CHEST XRAY INTERPRETATION FOR ANAESTHETISTS.
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INTERPRETATION OF CHEST XRAYS MADE FOR ANAESTHETISTS. THIS LECTURE WAS COMPLETED IN TWO SESSIONS. COMBINED TO MAKE A SINGLE PPT FOR EASY UPLOAD.
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CHEST XRAY INTERPRETATION FOR ANAESTHETISTS.
- 1. DR. RANJITH R THAMPI ANAESTHESIA & ICU MUBARAK AL KABEER HOSPITAL KUWAIT 12.12.2021
- 4. FILMS, NOW SENSORS
- 9. PIER
- 11. SENSO R SOURC E
- 12. SENSO R SOURC E
- 15. ANTERIOR RIBS POSTERIOR RIBS
- 16. OVERPENETRATED Absent lung markings Intervertebral discs clearly visible UNDERPENETRATE D Lungs and heart too white Cannot see behind the heart Intervertebral disc space not visible
- 23. INTERPRETATION
- 24. A B C D E F G H
- 26. Subglottic stenosis NORMAL CONSTRICTION AT LEVEL OF VOCAL CORDS SAMPLE 1
- 27. SAMPLE 2
- 28. SAMPLE 3
- 29. SAMPLE 4
- 31. SAMPLE 1
- 32. SAMPLE 2
- 33. SAMPLE 3
- 35. SAMPLE 1
- 36. MULTIPLE RIB # ICD SAMPLE 2 SCOLIOSIS
- 37. AXILLAE THORACIC WALL FEMALE PATIENTS POST MASTECTOMY SURGICAL EMPHYSEMA SAMPLE 3
- 41. PULMONARY OLIGAEMIA CARDIAC WATER BOTTLE DOUBLE DENSITY SIGN SAMPLE 1
- 42. SAMPLE 2
- 46. CONGENITAL DIAPHRAGMATIC HERNIA SLIDING HIATUS HERNIA
- 62. A B C D E F G H P I E R LUNG COLLAPSE A 19 year old male is admitted after a severe traumatic brain injury. Intubated and on mechanical ventilation.
- 64. A B C D E F G H P I E R 55 year old MALE Large neck mass. Presented with occasional dysphagia to solids. Diagnosed as GOITRE PEMBERTON SIGN
- 66. A B C D E F G H P I E R 65 yr old MALE LUNG FIBROSIS ANKYLOSING SPONDYLITIS
- 68. A B C D E F G H P I E R 35 YR OLD MALE COUGH, FEVER PNEUMONIA RIGHT MIDDLE LOBE
- 70. A B C D E F G H P I E R 20 YRS OLD FEMALE COUGH, FEVER, WEIGHT LOSS PULMONARY TB
- 72. 46 YEARS MALE WITH ACUTE ONSET BREATHLESSNESS ACUTE PULMONARY EDEMA
Editor's Notes
- Oldest and mostly commonly used medical imaging technique. More than a 100 years old. Most important investigation of choice for Anaesthesiologist. Why? Cheap, Easily Accessible, Effective Diagnostic tool.
- William Roentgen. Experiments on Cathode Ray Tubes.
- Xray production- SOURCE OF ELECTRONS, MEANS TO ACCELERATE THEM, MEANS TO STOP THEM. Xray tube has cathode and anode. Current through a filament makes it extremely hot, creates free electrons. For acceleration, electric voltage(kvP) creates a strong negative voltage and directs electrons to positive anode. For Deceleration, hits anode, produces heat and xrays.
- Spectrum of exposures onto a plate due to relative densities of different tissue and structures and their absorption. BLACK, WHITE, GREY Low Density- Air- Black High Density- Bone & Metal – White- prosthetic valves, devices, stents Intermediate- Fluid – Grey- Blood, Consolidation
- Date, Name, age, sex, File number. Also TIME. Error- Chest drain inserted to wrong side.
- AP, PA, Lateral, Lordotic, Decubitus Most departmental films are from posterior to anterior(PA). Xray source posterior to patient about 1.5-1.8m and plate placed anterior to patient.
- Patient facing Sensor/plate. Higher radiation dose, quality is less affected by rotation Structures nearest the film will have their size most faithfully represented. Further away structures- small with significant degree of magnification. When there is difficulty positioning the patient because of acute illness or patient being bedridden. ICU patients. AP image is taken.
- Patient facing source. Standard in ICU, lower radiation dose, quality is affected by rotation Structures nearest the film will have their size most faithfully represented. Further away structures- small with significant degree of magnification.
- Clavicle, Scapula, Ribs PA view- Narrow superior mediastinum, normal cardiac silhouette, scapula away from lung zones, Posterior ribs seen clearly, air fluid level in stomach. Can comment on cardiomegaly. AP view- superior Mediastinum appears widened, Heart appears enlarged, lungs appear underinflated. Don’t comment on cardiomegaly for a AP xray. If appears normal, can say not englarged. Scapula over lung zones. No air fluid in stomach.
