chest x ray in icu

1. CHEST X RAYS
PRESENTED BY : DR SWATI AGGARWAL
MODERATOR : DR.ZIA ARSHAD

2. A routine pattern of plain x-ray film
• Name
• Date.
• IPD/OPD NO.
• Markers (R/L)

3. Quality control
• Orientation
• Penetration
• Inspiration
• Rotation

6. PA vs AP views
PA view
• Scapula is seen in periphery of
thorax
• Clavicles project over lung fields
• Posterior ribs are distinct
• Heart not magnified
AP view
• Scapulae are over lung
fields
• Clavicles are above the
apex of lung fields
• Anterior ribs are distinct
• Magnified heart

7. Why is PA preferred over AP
Reduces magnification of heart therefore preventing
appearance of cardiomegaly
Reduces radiation dose to radiation sensitive organs such
as thyroid,eyes,breasts
Visualised maximum areas of lung
Moves scapula away from the lung fields

8. Penetration / Exposure
• Able to see ribs through the heart
• Barely see the spine through the
heart
• Pulmonary vessels can be traced
nearly to the edges of the lungs
•

9. Hemi diaphragms are obscured
Pulmonary markings more
prominent than they actually
UNDER PENETRATED FILM

10. Over penetrated Film
• Lung fields darker than
normal—may obscure subtle
pathologies
• See spine well beyond the
diaphragms
• Inadequate lung detail

11. Inspiration
• The volume of air in the hemithorax will affect the
configuration of the heart in relation to cardiac size.
• The level of inspiration can be estimated by
counting ribs.
• Visualization of nine posterior ribs, or seven
anterior ribs on an upright PA radiograph projecting
above the diaphragm would indicate a satisfactory
inspiration

12. Chest radiographs on the same patient few minutes apart showing the
effect of technique; the left image shows medistinal widening and basal
cloudning due to poor inspiratory effort

13. Positioning / Rotation
Does the thoracic spine align in the center of
the sternum and between the clavicles?
Clavicles – equidistant from spine

14. Rotation

16. CXR Interpretation
Normal structures visible
A. Costophrenic angle
B. Diaphragm
C. Heart
D. Aortic arch
E. Trachea
F. Hilum
G. Main carina
H. Stomach bubble

17. Specific Radiological Checklist:
A - Airway
• Ensure trachea is visible and in midline
o Trachea gets pushed away from abnormality, eg pleural effusion or
tension pneumothorax
o Trachea gets pulled towards abnormality, eg atelectasis

18. • Trachea normally narrows at the vocal cords
• View the carina, angle - between 60 –100 degrees
• Beware of things that may increase this angle, eg left atrial
enlargement, lymph node enlargement and left upper lobe atelectasis
• Follow out both main stem bronchi
• Check for tubes, pacemaker, wires, lines foreign bodies etc
• Check for a widened mediastinum

19. B – Bones
-Spine
-humerus
-ribs
-clavicle
Check for fractures, dislocation, subluxation, osteoblastic or osteolytic lesions/
osteoarthritic changes
• At this time also check the soft tissues for subcutaneous air, foreign bodies and
surgical clips
• Caution with nipple shadows, which may mimic intrapulmonary nodules
• compare side to side, if on both sides the “nodules” in question are in the same
position, then they are likely to be due to nipple shadows

20. • - Cardiac
• Check heart size and heart borders
-Appropriate or blunted
-Thin rim of air around the heart, think of
pneumomediastinum
• Check aorta
-Widening, tortuosity, calcification
• Check heart valves
- Calcification, valve replacements
• Check SVC, IVC, azygos vein
-Widening, tortuosity

22. D – Diaphragm
Right hemidiaphragm
o Should be higher than the left
o If much higher, think of effusion, lobar collapse,diaphragmatic
paralysis
o If you cannot see parts of the diaphragm, consider infiltrate
or effusion
If film is taken in erect or upright position you may see free air
under the diaphragm if intra-abdominal perforation is present

23. •DIAPHRAGM
•Both diaphragms
should form a sharp
margin with the lateral
chest wall
•Both diaphragm
contours should be
clearly visible medially
to the spine
Position of stomach
gas bubble (not present
on this CXR)

24. • E – Effusion
• Effusions
• o Look for blunting of the costophrenic angle
• o Identify the major fissures, if you can see them more obvious
than usual, then this could mean that fluid is tracking along the
fissure
• Check out the pleura
• o Thickening, loculations, calcifications and pneumothorax

25. • F – Fields (Lungfields)
• Infiltrates****
• Increased interstitial markings
• Masses
• Absence of normal margins
• Air bronchograms
• Increased vascularity
*****Identify the location and pattern of infiltrates
o Remember that right middle lobe abuts the heart, but the right lower lobe does not
o The lingula abuts the left side of the heart
• o Interstitial pattern (reticular) versus alveolar (patchy or nodular) pattern
• o Lobar collapse
• o Look for air bronchograms, tram tracking, nodules, Kerley B lines
• o Pay attention to the apices
• Check for granulomas, tumour and pneumothorax
An air bronchogram is a tubular outline of an airway made visible by filling of the
surrounding alveoli by fluid or inflammatory exudates.

