffuse in the acute
phase
• Densit is mainly increased in dependent (posterobasal) lung zones
• The CT features of intrapulmonary edema:
• “crazy paving” pattern
• Bronchial cuffing
• Density ranges from ground-glass opacity to dense consolidation
• Degree of opacity correlates with the extravascular fluid volume
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33. Cont….
Butterfly pattern of perihilar consolidation
The vessels are no longer defined.
Note the absence of air bronchograms and
the sparing of the subpleural space
a ARDS
b Alveolar proteinosis “crazy paving
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34. Cont…
a Interstitial edema with thickened interlobular septa (Kerley
lines
b Diffuse ground-glass opacity due to alveolar fluid
accumulation.
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35. Cont..
ARDS:
• ARDS is a diffuse, acute, inflammatory lung injury manifeste
• Severe hypoxia
• bilateral radiographic infiltrates of noncardiogenic etiology
• From either direct pulmonary injury
• Response to a systemic insult
• Imaging plays an important role in the diagnosis of ARDS
• Help determine its underlying etiology
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36. Cont…
Exudative phase(days 1-7):
• Endothelial and epithelial injury and an influx of protein rich fluid,
• First into the interstitium and subsequently into the alveoli
• Alveolar atelectasis and hyaline membrane formation
• Radiographically
• Interstitial edema is initially seen
• Followed by alveolar consolidation
• Both patterns may be present concurrently
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37. Cont…
Proliferative phase(days 8-14)
• Infiltration with fibroblasts and type II pneumocytes occurs
• reticular opacities may develop on the chest radiograph.
• Imaging will remain relatively static, as alveolar and interstitial edema
• The development of additional airspace opacities should generate con
cern for new infection or other complications.
• Fibrotic phase (day 15 on ward)
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40. Cont…
• Pulmonary opacities in patients diagnosed with ARDS take on a
variety of appearances on CT
• Early or exudative phase
• The dominant findings are ground-glass opacities and thickened
interstitial septa
• Intermediate phase.
• The intermediate phase is characterized by increasing opacification,
which may present various patterns
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41. Cont…
(a) to symmetrical opacities with an anteroposterior gradient
(“typical”ARDS, more common with an extrapulmonary cause)
(b) or asymmetrical, patchy, inhomogeneous opacities
(“atypical” ARDS, more common with a pulmonary cause)
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42. Pleural effusion
• visualized and distinguished fro
m lung parenchyma with CT or b
edside ultrasound
• free pleural effusions typically
• a concave,upwardsloping interfa
ce with the lung
• result in blunting of the
costophrenic angle
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43. Cont…
• Pleural effusions
• On CT typically appear as sickle
shaped, posterior opacities
• CT is extremely sensitive
• Consolidated lung will enhanced
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45. Pneumonia
• The radiographic appearance of pneumonia may be difficult to
differentiate from atelectasis or early ARDS
• Classically, pneumonia first appears as patchy opacifications or ill-
defined nodules
• It is often multifocal and bilateral, occurring most often in the gravity
dependent areas of the lung
• This feature makes it difficult to distinguish from atelectasis or
pulmonary oedema
• E-coli and pseudomonas species can rapidly involve the entire lung
• Their symmetric pattern often simulates pulmonary oedema
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46. Cont….
Factors that support the diagnosis of pneumonia
• air space opacities
• air bronchograms
• ill-defined segmental consolidation or associated pleural effusion
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49. Cont…
Right middle lobe opacity
• The silhouette sign is the loss of
clear demarcation between
normal lung and soft tissue (e.g.,
heart, diaphragm).
• lung parenchyma is no longer
filled with air
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11/06/2022
51. Atelectasis
• Atelectasis: It is the most frequent abnormality detected in the ICU chest
film
• occurs most frequently in the left lower lobe,.
• Usually atelectasis is more extensive than is suggested by the radiograph.
• Radiographically, atelectasis may vary from complete lung collapse to
relatively normal-appearing lungs.
• For example, acute mucus plugging may cause only a slight diffuse
reduction in lobar or lung volume without visible opacity.
• Mild atelectasis usually takes the form of minimal basilar shadowing or
linear streaks (subsegmental or "discoid" atelectasis) and may not be
physiologically significant
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11/06/2022
52. Cont…
• Atelectasis may also appear similar to pulmonary consolidation
• making it difficult to distinguish from pneumonia or other causes of
consolidation.