- Full inspiration ideal Diaphragm should be seen at level of 8-10th posterior ribs, 6th anterior rib. Indicates good inspiration.
- Full inspiration ideal Diaphragm should be seen at level of 8-10th posterior ribs, 6th anterior rib. Indicates good inspiration.
- A well penetrated chest X-ray is one where the vertebrae are just visible behind the heart. Bony details need not be seen. The left hemidiaphragm should be visible to the edge of the spine. Loss of the hemidiaphragm contour or of the paravertebral tissue lines may be due to lung or mediastinal pathology. Overpenetrated vs Underpenetrated O- decreased or absent lung marking U- excess white present
- Look at medial end of clavicles, should be equidistant from thoracic spinous process. Errors- Increase in cardiac size, opacification of lung bases because of overlying soft tissues.
- ECG electrode sticker
- Button
- Hair band
- Hair- mimics apical pneumothorax
- So many things to see in a chest Xray. A structured approach will go a long way.
- The trachea and bronchi are visible - branching at the carina (5-7th thoracic vertebral level) The trachea passes to the right of the aorta and so may be slightly off mid-line to the right T- midline or deviated. If deviated, need to r/o if this is due to rotation or true deviation. Deviated? Pushed or pulled?
- Subglottic stenosis
- Tracheal mass causing deviation and compression
- Tracheal stent for tracheomalacia
- Foreign Body- SCREW OCCLUDING LEFT MAIN BRONCHUS
- Width is 8 cm or greater when measured just above the aortic knob.
- 20 yr old male presented with neck swelling. D/D- LYMPHOMA, thymoma, germ cell tumour
- Pneumomediastinum- perforation of upper esophagus
- Thoracic Aortic Aneurysm ELDERLY AGE- CALCIFICATION- AORTA UNFOLDING.
- Check for fractures, dislocation, subluxation, osteoblastic or osteolytic lesions in clavicles, ribs, thoracic Spine and humerus including 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
- -Chest trauma rule out pneumo -Scoliosis
- 1. Mastectomy 2. Subcutaneous emphysema
- Left- left BCV, aortic knuckle, left MPA, left atrial appendage, LV Right- right BCV, SVC, RPA, RA, IVC
- CT ratio> 50% cardiomegaly
- 1. PERICARDIAL EFFUSION 2. LEFT ATRIAL ENLARGEMENT
- Pulmonary HTN
- 1. PAH- Prominent BVM, peripheral hypovascularity 3. Emphysema- early and late(pulmonary oligaemia)
- -PNEUMOPERITONEUM -ELEVATED RIGHT HEMIDIAPHRAGM
- -CDH -HIATUS HERNIA
- Oblique fissures- not usually seen as positioned facing toward the Xray beam Horizontal fissure- tangential to beam. Seen in 50% patients. At level or 6th rib laterally.
- Check for infiltrates Identify the location of infiltrates by use of known radiological phenomena, eg loss of heart borders or of the contour of the diaphragm Remember that right middle lobe abuts the heart, but the right lower lobe does not The lingula abuts the left side of the heart Identify the pattern of infiltration Interstitial pattern (reticular) versus alveolar (patchy or nodular) pattern Lobar collapse Look for air bronchograms, tram tracking, nodules, Kerley B lines Pay attention to the apices Check for granulomas, tumour and pneumothorax
- Fluid filling of space within the alveoli Fluid may be exudate, transudate, blood, protein, infiltration- malignant or non malignant. Mobile structures will not be displaced from their normal positions. Cardinal feature- infiltration of edema around the bronchi. 1. Right LL consolidation 2. Right middle lobe consolidation 3. Right middle lobe consol- aspiration (common)
- Volume loss resulting in increased opacification similar to consolidation and effusion. Primary sign is displacement of fissure. 1. Pneumothorax with right lung collapse 2. Endobronchial intubation
- >150ml for detection on CXR. Smaller volumes >75 ml with patient on side of suspected effusion or decubitus position. 1. Blunting of costophrenic and cardiophrenic angles. Meniscus sign
- 1. Bilateral Pleural effusion 2. Pulmonary Edema.- Bilateral, diffuse, fluffy lesions, coalescing, air bronchogram.
- NORMALLY. LEFT HILUM HIGHER THAN RIGHT. Left- CALCIFIED B/L HILAR LYMPHADENOPATHY IN SARCOIDOSIS RIGHT- PAH Unilateral: Infection: tuberculosis, viral infection in children Vascular: pulmonary artery stenosis, pulmonary artery aneurysm Tumour: lymph nodes (metastases; lymphoma; bronchial carcinoma) Bilateral: Sarcoidosis Tumour: metastases, lymphoma Vascular: pulmonary arterial hypertension (COPD; mitral valve disease; left to right shunt; recurrent pulmonary embolism) Infection: tuberculosis (occasionally)
- ET- 4cm above carina
- Right IJV, central line- just above level of carina. Within svc.
