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

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

Jan 04, 2023 258 likes •915 views

(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

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Lung Anatomy

Right Left Anterior Posterior

(1)

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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

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Approaching a CXR

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History

A 35-year-old gentleman presents with a fever and cough. He has a background

  • f

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

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Case-based discussion: 1

PLEASE INSERT IMAGE HERE (if appropriate)

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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

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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

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Lung Anatomy

Right Left Anterior Posterior

(1)

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Lung Anatomy

Right Left Anterior Posterior

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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

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Silhouette sign

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History

A 35 year old gentleman presents with a fever and cough. He has a background

  • f

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

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Case-based discussion: 1

PLEASE INSERT IMAGE HERE (if appropriate)

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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

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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

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History

A 30-year-old man presents to the 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

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Case-based discussion: 2

PLEASE INSERT IMAGE HERE (if appropriate)

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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

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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

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Pneumothorax

Definition

  • Presence of gas within the

pleural cavity

(2) (3)

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History

A 30-year-old man presents to the 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

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Case-based discussion: 2

PLEASE INSERT IMAGE HERE (if appropriate)

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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

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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

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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

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Approaching a CXR

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History

A 75-year-old man who was admitted 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

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Case-based discussion: 3

PLEASE INSERT IMAGE HERE (if appropriate)

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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

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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

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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

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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

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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)

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NG Tube Assessment

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History

A 57 year-old man presents with a cough and weight loss. He is an ex- 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

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Case-based discussion: 4

PLEASE INSERT IMAGE HERE (if appropriate)

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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

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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

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Lung Anatomy

Right Left Anterior Posterior

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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

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Approaching a CXR

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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

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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

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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)

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Summary of Left Lower Lobe Collapse

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History

A 40-year-old woman who was admitted with osteomyelitis in her foot is due to be discharged with long term

  • utpatient

antibiotic therapy. She has a past medical history of type 2 Diabetes Mellitus. You are are reviewing her most recent chest XR with your consultant before discharging her.

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Case-based discussion: 5

PLEASE INSERT IMAGE HERE (if appropriate)

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Question: 9

How should you manage the patient? 1) Request a chest CT 2) Insert a cannula and discharge patient home for OPAT 3) Discharge patient for OPAT 4) Insert a chest drain 5) None of the above

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Question: 9

How should you manage the patient? 1) Request a chest CT 2) Insert a cannula and discharge patient home for OPAT 3) Discharge patient for OPAT 4) Insert a chest drain 5) None of the above

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(4)

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History

A 31-year-old woman presents to the Emergency Department with acute shortness of breath and wheeze. She has a past medical history of asthma. On examination, she has a widespread wheeze. Dullness to percussion at the right apex

Observations

HR 90, BP 110/80, RR 25, SpO2 100%, Temp 37.8

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Case-based discussion: 6

PLEASE INSERT IMAGE HERE (if appropriate)

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Question: 10

Based on the clinical findings and chest radiograph, what is the most likely diagnosis? 1) Right upper lobe collapse secondary to mucus plugging 2) Right upper zone primary lung carcinoma 3) Right upper lobe collapse secondary to an endobronchial carcinoma 4) Right upper zone pneumonia 5) Acute exacerbation of asthma

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Question: 10

Based on the clinical findings and chest radiograph, what is the most likely diagnosis? 1) Right upper lobe collapse secondary to mucus plugging 2) Right upper zone primary lung carcinoma 3) Right upper lobe collapse secondary to an endobronchial carcinoma 4) Right upper zone pneumonia 5) Acute exacerbation of asthma

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Question: 11

Which of the following is not a sign of loss of volume in right upper lobe collapse? 1) Elevation of the right hemidiaphragm 2) Decreased spacing between the right ribs 3) Right upper zone opacification 4) Rightward tracheal deviation 5) Elevation of the right hilum

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Question: 11

Which of the following is not a sign of loss of volume in right upper lobe collapse? 1) Elevation of the right hemidiaphragm 2) Decreased spacing between the right ribs 3) Right upper zone opacification 4) Rightward tracheal deviation 5) Elevation of the right hilum

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  • 1. Deviation of structures:
  • 1. Trachea
  • 2. Hila
  • 3. Mediastinum
  • 2. Elevation of the diaphragm
  • 3. Decreased spacing between the ribs

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Signs of volume loss

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History

A 45-year-old man presents to the Emergency Department with central chest pain. He is normally fit and well but has been taking regular NSAIDs following an injury a month ago. On examination, the lungs are clear.

Observations

HR 103, BP 98/62, RR 25, SpO2 94%, Temp 38.1 A blood gas reveals a lactate of 3.2

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Case-based discussion: 7

PLEASE INSERT IMAGE HERE (if appropriate)

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Question: 12

What finding is present on the chest radiograph? 1) Bilateral hilar enlargement 2) Pneumoperitoneum 3) Right apical pneumothorax 4) Left apical pneumothorax 5) Widened mediastinum

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Question: 12

What finding is present on the chest radiograph? 1) Bilateral hilar enlargement 2) Pneumoperitoneum 3) Right apical pneumothorax 4) Left apical pneumothorax 5) Widened mediastinum

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References

1) By David Richfield and Mikael Häggström, M.D.- Author info- Reusing images, CC BY-SA 4.0, https://commons.wikimedia.org/w/index.php?curid=76719949 2) By OpenStax College - Anatomy & Physiology, Connexions Web site. http://cnx.org/content/col11496/1.6/, Jun 19, 2013., CC BY 3.0, https://commons.wikimedia.org/w/index.php?curid=30148380 3) By BruceBlaus. When using this image in external sources it can be cited as:Blausen.com staff (2014). "Medical gallery of Blausen Medical 2014". WikiJournal of Medicine 1 (2). DOI:10.15347/wjm/2014.010. ISSN 2002-4436. - Own work, CC BY 3.0, https://commons.wikimedia.org/w/index.php?curid=27924395 4) By OpenStax College - Anatomy & Physiology, Connexions Web site. http://cnx.org/content/col11496/1.6/, Jun 19, 2013., CC BY 3.0, https://commons.wikimedia.org/w/index.php?curid=30148288

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