28. • G – Gastric Air Bubble
• Check correct position
• Beware of hiatus hernia
• Look for fee air

29. • H – Hilum
• Check the position and size
bilaterally
• Enlarged lymph nodes
• Calcified nodules
• Mass lesions
• Pulmonary arteries, if greater
than 1.5cm think about possible
causes of enlargement

30. RADIOGRAPHY IN ICU PATIENTS
• American College of Radiology recommends daily chest radiography
for critically ill patients who have acute cardiopulmonary
disease or are receiving mechanical ventilation
as well as immediate imaging
all patients who have undergone placement of endotracheal tubes
(ETTs), feeding tubes, vascular catheters, and chest tubes

31.  To check it is in the right position
 To check for complications of placement
of the tube/line

32. •Endotracheal tube
•Nasogastric tubes
•Intercostal chest
drainsdrains

33. The tip should lie between the
clavicles, at least 5cm above the carina

34. t he carina can beDee method for approximating the position o f
used.
This involves defining the aortic arch and then drawing a line
Infer omedially through the middle of the arch at a45 degree

35. The Ideal position for endotracheal tubes is in the
mid trachea, 5cm from the carina, when the head is
neither flexed nor extended. This allows for
movement of the tip with head movements +/- 2cms.
The minimal safe distance from the carina is 2cm.

36. ENDOTRACHEAL AND TRACHEOSTOMY TUBES
.
• ETT’s occluding cuff may cause
vocal cord injury
• tip of the ETT = at least 3 cm
distal to VC
• . Overinflation of the balloon to
1.5 times the diameter of the
normal trachea has been shown
to cause tracheal injury

37. • segmental or complete collapse
of the contralateral lung /
• overinflation of the ipsilateral
lung /increased
• risk of pneumothorax

38. • ETT-related tracheal rupture
membranous posterior wall
of the trachea within 7 cm of
the carina
• Radiographic indications :
subcutaneous emphysema,
pneumomediastinum,
pneumothorax, right oblique
displacement of the distal
portion of the ETT,
overdistension of the ETT
balloon (> 2.8 cm), and
reduced balloon-to-tip
distance (i.e., distance < 1.3
cm; the normal balloon-to-
tip distance is 2.5 cm)

39.  This depends on why the drain is being
inserted:
› Pneumothorax
 Towards lung apex (superiorly)
› Pleural fluid drainage
 Towards cardiophrenic border
(inferiorly)iophrenic border (inferiorly)
CHEST TUBES

40. • If a chest tube fails to drain the air or fluid, malposition should be
suspected
• On radiograph, a radiopaque stripe is seen along the length of the
tube and allows identification of the tip and holes
• The side hole should be always positioned medial to the inner margin
of the ribs

41. EXTRAPLEURAL PLACEMENT
• should be suspected - when there is poor
visualization of the nonopaque wall of the tube
• When tube is in intrapleural position,
the nonopaque wall is better seen because
there is air both inside and outside of
the tube.
• subcutaneous placement,the nonopaque wall is
obscured by the soft tissue

42. INTRAFISSURAL PLACEMENT
• Intrafissural positioning
of the tube is
suspected on frontal chest
radiograph when
the tube has a horizontal or
oblique upward
course and can be
confirmed by a lateral
view, fluoroscopy, or CT
• Complications
 inadequate pleural
drainage
 herniation of the lung
parenchyma into the
lumen of the tube
causing infarction

43. INTRAPARENCHYMAL PLACEMENT
Complications:
pulmonary laceration, hematoma,
infarction,
and bronchopleural fistula
• It is usually not identified
radiographically
and first noted on CT but
should be suspected when
one of the above mentioned
complications is
present on the radiograph

44.  These mostly occur with drain placement
› Pain, damage to neurovascular bundle
› Trauma to liver, spleen, lung
› Drainage ports
These must lie within the
chest or there is a risk of
surgical emphysema and
drain failure
Drainage hole correctly sited
within chest

45. • During thoracentesis, an intercostal vein
or artery may be torn, causing an extrapleural
hematoma.
• chest tube should be introduced
over the superior margin of the rib
• An extrapleural hematoma
usually appears - focal lobulated
• Extrapleural hematomas will not change
configuration with changes in patient position
• A CT scan is confirmatory

