This document discusses chest imaging in the ICU, beginning with objectives and an introduction on how to approach chest x-ray reading and key anatomical landmarks. It then provides an overview of different chest imaging modalities used in the ICU like chest x-ray, ultrasound, CT and their clinical applications. Common radiographic abnormalities seen in the ICU like pulmonary edema, ARDS, pneumonia and atelectasis are described. The role of point-of-care ultrasound in the ICU is also discussed.
An educational material describing the Indications for Tracheostomy-Complications of Tracheostomy-Timing of Tracheostomy-Tracheostomy Technique-Tracheostomy Decannulation and types of Tracheostomy Tubes.
An educational material describing the Indications for Tracheostomy-Complications of Tracheostomy-Timing of Tracheostomy-Tracheostomy Technique-Tracheostomy Decannulation and types of Tracheostomy Tubes. Quite useful for general surgery residents and medical students and also general physicians.
An educational material describing the Indications for Tracheostomy-Complications of Tracheostomy-Timing of Tracheostomy-Tracheostomy Technique-Tracheostomy Decannulation and types of Tracheostomy Tubes
An educational material describing the Indications for Tracheostomy-Complications of Tracheostomy-Timing of Tracheostomy-Tracheostomy Technique-Tracheostomy Decannulation and types of Tracheostomy Tubes.
An educational material describing the Indications for Tracheostomy-Complications of Tracheostomy-Timing of Tracheostomy-Tracheostomy Technique-Tracheostomy Decannulation and types of Tracheostomy Tubes. Quite useful for general surgery residents and medical students and also general physicians.
An educational material describing the Indications for Tracheostomy-Complications of Tracheostomy-Timing of Tracheostomy-Tracheostomy Technique-Tracheostomy Decannulation and types of Tracheostomy Tubes
Resection and reconstruction of the SVC is still considered a surgical challenge.
However, with the appropriate indications and surgical technique a clear benefit has been documented in a selected group of patients. This lengthy power point presentation addresses the elective and emergency surgical procedures which can be done on the SVC. The viewer is expected to appreciate the technical challenges of SVC surgery and the ways how to overcome them.....
Video-assisted thoracic surgery (VATS).pptxRacheen Salih
Presentation about video-assisted thoracic surgery (VATS), which is minimally invasive thoracic surgery that does not use a formal thoracotomy incision, it is principally employed in the management of (pulmonary, mediastinal, and pleural pathology.
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
Resection and reconstruction of the SVC is still considered a surgical challenge.
However, with the appropriate indications and surgical technique a clear benefit has been documented in a selected group of patients. This lengthy power point presentation addresses the elective and emergency surgical procedures which can be done on the SVC. The viewer is expected to appreciate the technical challenges of SVC surgery and the ways how to overcome them.....
Video-assisted thoracic surgery (VATS).pptxRacheen Salih
Presentation about video-assisted thoracic surgery (VATS), which is minimally invasive thoracic surgery that does not use a formal thoracotomy incision, it is principally employed in the management of (pulmonary, mediastinal, and pleural pathology.
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
CDSCO and Phamacovigilance {Regulatory body in India}NEHA GUPTA
The Central Drugs Standard Control Organization (CDSCO) is India's national regulatory body for pharmaceuticals and medical devices. Operating under the Directorate General of Health Services, Ministry of Health & Family Welfare, Government of India, the CDSCO is responsible for approving new drugs, conducting clinical trials, setting standards for drugs, controlling the quality of imported drugs, and coordinating the activities of State Drug Control Organizations by providing expert advice.
Pharmacovigilance, on the other hand, is the science and activities related to the detection, assessment, understanding, and prevention of adverse effects or any other drug-related problems. The primary aim of pharmacovigilance is to ensure the safety and efficacy of medicines, thereby protecting public health.
In India, pharmacovigilance activities are monitored by the Pharmacovigilance Programme of India (PvPI), which works closely with CDSCO to collect, analyze, and act upon data regarding adverse drug reactions (ADRs). Together, they play a critical role in ensuring that the benefits of drugs outweigh their risks, maintaining high standards of patient safety, and promoting the rational use of medicines.
