Presentation on theme: "Night Float Module Interpretation of Chest Radiographs"— Presentation transcript:
1 Night Float Module Interpretation of Chest Radiographs National Pediatric Nighttime CurriculumWritten by LaToya S. Barber, MD andFrancine D. Bynum, MDChildrens Hospital Los Angeles
2 Goals And ObjectivesDevelop a comprehensive approach to reading chest x-raysIdentify the following conditions on chest x-raypneumonia and its complicationspneumothoraxatelectasisDescribe two radiographic features for both pneumonia and pneumothoraxACGME Pediatric Milestones:Pediatric Core Competencies:Develop a comprehensive approach to reading Chest X-rays:Pediatric Milestone A. Patient Care and B. Medical KnowledgePediatric Core Competencies Pneumonia, Radiographic Interpretation, Evidence Based MedicineIdentify the following conditions on chest X-rayPediatric Milestone B. Medical Knowledge and C. Practice based learning and improvementPediatric Core Competencies Pneumonia, Radiographic InterpretationDescribe two radiographic features for both pneumonia and pneumothorax
3 Case # 14 year old male with 2 weeks of cough, rhinorrhea and a one day history of tactile fevers, brought to the emergency department for increased WOB and hypoxia.Vitals Temp 38.8 HR 130 RR 40 BP 101/50 Pulse Ox 92%What are the top three diagnoses on your differential?Is it appropriate to obtain a Chest X-ray in this situation?What factors would support obtaining a Chest X-ray?What factors would deter you from obtaining a Chest X-ray?Allow residents to discuss answers for 2-3 minMove on; this case will be re-visited later
4 Case # 212 year old tall thin male is admitted overnight for monitoring after having a complicated eye surgery.3 hours into your shift you receive a consult from Ophthalmology to evaluate the patientHe is complaining of a sharp, persistent chest pain and shortness of breath. On exam, you note long fingers and thin skinWhat are the top three diagnoses on your differential?Is a Chest X-ray Indicated?Should it be ordered routine or stat?Allow residents to discuss answers for 2-3 minMove on; this case will be re-visited later
5 Chest Radiography Proven and useful tool for the evaluation of… Airways, lungs, pleura, and chest wallHeart, pulmonary vessels, and mediastinumMost common type is posteroanterior (PA)Anteroposterior (AP) and lateral films also commonThe most common cause for obtaining a Chest X-ray at night is an Acute Respiratory illnessDefinition“One or more of the following: cough, sputum production, chest pain, or dyspnea (with or without fever)Determination of need for Chest X-ray or other imaging depends on other history and physical exam findingsPA X-ray: x-rays enter through the posterior (back) aspect of the chest and exit out of the anterior (front) aspect of the chest)AP X-ray: x-rays enter through the anterior (front) aspect of the chest and exit out of the posterior (back) aspect of the chest: AP films are harder to interpret and are used in special situations; like a patient who cannot get out of bedThe most common cause for obtaining a chest x-ray at night was an Acute Respiratory Illness. Definition: "One or more of the following: cough, sputum production, chest pain, or dyspnea (with or without fever)Determination of need for Chest X-ray or other imaging depends on other history and physical exam findings. Use high level of suspicion. Some studies showed “clinical history and physical exam were poor predictors of radiography-detected abnormality”In hospitalized patients common causes of acute respiratory illness include: Pneumonia, Pneumothorax , and Pulmonary Edema
6 Components of a PA Chest X-Ray Inclusive of following structures:Both lung apicesBoth costophrenic anglesMid-thoracic vertebral bodies, centered on filmLeft retro-cardiac pulmonary vesselsGo Over Anatomy with residents; allow questionsTechnical considerations:Arms must be elevated to prevent scapula from obscuring lung fields (PA film) and upper arms from obscuring chest (lateral film)
