1. Cardio-Respiratory II-4 Physiotherapy Management Imaging the chest

2. Review

3. Functional Anatomy Can you name the Origin, Insertion, Function, Innervation? Palpate these structures

4. Functional Anatomy of Lungs

5. 1.Tracheal air column 2.Carina 3.First rib; count down from here for diaphragmatic level 4.Peripheral 1-2 cm of lung fields have no markings except 5.The minor fissure 6.Top of the diaphragm is near the medial half of its length. The top of the right diaphragm is normally at a level between the anterior end of the anterior 6th rib and the anterior 7th rib. The level of the diaphragm can also be reported eith reference to the posterior ribs: on full inspiration, the domes of the diaphragm are seen overlying the posterior aspects fot he 10th and 11th ribs. 7.Left diaphragm is lower in 90-95% of normals by roughly half an interspace (2% greater than 3 cm) 8.Inferior margins of the posterior ribs are often ill-defined. 9.Anterior mediastinal line (apposed visceral and parietal pleura of the two upper lobes 10.Superior vena cava shadow blends imperceptibly into the shadows of the neck 11.Region of the azygous vein (vein not visible). A caliber greater than 7 mm is suggestive of raised venous pressure, or enlargement of adjacent node. Normal may be up to 10 mm. 12.Right descending pulmonary artery. Not greater than 16 mm in men, 15 mm in women 13.Pulmonary arteries and veins. Hard to distinguish the two. Arteries are vertical and medial and emerge from the hilum. Veins are horizontal and lateral ad run toward the left atrium below the hilum. 14.Border of the right atrium 15.Inferior vena cava 16.Aortic arch 17.Left pulmonary artery 18.Border of the left ventricle 19. Descending aorta 20.Fat density lines in the intermuscular fascial layers

6. PA vs AP film PA film = posteroanteriorAP film = anteroposteriorly beam is directed from the back > optimum view of the lungs Patient is taking a deep breath in standing position, shoulders abducted > medial borders of scapula don’t obscure lungs Erect position ensures gas passes upwards Pneumothorax easy to detect, fluid passes downwards, so pleural effusion is easy to see Used for less mobile patients, unable to tale a deep breath Heart is magnified by 15-20%, anterior ribs are less clear, lung fields are partly obscured by scapula & raise diaphragm Pleural effusion > non-specific homogenous density > DIFFICULT Differentiation helps to avoid misunderstandings about the heart or diaphragm.

7. PA film AP film

8. Pleural effusion Left

9. Preliminary checks Check: Patient’s name, Date, PA or AP film, check exposure, check symmetry of spinous processes, placement of heart Overexposed film > too block, low density lesions can be missed Underexposed film > falsely white Correct exposure > vertebral bodies are visible through the upper BUT not the lower heart shadow! Spinous processes symmetry correct > appear as teardrop shapes down spine, midway between medial ends of clavicles Heart > at front of the chest; patient rotated > heart shadow appears shifted towards the sight

10. Systematic analysis Observe first from distance & then close up. Previous films can be used as comparison. Abnormalities can be identified as: Too black/white Too big In the wrong place Dense structures absorb rays & are opaque Air has a low density & appears black

11. Structures TracheaHeart Dark column of air, overlying upper vertebrae Midline down to the clavicles Slightly displaced to the right by the aortic arch, before branching to the main bronchi May move with mediastinum, if heart is displaced Position: normally extended slightly left of midline Size: transverse diameter < half of internal diameter of chest in PA film Big heart > result of ventricular, pulmonary hypertension or poor inspiratory effort Narrow heart > caused by hyperinflation, when diaphragm pulls down the mediastinum or its normal in tall, THIN people Shape: boot shaped > right ventricular hypertrophy; rounded heart > indication pericardial effusion Specific lobes are collapsed/consodilated if the following Borders are obscured: LLL (left lower lobe) > left hemidiaphragm RLL (right upper lobe) > right hemidiaphragm LUL > aortic arch RUL > right upper mediastinum Lingula > left heart border Middle lobe > right heart border ESP slide 11