46. REEXPANSION PULMONARY EDEMA
• rapid removal of air or fluid from the pleural space, usually after
prolonged pulmonary atelectasis
• The clinical manifestations
 minimal symptoms to severe hypoxia and cardiorespiratory collapse
• appear within the first 2 hours after lung reexpansion, but
occasionally may take up to 48 hours
• usually lasts 1–2 days, but may take several days to resolve

47. The main radiographic finding is
a unilateral
airspace opacity, which can be
seen within a
few hours of reexpansion of the
lung
CT findings : ground-glass
opacities, consolidation,
and interlobular and
intralobular
septal thickening

48. NASOGASTRIC AND NASOENTERIC TUBE
ideal position :
• tip within the stomach beyond the cardia
• least 10cm lying within the stomach
• Small-bore nasoenteric feeding tubes ideally
should be positioned with the tip in the second
portion of the duodenum

49. The tip
should lie
below the
diaphragm
coiled within
the stomach

50. Frontal(A) and lateral (B) radiographs of the neck
show An tube(arrow) coiled in the upper esophagus
with its tip in the oropharynx(arrowhead)

54.  Commonest (and most dangerous) is
placement within bronchial tree
› This can be FATAL if NG feeding occurs into the
lung
 Perforation of oesophagus is rare
Be suspicious of a misplaced NG tube if the patient
is extremely uncomfortable during tube insertion with
severe coughing

55. Frontal radiograph of the chest shows a NG tube forming
a loop in the left bronchus(arrow) before the
tip(arrowhead)reaches the right lower lobe bronchus

56. CENTRAL VENOUS CATHETERS
 The CVC tip : located in the superior vena cava (SVC), below the
anterior first rib on the chest radiograph, ideally slightly above the
right atrium
 Although the right atrium accurately reflects central venous
pressure, the tip of theCVC should not be placed in this region
because such placement increases the risks of arrhythmia,
myocardial rupture, and cardiac tamponade

57. Lateral to thoracic spine, inferior to medial end of right
clavicle
igures copyright Primal Pictures 1993

58. Lateral to
thoracic
spine,
inferior to
medial
end of
right
clavicle

60. Right internal jugular
venous line in good position
(red arrow)
The tip of this left internal
jugular venous line lies at
the origin of the SVC
(green arrow)

61. A central venous line inserted
into the right subclavian vein
has passed up into the right
internal
jugular vein

62. Left internal jugular venous line. The tip lies too
inferiorly, within the right atrium (white arrow) and should be
withdrawn to the SVC (green arrow)

63. Frontal chest radiograph following placement of a central
venous catheter shows right paratracheal soft tissue with
abulging contour(arrows),due to mediastinal hematoma.

64. Frontal chest radiograp h shows an abnormally
medial course of the catheter(arrows)in acase of
inadvertent carotid cannulation

69. • Inadvertent
catheterization of the
subclavian artery will
present with a
pulsatile flow in the
catheter and an
abnormal catheter
position on radiograph

70. PINCH OFF SYNDROME
Catheter fragmentation –(
1%) of CVC placements
may result from
compression between the
first rib and clavicle,
designated a “pinch-off
syndrome”
Migration :may result in
arrhythmia, vascular injury,
embolism, or rarely death

71. • Vascular perforation is another life-threatening complication
• Radiographic findings :
Unusual trajectory of the catheter
 an apical cap due to extrapleural hematoma
 a new pleural effusion due to hemothorax
Mediastinal widening due to mediastinal hematoma
 A gentle curve of the tip of the catheter against the lateral wall of the SVC are
potential signs of impend venous perforation

72. • Pneumothorax a chest radiograph should be
always obtained after any successful or
unsuccessful attempt at CVC
• an upright or contralateral decubitus
radiograph
when looking for small pneumothoraces, which
could become larger, particularly in patients
receiving positive pressure ventilation

73. How much fluid must accumulate before
you expect to see changes in the supine
patient's chestx-ray?
1.5 ml
2.50 ml
3.>500
ml
FLUID IN THE CHEST

74. How much fuid must collect before costo
phrenic blunting is visible in the erect
patient?
1.20 ml
2.50-75 ml
3.100-200ml
4.>500ml

75. Howmuchfuidmustcollectbeforecostoph
renicbluntingisvisibleintheerectpatient?
1.20 ml
2.50-75 ml
3.100-200ml
4.>500ml
This Pa chest film of an erect patient shows a large
Pleural effusion on the right. Even an effusion this size may
be difficult to detect in a supine film.

76. The most common cause of lung opacity in an ICU
patient.
The left lower lobe is the most common location.

77. Left lower lobe atelectasis with lost of the
hemidiaphragmatic shadow (arrows).

78. Aspiration is very
common in ICU
patients.
aspirate.

79. This patient suffered a witnessed aspiration during intubation. This film was
taken 24 hours later. Note the patchy infiltrates maximal at the left base.

82. • Thank you