7 PA Chest X-Ray: Anatomic Correlation Choose different residents to point out landmarks on this filmGo over correlation at bottom with residents
8 Lateral Chest X-ray: Anatomic Correlation Go over anatomy with residents
9 Approach to Interpretation of Chest X-ray: “Top to Bottom” AAirway:Evaluate Trachea and thoracic inlet (should be centrally located)LLungs:Look at expansion and inspiratory effort (should be able to count 11 ribs)Look for opacities, consolidation, fissures, fluid, air bronchogramsCompare the right and left lungHHeart and Large Vessels:Evaluate heart size and shapeEvaluate the location and prominence of vesselsDDiaphragm:Look at elevation bilaterallyEvaluate for free air underneathBBones:Look for fractures and deformitiesEvaluate bone densityUUpper Abdomen:Look for stomach bubbleEvaluate liver sizeEach person should come up with a consistent approach to reading chest X-rays; one commonly used method is Top to BottomAnother is the Mnemonic “ ABCDEFGH”A: AirwayB: BoneC: Cardiac SilhouetteD: DiaphragmE: Empty Space or EffusionF: Fields (Lungs)G: Gastric BubbleH: Hilar area/Hardware
10 Lobes and FissuresGo over anatomy of Lobes on Chest X-ray with ResidentsEvaluation of the lobes and fissures allows you to localize the pathologyLULRULLULRULRMLRLLRMLLLLRLLLLLLeft Lateral ViewRight Lateral View
11 Case # 14 year old male with 2 weeks of cough, rhinorrhea and a one day history of tactile fevers, brought to the emergency department for increased WOB and hypoxia.Vitals Temp 38.8 HR 130 RR 40 BP 101/50 Pulse Ox 92%What are the top three diagnoses on your differential?Is it appropriate to obtain a Chest X- ray in this situation?What factors would support obtaining a Chest X-ray?What factors would deter you from obtaining a Chest X-ray?Only click once; on second and third click arrow and explanation of chest –xray come in (before arrow comes in)Top Diagnostic Considerations:Viral pneumonia – typically have URI symptoms (coryza, conjunctivitis, body aches, sick contacts), bilateral findings on auscultation can have focal areas of atelectasisBacterial pneumoniacommunity acquired - abrupt onset usually following an URI, with fever, toxicity, cough (productive), tachypnea, crackles, retractions, nasal flaringAtypical - myalgias, fever, malaise, headache, dry coughReactive Airways Disease- can also have focal areas of atelectasisDiscuss the Pros and Cons of obtaining a Chest X-ray;In discussion emphasize that pneumonia is a clinical diagnosis. Tachypnea is a very sensitive marker for pneumonia. If there are focal findings on exam, especially in the setting of fever and hypoxia, the diagnosis can be made.Other items to consider: duration of symptoms, URTI vs LRTI symptoms, PE findings, exposure to radiation, etc. Acute respiratory illness involves one or more of the following: cough, sputum production, chest pain, or dyspnea (with or without fever).2. Is it appropriate to obtain a Chest X-ray in this situation?Yes-- this patient is showing signs of an acute change in respiratory illness with worsening symptoms concerning for worsening disease--commonly a bacterial infection superimposed on a previous viral infection3. What factors would support obtaining a Chest X-ray?Hypoxia, new onset fever and history of viral upper respiratory infection, increased work of breathing4. What factors would deter you from obtaining a Chest X-ray?Patient is too unstable (respiratory failure requiring a higher degree of respiratory care); patient is stable with clinical signs of pneumonia or reactive airway diseaseLobar consolidationWhat Do You See?
12 Radiographic Findings in Pneumonia Air bronchograms = most correlativeNew or worsening lung opacitiesAsymmetric focal findingsInterstitial disease, especially in viral or atypical pneumoniaCavities, indicative of necrotizing pneumoniaHere are some common findings on chest x-ray when pneumonia is present. Again, emphasize that pneumonia is a clinical diagnosis. There can be a short lag period (12-24 hours) during which symptoms are present but the x-ray is normal. Also, findings on x-ray for uncomplicated bacterial pneumonia may take 4-6 weeks to resolve.