The distinction between atelectasis and other causes of consolidation
• atelectasis will often respond to increased ventilation
• Crowding of vessels
• shifting of structures such as interlobar fissures towards areas of lung
volume loss
• elevation of the hemidiaphragm suggests atelectasis
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11/06/2022
53. Cont…
• Right middle lobe atelectasis may cause minimal changes on the
frontal chest film
• A loss of definition of the right heart border is the key finding
• Right middle lobe collapse is usually more easily seen in the lateral
view
• Atelectasis of either the right or left lower lobe presents a similar
appearance
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11/06/2022
54. Cont…
Right middle lobe atelectasis
• Silhouetting of the corresponding hemidiaphragm
• crowding of vessels
• air bronchograms are standard
• silhouetting of descending aorta is seen on the left
right lower lobe atelectasis
• triangular opacity situated posteromedially
• collapsed lower lobe will usually show as a against the mediastinum.
• Silhouetting of the right hemidiaphragm and air bronchograms are
common signs of
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56. • Progression of findings in lower
lobe atelectasis of the right lung.
Note the progressive increase in
opacity and decrease in volume
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57. Cont…
• Left lower lobe atelectasis and
right lower lobe atelectasis with
mild middle lobe atelectasis
(b) distortion of the interlobar
fissures and compensatory
hyperinflation of the ventilated
upper lobe
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58. Cont…
• a diabetic patients insidious
onset of with low-grade fever,
sputum production with cough,
and dyspnea.
• AT ED
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59. Cont…
• A 34yrs male
• abdominal pain, vomiting, and
diarrhea,while on treatment
develops fever cough SOB
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60. Cont..
• A 53y male alcoholic patient
• acute onset of severe disease
with fever, rigors, and chest pain
and SOB
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61. Pulmonary Embolism
• The chest x-ray is also very useful when interpreting ventilation-
perfusion scans
• Without infarction there are few chest film signs of pulmonary emboli
• These include discoid atelectasis
• elevation of the hemidiaphragm
• Enlargement of the main pulmonary artery into and pulmonary
oligemia beyond the point of occlusion
• Decreased vascularity(Westermark's sign)
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62. CONT…
Pulmonary Infarction
• Multifocal consolidation of the affected lung may occur in 12 to 24
hours following the embolic event
• A consolidation which begins at the pleural surface and is rounded
centrally is called a Hamptom's Hump
• It is unusual for pulmonary infarctions to be diagnosed by chest
radiography although infarctions are known to occur much more
frequently
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70. Referance
• www.MedLibrary.info.(Critical Care Radiology Cornelia Schaefer-Prokop)
• Salvatore MM. Chest CT for A Practical Guide.
• Qadir N, Mathew R. Chapter 11: Imaging of the Critically Ill Patient:
Radiology. Crit Care [Internet]. 2017;1–36. Available from:
http://accessmedicine.mhmedical.com/content.aspx?bookid=1944§io
nid=143516056#1136413020
• Mcmahon D, Topa DM. A Beginner ’ s Guide to Mathematica A Beginner ’ s
Guide to Mathematica. New York [Internet]. 2006;0(June):1–6. Available
from: https://doi.org/10.1042/BIO20200034
• Godoy MCB, Leitman BS, De Groot PM, Vlahos I, Naidich DP. Chest
radiography in the ICU: Part 1, evaluation of airway, enteric, and pleural
tubes. Am J Roentgenol. 2012;198(3):563–71
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Radiographic interpretation is often hampered by superimposed foreign materials (dressings, metal implants, catheters, tubes, wires)
Radiographic equipment is frequently limited (portable radiography machine)
at a target-to-film distance of 72 inches with the patient in the upright position at maximum inspiration
up to a 15% difference between the width of the mediastinum in a 72-inch PA and a 40-inch AP view
putting more flow to the upper lobes and making diagnosis of cephalisation more difficult
May cause pressure erosion of the left brachiocephalic artery in front of the trachea or give rise to a tracheobronchial fistula
ree ribs). Catheters introduced via the subclavian vein and internal jugular vein should appear to cross each other on the AP radiograph. If they do not, the possibility of an extravascular or intra-arterial catheterization should be considered
Positioning errors that are rare or difficult to detect. Catheter malposition in the azygos vein or internal thoracic vein is more difficult to detect and may require biplane radiographs or contrast opacification
Ideally, the pulmonary artery catheter should be placed so that when the balloon is inflated, the catheter can easily advance into the lung for monitoring wedge pressures. While in the wedge position, the tip of the pulmonary artery catheter is located in a pulmonary artery branch and blood flow often carries the tip into a posterior area of the lung
Malposition
The most common positioning error is a peripheral malposition in which the catheter tip is in a pulmonary artery branch located more than 2cm from the hilum. This distal placement may result in a pulmonary infarction, or the tip may perforate a pulmonary arterial branch, causing hemorrhage. If placed too far proximally in the right ventricle, the catheter may cause arrhythmia, endothelial damage, or perforation
Bronchial wall thickening (bronchial cuffing) (arrows), Kerley lines (arrowhead), and blurring of vascular margins due to interstitial fluid accumulation
Increased parenchymal density combined with superimposed thickened (fluid-filled) interlobular and intralobular septa;crazy paving” pattern
CT scans also show thickening of the central bronchovascular interstitium; bronchial cuffing
(parenchymal architecture and vessels are still visible),,,,, ground-glass opacity
Butterfly pattern of perihilar consolidation. The vessels are no longer defined. Note the absence of air bronchograms (differentiation from pneumonia) and the sparing of the subpleural space.
