Lung Anatomy Anterior Posterior Right Left 2 Approaching a CXR - PowerPoint PPT Presentation

(1) Lung Anatomy Anterior Posterior Right Left 2

Approaching a CXR 1. Patient and clinical details 2. Technical adequacy 1. Projection 2. Inspiration 3. Rotation 3. ABCDE 1. Airway – position of trachea 2. Breathing – lungs 3. Circulation – cardiac and mediastinal contours 4. Diaphragm – contours and below the diaphragm 5. Everything else – lines and tubes 4. Review areas 1. Lung apices 2. Costophrenic angles 3. Behind the heart 4. Behind and below the diaphragm 3

Case-based discussion: 1 History PLEASE INSERT IMAGE HERE A 35-year-old gentleman presents with (if appropriate) a fever and cough. He has a background of HIV and his most recent CD4 count was normal. On examination, he has bronchial breathing and dull percussion on the left. Observations HR 101, BP 130/86, RR 22, SpO2 93%, Temp 38.8 4

Question: 1 What radiographic feature is most suggestive of consolidation? 1) Loss of the left heart border 2) Ill-defined opacification 3) Air bronchograms 4) Interstitial shadowing 5) Bronchial wall thickening 5

Question: 1 What radiographic feature is most suggestive of consolidation? 1) Loss of the left heart border 2) Ill-defined opacification 3) Air bronchograms 4) Interstitial shadowing 5) Bronchial wall thickening 6

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(1) Lung Anatomy Anterior Posterior Right Left 9

Lung Anatomy Anterior Posterior Right Left 10

Silhouette sign Definition : loss of a normal thoracic contour (e.g. heart border or diaphragmatic border) as a result of pathology that is contiguous with that border. Useful in lots of contexts! • Lobar collapse • Mediastinal masses • Consolidation 12

Case-based discussion: 1 History PLEASE INSERT IMAGE HERE A 35 year old gentleman presents (if appropriate) with a fever and cough. He has a background of HIV and his most recent CD4 count was normal. On examination, he has bronchial breathing and dull percussion on the left. Observations HR 101, BP 130/86, RR 22, SpO2 93%, Temp 38.8 13

Question: 2 What is the most likely causative organism? 1) SARS-CoV-2 2) Streptococcus pneumoniae 3) Mycobacterium tuberculosis 4) Pneumocystis jirovecii 5) Staphylococcus aureus 14

Question: 2 What is the most likely causative organism? 1) SARS-CoV-2 2) Streptococcus pneumoniae 3) Mycobacterium tuberculosis 4) Pneumocystis jirovecii 5) Staphylococcus aureus 15

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Case-based discussion: 2 History PLEASE INSERT IMAGE HERE A 30-year-old man presents to the (if appropriate) Emergency Department with pleuritic chest pain and shortness of breath. He is usually fit and well however is a smoker. On examination, he appears dyspneic but is not in respiratory distress. There is reduced air entry at the left apex. Observations HR 85, BP 110/80, RR 22, SpO2 95%, Temp 37.3 17

Question: 3 What is the most likely cause for the patient’s clinical presentation? 1) Pneumonia 2) Pulmonary embolism 3) Spontaneous pneumothorax 4) Tension pneumothorax 5) Costochondritis 18

Question: 3 What is the most likely cause for the patient’s clinical presentation? 1) Pneumonia 2) Pulmonary embolism 3) Spontaneous pneumothorax 4) Tension pneumothorax 5) Costochondritis 19

Pneumothorax Definition Presence of gas within the • pleural cavity (3) (2) 20

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Case-based discussion: 2 History PLEASE INSERT IMAGE HERE A 30-year-old man presents to the (if appropriate) Emergency Department with pleuritic chest pain and shortness of breath. He is usually fit and well however is a smoker. On examination, he appears dyspneic but is not in respiratory distress. There is reduced air entry at the left apex. Observations HR 85, BP 110/80, RR 22, SpO2 95%, Temp 37.3 23

Question: 4 How should you manage this patient? (Pneumothorax measures 1 cm at the hilum) 1) Pleurodesis 2) Aspirate and repeat imaging 3) Chest drain insertion 4) Observe for 24 hours 5) Discharge and review as outpatient 24

Question: 4 How should you manage this patient? (Pneumothorax measures 1 cm at the hilum) 1) Pleurodesis 2) Aspirate and repeat imaging 3) Chest drain insertion 4) Observe for 24 hours 5) Discharge and review as outpatient 25

