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    Survival Rad 15 - Lung Handout

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    LorraineYong
    This document provides an overview of a survival radiology course focusing on interpreting chest x-rays. It discusses lung anatomy, the systematic approach to reading CXRs, common radiographic densities, interpreting abnormalities, and assessing devices like tubes and drains in ICU patients. The goal is to teach participants to identify abnormalities, correlate with clinical history, and recognize limitations while focusing on the patient over specific findings.

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    Survival Rad 15 - Lung Handout

    Uploaded by

    LorraineYong
    146 views41 pages
    This document provides an overview of a survival radiology course focusing on interpreting chest x-rays. It discusses lung anatomy, the systematic approach to reading CXRs, common radiographic densities, interpreting abnormalities, and assessing devices like tubes and drains in ICU patients. The goal is to teach participants to identify abnormalities, correlate with clinical history, and recognize limitations while focusing on the patient over specific findings.

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    This document provides an overview of a survival radiology course focusing on interpreting chest x-rays. It discusses lung anatomy, the systematic approach to reading CXRs, common radiographic densities, interpreting abnormalities, and assessing devices like tubes and drains in ICU patients. The goal is to teach participants to identify abnormalities, correlate with clinical history, and recognize limitations while focusing on the patient over specific findings.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    146 views41 pages

    Survival Rad 15 - Lung Handout

    Uploaded by

    LorraineYong
    This document provides an overview of a survival radiology course focusing on interpreting chest x-rays. It discusses lung anatomy, the systematic approach to reading CXRs, common radiographic densities, interpreting abnormalities, and assessing devices like tubes and drains in ICU patients. The goal is to teach participants to identify abnormalities, correlate with clinical history, and recognize limitations while focusing on the patient over specific findings.

    Copyright:

    © All Rights Reserved
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    Download as pdf or txt
    of 41

    SURVIVAL RADIOLOGY COURSE 2015

    Lung
    Dr Ng Yuen Li
    B.Med.Sci, BMBS, MRCP(UK), FRCR(UK)
    Senior Consultant Radiologist, Department of Diagnostic Radiology, Singapore General Hospital

    1
    Lung Anatomy
    Lung Anatomy
    Lung Anatomy
    Lung Anatomy
    Lung Anatomy
    CXR : Systematic Approach
    Clavicles

    Identification – name, date


    Orientation - left / right

    Rotation - clavicles and Spinous Process


    spinous process

    Penetration Vertebral Body


    - thoracic spine visible
    Visible

    6
    Degree of Inspiration
    (anterior 6th and posterior
    10th ribs visible) 10
    CXR : Systematic Approach

    • Heart

    • Mediastinum

    • Hila

    • Lungs and Pleura

    • Bones & soft tissue


    CXR : Radiographic Densities

    Gas

    Fat
    Soft tissue
    (muscle, fluid, blood)

    Bone

    Metal
    CXR : Interpretation
    • What is the abnormality?
    White Black
    (abnormally dense) (abnormally lucent)

    • Where is it?
    - Lung
    Distribution - bi/unilateral, upper/lower zones, peripheral/central
    - Pleura / Chest wall
    - Mediastinum / Heart
    CXR : Difficult areas / Blind spots

    - Apices, behind heart and


    below diaphragms
    CXR : Difficult areas / Blind spots

    - Apices, behind heart and


    below diaphragms

    - Hila

    - Bones, soft tissues and neck


    CXR : Interpretation
    Clinical context is all important
    • CXR is not pathology

    • Several diagnoses may cause similar CXR patterns

    • CXR should fit clinical diagnosis, not vice versa

    • Treat the patient, not the CXR

    • Review prior CXR


    Outline
    Part 1 ‘White’ CXR Part 2 ‘Black’ CXR

    Airspace disease Abnormal gas


    Atelectasis / Collapse Lines and tubes
    Nodule / Mass
    Pleural disease
    Completely Opaque Hemithorax

    Patient A Patient B

    Patient C Patient D
    Consolidation / Airspace / Alveolar Disease
    Alveolar spaces may be filled with

    - Fluid
    e.g. pulmonary oedema

    - Blood
    e.g. pulmonary haemorrhage

    - Inflammatory cells
    e.g. infection/pneumonia

    - Tumour cells
    e.g. adenocarcinoma, lymphoma

    Patient A
    Air Bronchogram

    Consolidation (alveoli filled)


    - airways visible due to the difference in density
    CXR : Interpretation
    • History – Fever, cough
    productive of green sputum

