1. The CHEST Emergency Medical Conditions MI Zucker, MD

2. A dr Z Lecture

3. The WHAT: Normal chest films Abnormal patterns Atelectasis Infection Obstructive airway diseases Heart failure Noncardiac edema Pulmonary embolism Aortic dissection …and a few others

4. The WHY: Give you a basic approach to acute medical diseases emphasizing CHEST Radiographs Show you the most COMMON diseases Show you commonly MISSED findings

5. The NORMAL Chest PA/lateral Portable AP

6. The PA (adult and kid) and Lateral Check list Commonly overlooked areas

10. The PORTABLE AP The “bottom feeder” of chest radiology

12. Pitfalls in Chest Radiology Phase of respiration Position Comparison films Portables

13. Poor Inspiration

14. The PATTERNS Too dense Too lucent

15. Location, Location, Location Lung? Chest wall? Mediastinum? Pleura?

16. Lung: Too DENSE Alveolar pattern Interstitial pattern Masses

17. Lung: Alveolar Pattern Something of unit/soft tissue/water density replaces the air in the alveolar ducts, alveolar sacs and the alveoli

18. Alveolar Lung Pattern: causes PUS WATER BLOOD Lymphoma BAC Alveolar proteinosis

19. Alveolar Lung Pattern: findings Increased density Confluence Ill defined margins Air bronchograms

22. Lung: Interstitial Pattern Something thickens the interstitium of the lung parenchyma

23. What? Edema Inflammatory cells RBC’s Malignant cells Fibrosis

24. How? All of them ADD tissue to the peripheral and axial interstitium of the secondary pulmonary lobule

25. Secondary Pulmonary Lobules

26. Who? Many, many diseases present with the same interstitial patterns You need history, lab, and frequently biopsy to make a specific diagnosis

27. A Memory Aid “I Munch Ice Chips In Places Called Igloos”

28. Interstitial diseases Idiopathic Malignancy Infection UIP DIP LIP BOOP LAM PEG sarcoid Metastases, lymphoma Viral, PCP, mycoplasma. Fungi, TB, MAC

29. Interstitial diseases Congenital Iatrogenic Pulmonary edema NF TS CF Drugs, radiation Cardiogenic, renal, noncardiogenic

30. Interstitial diseases Collagen-vascular Inhalational RA, SLE, scleroderma, AS Allergic alveolitis, noxious gases, pneumoconiosis

31. The Interstitial Patterns Lines: fine, medium, or coarse Nodules: tiny to 3 cm Reticular: network of crossing lines Reticular-nodular: lines and nodules

32. Lines

33. Nodules

34. Reticular pattern

35. Lines and nodules

36. What do they mean? Coarse lines mean fibrosis, also called “honeycomb” pattern The other patterns usually mean more active disease, but aren’t specific

40. Kerley lines, A and B Thickened secondary lobule septae Often, but not always due to CHF Basically, they are just a slightly specialized intertstitial linear pattern A and B differ only by location

42. INFECTION The pneumonias

43. BACTERIAL PNEUMONIAS Pyogenic

45. The Silhouette Sign If two adjacent structures have the same density, the border between them is not visible. Replace air with an alveolar process and the border between the involved lung and the heart, or diaphragm, or aorta disappears

48. The Spine Sign On the lateral view the spine normally progressively looks darker caudally. If it looks whiter, there is an alveolar process in one of the lower lobes.

50. Atypical Pneumonias Mycoplasma Chlamydia

51. Patterns Diffuse bilateral patchy opacities Diffuse interstitial linear opacities

54. Viral Pneumonias Air-trapping Mucus plugs and atelectasis Diffuse interstitial linear and nodular opacities Findings more pronounced in kids

57. Pneumocystis carnii Pneumonia Interstitial linear nodular pattern, usually bilateral Followed by diffuse alveolar pattern Early, 10% of CXR’s in PCP can be negative. Later, atypical patterns are fairly common.

58. PCP

59. Tuberculosis Primary Post-primary

60. TB: primary

61. TB: postprimary, early

62. TB: postprimary, cavitary

63. A few more Infections Lung abscess Empyema Fungus

64. Lung abscess

65. Empyema: Hydro-pneumothorax

66. Coccidioidomycosis

67. ATELECTASIS Loss of Lung Volume

68. Atelectasis: types Obstructive Passive Compressive Cicatricial Adhesive

69. Atelectasis: signs Increased density Shift of fissure Elevation of diaphragm Shift of mediastinum Shift of heart Shift of hilum Compensatory hyperinflation

70. Subsegmental

71. Right upper lobe

72. Lower lobes

73. Right middle lobe

74. Left upper lobe

75. ATX: entire lung

76. Edema Cardiogenic Renal Noncardiogenic

77. Edema: pathogenesis Cardiogenic: increased hydrostatic pressure Noncardiogenic: increased alveolar- capillary membrane permeability Renal: multiple factors

78. Cardiogenic Congestive heart failure

79. CHF Cephalization 12 wedge pressure Interstitial edema 20 Alveolar edema 25 Cardiomegaly, pleural effusions

80. CHF: cephalization

81. CHF: interstitial edema

82. CHF: alveolar edema

83. Renal related Fluid overload Increased permeability CHF

84. Edema: renal

85. Noncardiogenic edema Near drowning High altitude Drugs Inhalation Hypoxia (ARDS)

86. Noncardiogenic edema

87. Obstructive lung disease Asthma COPD

88. Asthma Hyperinflation Mucus plugs/atelectasis Interstitial inflammation Barotrauma

89. Asthma: kid

90. Asthma: adult

91. COPD Hyperinflation Flat diaphragm Increased retrosternum air space Pulmonary arterial hypertension Look for pneumonia as cause of exacerbation

92. COPD

93. Pulmonary embolism

94. PE: diagnosis Clinical: dyspnea, chest pain, increased RR & PR D-dimer Doppler ultrasound *CXR *CTPA Lung scan Pulmonary angiography

95. Chest film Subsegmental atelectasis Small pleural effusion Elevated diaphragm Westermark’s (rare) Hampton’s (rare)

96. PE: CXR

97. PE: CTPA

98. Aortic Dissection

99. HYPERTENSION Marfans Coarctation Turners, SLE, pregnancy

100. Aortic Dissection Type A: more common, ascending aorta, surgery Type B: descending aorta, trial of medical management

101. AD: imaging CXR CTA MRI TEE Angiography

102. AD: CXR Mediastinum contour abnormality: abnormal shape or width A change in contour from previous film

103. AD: CXR Sensitivity: 80%

104. AD: CXR

106. AD: CTA axial

107. AD: CTA reformat

108. …and a few more

109. Sickle Cell Disease Cystic Fibrosis

110. Sickle Cell Disease

111. Cystic Fibrosis

112. Goodbye Copyright 2004 MI Zucker, MD