Local Advanced Lung Cancer: Artificial Intelligence, Synergetics, Complex Sys...Oleg Kshivets
Overall life span (LS) was 1671.7±1721.6 days and cumulative 5YS reached 62.4%, 10 years – 50.4%, 20 years – 44.6%. 94 LCP lived more than 5 years without cancer (LS=2958.6±1723.6 days), 22 – more than 10 years (LS=5571±1841.8 days). 67 LCP died because of LC (LS=471.9±344 days). AT significantly improved 5YS (68% vs. 53.7%) (P=0.028 by log-rank test). Cox modeling displayed that 5YS of LCP significantly depended on: N0-N12, T3-4, blood cell circuit, cell ratio factors (ratio between cancer cells-CC and blood cells subpopulations), LC cell dynamics, recalcification time, heparin tolerance, prothrombin index, protein, AT, procedure type (P=0.000-0.031). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and N0-12 (rank=1), thrombocytes/CC (rank=2), segmented neutrophils/CC (3), eosinophils/CC (4), erythrocytes/CC (5), healthy cells/CC (6), lymphocytes/CC (7), stick neutrophils/CC (8), leucocytes/CC (9), monocytes/CC (10). Correct prediction of 5YS was 100% by neural networks computing (error=0.000; area under ROC curve=1.0).
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These lecture slides, by Dr Sidra Arshad, offer a quick overview of the physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar lead (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
6. Describe the flow of current around the heart during the cardiac cycle
7. Discuss the placement and polarity of the leads of electrocardiograph
8. Describe the normal electrocardiograms recorded from the limb leads and explain the physiological basis of the different records that are obtained
9. Define mean electrical vector (axis) of the heart and give the normal range
10. Define the mean QRS vector
11. Describe the axes of leads (hexagonal reference system)
12. Comprehend the vectorial analysis of the normal ECG
13. Determine the mean electrical axis of the ventricular QRS and appreciate the mean axis deviation
14. Explain the concepts of current of injury, J point, and their significance
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. Chapter 3, Cardiology Explained, https://www.ncbi.nlm.nih.gov/books/NBK2214/
7. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
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
dr TEKIY 2
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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
dr TEKIY 3
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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
dr TEKIY 4
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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
dr TEKIY 5
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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
dr TEKIY 7
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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
dr TEKIY 8
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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
dr TEKIY 10
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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
dr TEKIY 11
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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
dr TEKIY 12
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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
dr TEKIY 13
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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
dr TEKIY 14
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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
dr TEKIY 15
11/06/2022
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)
dr TEKIY 16
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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
dr TEKIY 17
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21. Cont….
Intrathoracic tubes and lines
should be completely visualized
on radiographs
• Chest X-ray
• CT
• U/S
• Fluoroscopy
dr TEKIY 21
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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
dr TEKIY 22
11/06/2022
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
dr TEKIY 23
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
dr TEKIY 24
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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
dr TEKIY 25
11/06/2022
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
dr TEKIY 26
11/06/2022
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
dr TEKIY 27
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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
dr TEKIY 28
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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
dr TEKIY 29
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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
dr TEKIY 30
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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
dr TEKIY 31
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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
dr TEKIY 32
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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
dr TEKIY 33
11/06/2022
34. Cont…
a Interstitial edema with thickened interlobular septa (Kerley
lines
b Diffuse ground-glass opacity due to alveolar fluid
accumulation.
dr TEKIY 34
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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
dr TEKIY 35
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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
dr TEKIY 36
11/06/2022
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)
dr TEKIY 37
11/06/2022
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
dr TEKIY 40
11/06/2022
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)
dr TEKIY 41
11/06/2022
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
dr TEKIY 42
11/06/2022
43. Cont…
• Pleural effusions
• On CT typically appear as sickle
shaped, posterior opacities
• CT is extremely sensitive
• Consolidated lung will enhanced
dr TEKIY 43
11/06/2022
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
dr TEKIY 45
11/06/2022
46. Cont….
Factors that support the diagnosis of pneumonia
• air space opacities
• air bronchograms
• ill-defined segmental consolidation or associated pleural effusion
dr TEKIY 46
11/06/2022
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
dr TEKIY 49
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
dr TEKIY 51
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
dr TEKIY 52
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
dr TEKIY 53
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
dr TEKIY 54
11/06/2022
56. • Progression of findings in lower
lobe atelectasis of the right lung.
Note the progressive increase in
opacity and decrease in volume
dr TEKIY 56
11/06/2022
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
dr TEKIY 57
11/06/2022
58. Cont…
• a diabetic patients insidious
onset of with low-grade fever,
sputum production with cough,
and dyspnea.
• AT ED
dr TEKIY 58
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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