Approaching a CXR 1. Patient and clinical details 2. Technical adequacy 1. Projection 2. Inspiration 3. Rotation 3. ABCDE 1. Airway – position of trachea 2. Breathing – lungs 3. Circulation – cardiac and mediastinal contours 4. Diaphragm – contours and below the diaphragm 5. Everything else – lines and tubes 4. Review areas 1. Lung apices 2. Costophrenic angles 3. Behind the heart 4. Behind and below the diaphragm 26

Case-based discussion: 3 History PLEASE INSERT IMAGE HERE A 75-year-old man who was admitted (if appropriate) earlier in the day with an ischaemic stroke has developed increasing shortness of breath and a cough. On examination, he appears distressed. There are bibasal crepitations. Observations HR 90, BP 110/80, RR 28, SpO2 95%, Temp 37.8 27

Question: 5 How would you manage this patient? 1) IV antibiotics 2) IV diuretics 3) Discuss radiograph with seniors/radiology 4) Remove NG tube 5) None of the above 28

Question: 5 How would you manage this patient? 1) IV antibiotics 2) IV diuretics 3) Discuss radiograph with seniors/radiology 4) Remove NG tube 5) None of the above 29

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Question: 6 Which of the following is NOT correct when assessing the position of an NG tube? 1) It is safe to feed a patient through an NG tube with its tip in the duodenum 2) The NG tube must bisect the carina 3) The tip of the NG tube must be seen below the diaphragm 4) It is safe to feed a patient through an NG tube with its tip in the oesophagus 5) Measuring the pH of the aspirate is the first-line test 31

Question: 6 Which of the following is NOT correct when assessing the position of an NG tube? 1) It is safe to feed a patient through an NG tube with its tip in the duodenum 2) The NG tube must bisect the carina 3) The tip of the NG tube must be seen below the diaphragm 4) It is safe to feed a patient through an NG tube with its tip in the oesophagus 5) Measuring the pH of the aspirate is the first-line test 32

NG Tube Assessment An NG tube must: 1. Pass through the middle of the chest/mediastinum 2. It must bisect the carina 3. It must cross the diaphragm in the midline 4. Its tip must be clearly visible below the diaphragm (10 cm below the GOJ) 33

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Case-based discussion: 4 History A 57 year-old man presents with a PLEASE INSERT IMAGE HERE cough and weight loss. He is an ex- (if appropriate) smoker and uses inhalers for COPD. He attends A&E with worsening shortness of breath. On examination, he is dyspneic. Observations HR 88, BP 101/78, RR 25, SpO2 87%, Temp 37.1 ABG Shows a type 1 respiratory failure 35

Question: 7 What is the most likely cause for the patient’s type 1 respiratory failure? 1) Bronchogenic carcinoma 2) Exacerbation of COPD 3) Lobar collapse 4) Pneumonia 5) Heart failure 36

Question: 7 What is the most likely cause for the patient’s type 1 respiratory failure? 1) Bronchogenic carcinoma 2) Exacerbation of COPD 3) Lobar collapse 4) Pneumonia 5) Heart failure 37

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Lung Anatomy Anterior Posterior Right Left 39

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Approaching a CXR 1. Patient and clinical details 2. Technical adequacy 1. Projection 2. Inspiration 3. Rotation 3. ABCDE 1. Airway – position of trachea 2. Breathing – lungs 3. Circulation – cardiac and mediastinal contours 4. Diaphragm – contours and below the diaphragm 5. Everything else – lines and tubes 4. Review areas 1. Lung apices 2. Costophrenic angles 3. Behind the heart 4. Behind and below the diaphragm 42

Question: 8 The loss of the left hemidiaphragm in this case is known as which sign? 1) Felson’s sign 2) Mach effect 3) Luftsichel sign 4) Silhouette sign 5) Sail sign 43

Question: 8 The loss of the left hemidiaphragm in this case is known as which sign? 1) Felson’s sign 2) Mach effect 3) Luftsichel sign 4) Silhouette sign 5) Sail sign 44

Summary of Left Lower Lobe Collapse Aetiology: Endobronchial obstruction • Mucus plug in young asthmatic • Endobronchial carcinoma until proven otherwise in older patient or smoker • Foreign body in children • Radiographic features: Triangular retrocardiac opacity (sail sign) represents the collapsed left lower lobe • Loss of most of the left hemidiaphragm (silhouette sign) – due to loss of the air-tissue interface • Loss of the left hilum (pulled down due to volume loss) • Tracheal deviation towards the side of the collapsed lung (not seen in this case) which is also • due to volume loss Increased lucency within the remaining left lung (hyperinflation of the left upper lobe) • 45

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