Teaching point #2 Choose and utilize a standardized way to view each radiograph Alphabet method BIO (Between, inside, outside the lungs) Top down Other My approach: Abnormalities, right lung, left lung, compare the two lungs, trachea, mediastinum, heart, outside the lungs (including abdomen) and bones

Now that you have a search pattern What structures should you normally see? Anatomy important for lines and tubes Trachea and carina Aortic arch Cavoatrial junction Subclavian vein/artery Internal jugular vein

Trachea Carina Left main bronchus Right main bronchus In the normal chest radiograph only airways within the mediastinum are apparent

SVC

Aortic arch Aortopulmonary recess Main Pulmonary Artery Cavoatrial junction

Cavoatrial junction Our perspective on most central lines Is it central? Yes = good Is it flopping around hitting the AV Valve? Yes = bad Close to the CAJ is fine CAJ landmarks About 2 cm below the bulge of the right atrial appendage About 2 vertebral bodies below the carina (better for peds)

Appropriately placed IJ line? Good placement or not? Yep

Lobar anatomy Lesson for today – the upper lobes aren’t just at the top of the CXR, and the lower lobes aren’t just at the bottom.

Right Lung: Lobes and Fissures

Right Upper & Right Middle Lobes Lobar Anatomy: Right Upper & Right Middle Lobes RUL RUL RML RML

Lobar Anatomy: Right Lower Lobe RLL RLL

Lobar Anatomy: Left Upper Lobe LUL LUL

Lobar Anatomy: Left Lower Lobe LLL LLL

Which lobe is collapsed?

Which lobe has a pneumonia?

Pattern and Distribution Abnormalities have two important imaging clues: Pattern of disease Distribution of disease location, location, location!

Patterns Consolidation Ground Glass Lines (interstitial or septal thickening) Reticulation Peripheral Lace-like opacities Cysts Nodules Tree-in-Bud or Budding Tree opacities

Patterns *Infiltrate is not one of these patterns* Consolidation Ground Glass Lines (interstitial or septal thickening) Reticulation Cysts Nodules

We can do better “Infiltrate”: A vague term at best, used to describe any abnormality. Avoid it! Lung “fields”: Fields are for cows! They are lungs or lobes “Poor inspiratory effort”: Low lung volumes is at least more appropriate “Nonspecific”: Earn your paycheck

Fields are for cows 

Patterns Consolidation Ground Glass Lines (interstitial or septal thickening) Reticulation Cysts Nodules Tree-in-Bud or Budding Tree opacities

Distribution of Disease Focal (or multifocal) versus diffuse Dependent distribution (varies with position!) Upper lobe Bronchovascular Peripheral Random

Normal versus consolidation

Acute Consolidation Infection Water Blood Indeterminate White Blob (IWB) Infection Bacterial pneumonia Water Pulmonary edema Blood Pulmonary hemorrhage, contusion

Acute? Think Infection, Water, Blood

Normal Ground Glass

Acute Ground Glass Opacity Indeterminate White Blob (IWB) Infection PCP, viral pneumonia Water Pulmonary edema Blood Pulmonary hemorrhage

17 yo Male: Sudden Onset Dyspnea

Acute Ground Glass Opacity (2 Weeks of symptoms) & Upper Lobe Distribution

Diffuse GGO versus focal consolidation

Questions?

Teaching points Name the 5 densities that are seen on standard radiographs Choose and utilize a standardized way to view each radiograph Locate the following anatomic structures: Trachea, carina, subclavian artery and vein, SVC, cavoatrial junction Name the 6 patterns seen on chest imaging

Teaching points Name the 5 densities that are seen on standard radiographs Air Fat Densities Water/tissue Bone Metal

Teaching points Choose and utilize a standardized way to view each radiograph Alphabet method (Airspaces, Bones, Cardiac, etc.) BIO (Between, inside, outside the lungs) Top down Other

Teaching points Locate important anatomic structures: SVC begins at approximately the 1st anterior rib space Cavoatrial junction: 2 cm below the initial SVC-right atrium bump, or about 2 vertebral bodies below the carina Carina is the branch point of the trachea, it’s usually directly identifiable If it’s not, it should be around T6

Teaching Points Consolidation Ground Glass Lines (interstitial or septal thickening) Reticulation Cysts Nodules Tree-in-Bud or Budding Tree opacities