Diffuse alveolar opacities are nonspecific in themselves and may result from a range of conditions. a ARDS. b Alveolar proteinosis (“crazy paving”). c Parenchymal hemorrhage in Goodpasture syndrome (anteroposterior gradient).
a Interstitial edema with thickened interlobular septa (Kerley lines
Diffuse ground-glass opacity due to alveolar fluid accumulation.
Additionally, if a direct lung injury such as pneumonia was the trigger for ARDS, its presence may be evident
This late phase of ARDS may overlap with the proliferative phase and is characterized by collagen depositionand fibrosis.
The degree of fibrosis is variable and the radiographic findings can range from complete resolution to the development of widespread reticular markings, cysts, airway distortion, and persistent groundglass opacities (
Typical ARDS (caused by extrapulmonary injury in ca. 80% of cases) shows a characteristic AP density gradient with areas of consolidation (=atelectasis) in the posterior lung, ground-glass opacities in the mid-lung, and well-ventilated areas in the anterior lung (Fig. 2.39b. Another possible pattern is diffuse homogeneous opacification throughout the lung parenchyma with no apparent density gradient (Fig.2.39a). ■ “Atypical” ARDS (most common after direct lung injury) is characterized by very nonuniform, patchy areas of consolidation that also involve the anterior lung and areas of apparent normal lucency and aeration. This form is considerably more difficult to ventilate
(a) to symmetrical opacities with an anteroposterior gradient (“typical”ARDS, more common with an extrapulmonary cause) (b) or asymmetrical, patchy, inhomogeneous opacities (“atypical” ARDS, more common with a pulmonary cause)
Multiple diagnostic challenges exist when visualizing pleural effusions with a chest radiograph. Atelectasis and lung consolidation may be difficult to distinguish from pleural effusion because they too may obscure the hemidiaphragm. Pleural fluid can accumulate along the pleural fissures and result in a masslike appearance, or pseudotumor. However, unlike a true mass, a pseudotumor will change in shape and size as the patient is repositioned. Pleural effusions may also be found in a subpulmonary location between the lung base and diaphragm without causing blunting of the lateral costophrenic sulcus. The chest radiograph will reveal what appears to be an elevated hemidiaphragm, which is actually the displaced pleuralvisceral interface simulating a “pseudodiaphragm.” Signs that can help distinguish subpulmonic effusion from diaphragmatic elevation include the flatter shape of the pseudodiaphragm in comparison with a true hemidiaphragm, and increased distance between the gastric bubble and the pseudodiaphragm
CT is extremely sensitive in the detection of small effusions, demonstrating loculations, and distinguishing pleural and parenchymal processes
Occasionally, in gram-negative pneumonias small lucencies may be found within consolidated lung which may represent unaffected acini or areas of air trapping
This is particularly likely to occur in patients with underlying COPD
Should be distinguished from lucencies created by cavitation and abscess formation
CXR showing (Klebsiella) Pneumonia
Tree-bud aperance
presumably due to compression of the lower lobe bronchus by the heart, in the supine patient.
Contributing to this tendency is the relatively greater difficulty of blind suctioning of the left lower lobe
to pulmonary consolidation (dense opacification of all or a portion of a lung due to filling of air spaces by abnormal material),
Another key for distinguishing between atelectasis and consolidation is recognition of the typical patterns that each pulmonary lobe follows when collapsing Right upper lobe atelectasis is easily detected as the lobe migrates superomedially toward the apex and mediastinum
Use of urinary Legionella antigen testing in patients with appropriate clinical suspicion can confirm the diagnosis.
Due to its relative lack of sensitivity, the chest x-ray in patients with suspected pulmonary embolism is usually relegated to the role of ruling out other disorders which may have a similar clinical presentationThough the majority of patients with pulmonary embolism in retrospect do have abnormalities on the chest xray, findings are usually too non-specific to be of diagnostic value. what has been described as the shape of a "sausage" or a "knuckle" (Palla's sign),
These types of consolidation differ from pneumonia in that they lack air bronchograms. Up to 50% of
patients with pulmonary embolism will also have ipsilateral or bilateral nonspecific pulmonary effusions