    • CXR finding - Airspace


    disease / Consolidation

    • Diagnosis – Infective
    (Bacterial) Pneumonia
    CXR finding
    - Consolidation
    - Bilateral, symmetrical
    - Perihilar/central
    - Cardiomegaly

    Differential diagnoses
    - Pulmonary oedema
    - Pneumonia (atypical)
    - Inhalation injury
    - Haemorrhage
    69-year-old man with SOB and lower limb oedema

    CXR finding
    - Consolidation
    - Bilateral, symmetrical
    - Perihilar/central
    - Cardiomegaly

    Diagnosis
    Cardiogenic pulmonary
    oedema
    Silhouette Sign
    Loss of normal silhouette
    due to effacement of a normal structure by a process of
    similar density

    • To localize lesion
    • To detect lesions when the loss of silhouette is more
    obvious than the lesion itself

    Felson B and Felson H. Radiology 1950;55:363-374.


    Complete Left Lung Collapse
    Heart and mediastinum in
    the left hemithorax

    Volume loss of the left


    lung

    ETT too low,


    in right main bronchus

    Patient B
    Linear (Discoid / Plate)
    due to hypoventilation /
    suboptimal inspiration
    Lobar Atelectasis / Collapse
    • Volume loss
    • Triangular shape, apex at hilum
    • Displaced fissures typically
    convex towards atelectatic lung
    LLL Collapse
    Secondary to central obstructing tumour
    Large Left Pleural Effusion

    - Contralateral shift of
    mediastinum and heart

    - Homogeneous opacity

    Patient C
    Large Left Pleural Effusion
    *

    *
    *

    *
    Supine CXR : Pleural Effusion
    Fluid in Dependent Region in Supine Patient
    Post Right Pneumonectomy

    Check history and prior CXR

    Patient D
    Post Right Pneumonectomy
    Recurrent carcinoma with rib destruction

    Current 8 months ago


    Pulmonary Nodule and Mass
    • Nodule = well-defined
    spherical or ovoid opacity
    up to 3cm

    • Mass = greater than 3cm


    diameter

    Fleischner Society: glossary of terms for thoracic imaging. Radiology 2008; 246:697–722
    Solitary or Multiple
    Pulmonary Nodule(s)
    • Neoplastic (Malignant / Benign)
    • Inflammatory
    (Infective / Non-infective)

    • Vascular (e.g. avm)

    • Congenital
    Mediastinal Mass
    • Anterior
    – 4 Ts - thyroid, teratoma, thymoma,
    terrible lymphoma

    • Middle
    – carcinoma, nodes, aneurysm,
    bronchogenic cyst

    • Posterior
    – oesophagus, neurogenic tumour,
    abscess
    Role of CXR in the ICU
    • Diagnosis usually known
    • Not making ‘amazing’ diagnoses

    → Assess devices (lines and tubes)


    → Assess cardiopulmonary status
    → Assess for any change
    Portable CXR on ICU
    As usual → Systematic approach

    • Technical factors
    • Lines and tubes
    • Surgical/interventional history
    • Barotrauma
    • Beware of patient position (for assessment of pneumothorax
    and pleural effusion)
    • Always review previous serial CXRs
    Lines & Tubes
    ETT
    • Ideally 3-5 cm above carina
    • just above aortic arch
    • T5/T6 vertebral body
    (midway between vocal cords and carina)
    • Flexion and extension of head can move ETT 2 to 4 cm (down
    and up respectively)
    • Malposition common (10 - 15%)
    Lines & Tubes
    Central lines
    • Haemodynamic monitoring & infusions of fluid and medication
    • Usually via subclavian or internal jugular vein
    • Sited in SVC or brachiocephalic veins
    • Not in RA or RV – risk of arrhythmias / pericardial tamponade
    • Not too high (> 2.5cm peripheral to brachiocephalic veins) –
    presence of valves
    • Below anterior end of 1st ribs

    • Tip should not be curved


    • Malposition common – up to 1/3
    • Complications – 6% pneumothorax
    Lines & Tubes
    Complications
    • Malposition
    • Haematoma
    • Haemothorax
    • Pneumothorax / Pneumomediastinum
    • Pericardial tamponade
    Lines & Tubes
    Chest drains

    • Apical - pneumothorax
    • Basal - effusion
    • Not against great vessels
    Supine Pneumothorax

    Deep Sulcus Sign


    Summary
    • Be systematic

    • Review difficult areas and ‘blind spots’

    • Review prior CXR

    • Clinical History is all important

    • Treat the patient and not the CXR

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