Jennifer Lim-Dunham, MD Arcot J. Chandrasekhar, M.D. December 10, 2014 CXR Review TCM2 Jennifer Lim-Dunham, MD Arcot J. Chandrasekhar, M.D. December 10, 2014 LOYOLA UNIVERSITY MEDICAL CENTER Loyola University Chicago LOYOLA UNIVERSITY MEDICAL CENTER Loyola University Chicago

Is this a PA or AP film? PA film AP film

AP Supine film Scapula (red arrow) projecting overlapping lung fields Clavicles projecting above the inlet of thorax. No air fluid levels in abdomen or chest Underpenetrated (too white, not enough xrays going through the body) PA Upright film Scapula does not overlap lung fields Clavicles projecting over upper chest Air fluid levels in abdomen or chest Penetration/exposure normal

Is this film centered? Yes No

Not centered. Patient rotated to his right Draw a line along the central spinous process Draw a line along the medial end of clavicles Is the distance between medial end of clavicle and midline equal? Right ribs longer than left

Image Characteristics PA or AP Centered or rotated Degree of penetration Degree of inspiration

What is your answer? Cavity Mass Consolidation Pneumothorax Pleural effusion

Consolidation Triangular density Air bronchogram (red arrows) No loss of lung volume (midline). Distinguishes consolidation/pneumonia from atelectasis Unrecognizable vasculature R upper lobe (Silhouette sign) Know that these are the hallmarks of alveolar or airspace disease or consolidation, usually from pneumonia

Roentgen Signs Silhouette Sign Loss of silhouette indicates that there is airless (lung or mass or fluid) adjacent to that silhouette. Know the loss of which heart borders correspond to which lobes. http://www.stritch.luc.edu/lumen/MedEd/Radio/curriculum/radiology-curric1_f.htm (“Consolidation”)

What is your assessment? Consolidation Atelectasis Congestion Mass Pleural effusion

Resorptive Atelectasis Triangular density Loss of lung volume. Minor/horizontal fissure is elevated (arrows). Unrecognizable vasculature Right upper lobe (Silhouette sign) Compensatory hyperinflation Know types of atelectasis: resorptive, relaxation, adhesive. Know which fissures become elevated in atelectasis http://www.stritch.luc.edu/lumen/MedEd/Radio/curriculum/radiology-curric1_f.htm (“Atelectasis”)

What is your choice? Mass Consolidation Congestion Cavity Diffuse interstitial disease

Cavitating Mass Hole in lung Wall characteristics Lumen characteristics Contents Number Location Cavity signifies lung abscess or necrotic mass or tumor

What is your diagnosis? Pneumothorax Pleural effusion Consolidation Atelectasis Congestion

Pleural Effusion Homogenous density Dependent position Loss of diaphragm and costophrenic angle (Silhouette sign) Slanting meniscus Mediastinal shift to contralateral side

Unilateral White Out Pleural Effusion Mediastinal shift to contralateral side Larger hemithorax

Your choice? Diffuse alveolar disease Diffuse interstitial disease

Acute Diffuse Alveolar Disease Soft fluffy densities Butterfly distribution Air bronchogram Diffuse white out Acute vs. chronic

Acute diffuse alveolar disease You choice? Pulmonary edema Pulmonary hemorrhage Influenza Adult respiratory distress syndrome

Acute LV Failure: Pulmonary Edema Diffuse white out Soft fluffy densities Butterfly distribution Air bronchogram (arrowheads) A: ET tube, B: NG tube, C: Central line

Chronic Heart Failure Vascular Phase First phase: Cephalization

Congestive Heart Failure Interstitial Phase Second phase. Kerley B lines

Congestive Heart Failure Alveolar Phase Third phase Basal densities Pleural effusions Hilar fullness Peribronchial edema

What is your diagnosis? Diffuse alveolar disease Diffuse interstitial disease

Diffuse Interstitial Disease Miliary Tuberculosis Reticulonodular Ground glass / dirty lungs Kerley lines Miliary nodules Honeycombing These terms are used to described specific types of intersititial disease Distinguish interstitial from airspace disease

What is your impression? Atelectasis Pneumothorax Consolidation Lung mass

Pneumothorax Air in pleural cavity Visible lung margin Relaxation atelectasis Mediastinal shift to contralateral side Enlarged hemithorax Deep costophrenic sulcus

Mediastinal Widening Supracardiac Vessel / Anterior mediastinal Area Mediastinal nodes Mediastinal mass Aortic aneurysms

Tubes and Lines Learn to identify them. Make sure that the tip is in the right place. There are no complications from their placement. ET tube NG tube Central line (PICC, subclavian) Swan Ganz catheter Aortic balloon pump IV tubing, oxygen tubing, EKG leads Artifacts Foreign bodies http://www.stritch.luc.edu/lumen/MedEd/Radio/curriculum/radiology-curric1_f.htm (“Tubes and lines”)

COPD (chronic bronchitis and emphysema) Hyperinflated lungs Flattened diaphragm (yellow arrow) Retrosternal air (red arrow) Hyperlucent lungs Blebs (white arrow) in emphysema only Avascular zones