12. LUL pneumonia with volume loss Note the difference when there are only two lobes Loss of heart borders/silhouetting Note anterior displacement of fissure on lateral view

13. Pulmonary Nodule Lateral film

14. RUL collapse Note differences: 3 vs. 2 lobes Only fissures give straight lines

15. Structures HilaDiaphragm Hilar shadows > blood & lymph vessels Hila are elevated by upper lobe fibrosis, atelactasis or lobectomy & depressed by lower lobe atelactasis Bilateral enlargement of hilar shadows > pulmonary hypertension/lymph node enlargement Unilateral enlargement > suspicion > malignancy Height: full inspiration > diaphragm = level with 6 th rib anteriorly, 8 th rib laterally & 10 th rib posteriorly > with the right side 2cm higher than the left > R pushed up by the liver Low, flat diaphragm > hyperinflation Elevated diaphragm > positional as on AP film, lack of full inspiration, pathological from pressure below i.e. abdominal distension One side of diaphragm raised > lower lobe atelactasis, paralysed hemidiaphragm or on the L excess gas in the stomach Shape: Diaphragm = dome-shaped & smooth Flattening > hyperinflation Costophrenic angles (CA)> 200 ml of fluids needs to accumulate in pleura before blunting the CA Subphrenic abscess/perforated gut: Air under right hemidiaphragm expected after abdominal surgery

16. Lung fields Vascular markings Horizontal fissure Diffuse shadowing i.e. Localized opacities i.e. Unilateral white-out Ring shadows Air bronchogram Fine White lines from hila = blood vessels Pneumothor ax > black, non-vascular area demarcated medially by white line of visceral pleura If visible, opposite to right hilum & meets 6 th rib in axilla >10° incline = abnormal Ground glass appearance > alveolar pathology Coarser honeybomb pattern > progressive damage in interstitial disease Consodilatio n > patchy opacity & pneumonia, occupying segment /lobe Bronchial tumors > located proximally; metastasis scattered Dense opacities can be caused by collapse/ penumonect omy/ large pleural effusion Bulla > hair line border, air filled > emphysem a/barotrau ma Cyst > wall thickness >1mm > bronchiect asis Airways visible, if contrasted against opacity If area of collapse has no bronchogram > obstructed airway

17. Bones Check for cardiopulmonary resuscitation or other trauma, osteoporosis or malignant sec. deposit Fresh rib fracture > discontinuation of border of rib Old fractures > callous formation ESP slide 17

18. Empyhsema Flattening of diaphragms/increased lung volumes Enlarged left pulmonary artery Attenuation of vessels Diffuse hyperlucency

19. References Hough “Physiotherapy in Respiratory Care” http://images.google.com/imgres?imgurl=http://brighamrad.harvard.edu/education/online/clerk_2/g raphics/nml.gif&imgrefurl=http://brighamrad.harvard.edu/education/online/clerk_2/normal_cxr.html &usg=__AbgKaFE7YctJ2c8fFMZ- CeffXjQ=&h=326&w=353&sz=89&hl=de&start=2&tbnid=2Y1x2C2- w4NHaM:&tbnh=112&tbnw=121&prev=/images%3Fq%3Dnormal%2BPA%2Bfilm%26gbv%3D2% 26hl%3Dde%26sa%3DG http://images.google.com/imgres?imgurl=http://www.colorado.edu/intphys/Class/IPHY3430- 200/image/17-1.jpg&imgrefurl=http://www.colorado.edu/intphys/Class/IPHY3430- 200/015breathing.htm&usg=__Yho6k9KeVbZIohDN2BrhX- HGpDE=&h=490&w=919&sz=234&hl=de&start=1&tbnid=o5vDonmFufOhTM:&tbnh=78&tbnw=14 7&prev=/images%3Fq%3Dfunctional%2Banatomy%2Bof%2Blungs%26gbv%3D2%26hl%3Dde% 26sa%3DG ESP slide 19