- Pneumomediastinum
- This is a PA view of the chest with normal exposure, proper centering The trachea is centrally placed with no deviation or narrowing. Mediastinum appears normal No apparent bony or soft tissue abnormality; cardiovascular silhouette is within normal limit with normal cardiothoracic ratio. The costophrenic and cardiophrenic angles, domes of the diaphragm show no abnormality No Effusions Lung fields are clear with normal bronchovascular markings, GASTRIC BUBBLE NORMAL CHEST XRAY
- Mucus plugging. Lung collapse
- 72 year old MALE with history of Complete Heart Block with Pacemaker Insitu. AP VIEW. # Pacemaker Lead
- Retrosternal Goitre Pemberton Sign- A positive Pemberton's sign is marked by the presence of facial congestion and cyanosis, as well as respiratory distress after approximately one minute. XRAY NECK AP and Lateral CT NECK and CT CHEST.
- Post scoliotic correction. Thoraco lumbar. Levoscoliosis Spine Instrumentation Rib crowding. Cob Measurement. Harrington Rod Look for Lung hypoplasia H/o Multiple Blood Transfusion. Spirometry
- B/L upper lobe Fibrosis Right middle lobe fibrosis. ANKYLOSING SPONDYLITIS Bamboo spine- COMPLETE FUSION OF BONES OF SPINE. BAMB
- The left lower zone is uniformly white At the top of this white area there is a concave surface - meniscus sign The left heart border, costophrenic angle and hemidiaphragm are obscured Slight blunting of the right costophrenic angle indicates a small pleural effusion on that side PLEURAL EFFUSION. BRONCHOGENIC CARCINOMA
- INCREASED BVM. R>L RIGHT LOWER ZONE BRONCHOGRAM. CONSOLIDATION RIGHT MIDDLE LOBE CONSOLIDATION MORE CLEAR ON LATERAL PROJECTION XRAY PNEUMONIA- RIGHT MIDDLE LOBE
- 35-year-old woman with mental retardation and pre-existing gastric bezoar with a witnessed aspiration and respiratory distress necessitating emergent intubation
- Multifocal patchy opacities in the right upper lobe with thickening FIBROSIS. TB
- EMPHYSEMA- FLATTENED DOME, NARRROW MEDIASTINUM, HYPERINFLATION OF BOTH LUNGS, MORE THAN 10 POSTERIOR RIBS, DECREASED LUNG MARKINGS. CHRONIC BRONCHITIS- PROMINENT BRONCHOVASCULAR MARKINGS, CARDIOMEGALY
- ACUTE PULMONARY EDEMA Stage 1- Congestion- cardiomegaly, broad vascular pedicle Stage 2- Interstitial edema- Kerley lines, peribronchial cuffing, thickened interlobar fissure Stage 3- Alveolar edema(OCWO>25mm Hg)- Consolidation, air bronchogram, cotton wool appearace, pleural effusion Kerley A lines- hilum to upper lobes(thickening of interlobular septa. caused by distention of anastomotic channels between peripheral and central lymphatics It shows evidence of both interstitial and alveolar edema. Alveolar edema manifests as ill-defined nodular opacities tending to confluence. Interstitial edema can be seen as peripheral septal lines - Kerley B lines (arrowheads). REPRESENT Edema of the interlobular septa and though not specific, they frequently imply left ventricular failure
- CARDIOGENIC- patchy infiltrates in lung bases first. Effusions may be present. Clinical signs and symptoms lag behind radiographic evidence.(CXR more severe than patient hypoxemia.) NON CARDIOGENIC- infiltrates more homogenous. No pleural effusion. No kerley B lines. Radiographic evidence lags behind clinical signs and symptoms.
- ANKYLOSING SPONDYLITIS Complete fusion of anterior and posterior elements RIGID, IMMOBILE SPINE. DIFFICULT AIRWAY.
- DOWNS SUSPECT IF DISTANCE BETWEEN OCCIPIT CONDYLES AND C1>5MM The patient is asked to slowly flex the head performing a slight cervical nod, at the same time the examiner presses posteriorly on the patient's forehead. A sliding motion of the head in relation to the axis indicates atlantoaxial instability. Atlanto-axial subluxation is a disorder of C1-C2 causing impairment in rotation of the neck. The anterior facet of C1 is fixed on the facet of C2. It may be associated with dislocation of the lateral mass of C1 on C2.
- Blunt trauma neck RETROPHARYNGEAL ABSCESS
- ACDF