13 Air Bronchograms Indicates airspace disease Visualized when an air-filled bronchus is surrounded by opacified alveoliCan be seen with :pulmonary consolidationpulmonary edemanon-obstructive atelectasissevere interstitial diseaseneoplasmpulmonary infarctionnormal expirationPoint out air bronchograms; Emphasize no all air bronchograms are pneumonia
14 Viral Pneumonia Atypical Pneumonia Common Findings in other types of pneumonia:Viral pneumonia tends to appear as more diffuse, interstitial disease on chest x-ray.Atypical pneumonia also tends to appear as interstitial disease, but the infiltrates may be more discrete and patchy.Viral PneumoniaAtypical Pneumonia
15 Atelectasis Volume loss with displacement of fissures White out of lobe or lungIf large volume of lung involved, may get elevation of hemi- diaphragm and displacement of mediastinal structuresRadiographic findings resolve within hours to daysAtelectasis refers to the incomplete collapse of air-bearing tissue. It can be caused by compression of lung structures, either intra- or extra-luminally. Several factors predispose to atelectasis, including decreased lung compliance, chronic lung disease, scoliosis, and cystic fibrosis.Patients with atelectasis commonly have dyspnea, tachycardia, and hypoxia. Some may have fever, or be asymptomatic.Atelectasis is treated by encouraging cough (with or without device), incentive spirometry, chest physiotherapy, other airway clearance therapy. For those with assisted ventilation, increasing positive pressure may help.
16 Complications of Pneumonia on Chest X-ray Pulmonary Effusion: commonly occurs in setting of bacterial pneumonia, may be sterile or purulent (those with purulent effusions tend to look more toxic). This diagnosis is established by physical exam and supported by plain radiographs. Lateral decubitus films can help determine if the fluid is loculated or free-flowing. There are times when an x-ray does not provide all of the information that is needed to make management decisions. Ultrasound can help determine the location, quantity, and quality of the fluid. It can also help identify the optimal location for chest tube placement.Empyema: develop as a sequela to purulent effusions and typically do not layer out on lateral decubitus films. For more detailed information about the lung parenchyma and the empyema, a CT scan can be helpful.EmpyemaAppears as solid white consolidate that blunts the costophrenic angleMay not layer out on lateral decubitusPleural EffusionAppears as white density within lung fieldIf not loculated, will layer out on lateral decubitus film
17 Lateral Decubitus Assess volume of pleural effusion Determine if effusion is mobile or loculatedNote layering of fluid; in a loculated effusion; no layering will be noted
18 Case # 212 year old tall thin male admitted overnight for monitoring after having a complicated eye surgery.3 Hours into your shift you receive a consult from Ophthalmology to evaluated the patientHe is complaining of a sharp, persistent chest pain and shortness of breath. You note on exam long fingers and thin skinWhat are the top three diagnoses on your differential?Is a Chest X-ray Indicated?Should it be ordered routine or stat?Top diagnostic considerations: pneumothorax, pleural effusion, and aortic dissection2. Is the Chest X-ray indicated? Chest x-ray is definitely indicated as some of the considerations are true medical emergencies—this patient is showing signs of an acute change in his respiratory status and given his other clinical features there is a significant concern for Marfans and possible aortic dissection3. Should it be ordered routine or stat? The x-ray should be ordered stat as the patient can deteriorate rapidly depending on the size of the pneumothorax and a dissection is a medical emergencyWhat Do You See: Discuss PneumothoraxNote the lung is removed from borders of the pleural cavity and the Area of lucency around diaphragmWhat Do You See?
19 Pneumothorax on Chest X-ray Consider if the X-ray is supine or erectSupineAir tends to accumulate in the posterior chest wallMay appear near diaphragm firstErectAir accumulates near the apicesPneumothorax occurs when there is air in the pleural space. Chest x-rays can determine the presence and amount of air with good accuracy. Type of film and position of patient will determine where the air is localized and visualized on chest x-ray.
20 Take Home PointsA chest x-ray is a simple test that can be used in the diagnosis of many diseases.Pneumonia is a clinical diagnosis. Chest x-ray can be a useful tool to support the diagnosis and identify complications.When pneumothorax is suspected, chest x-ray should be obtained to determine its size and location and help guide management decisions.
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22 ReferencesSwischuk,E. Leonard. Emergency Imaging of the Acutely Ill or Injured Child. Lippencot Williams and Wilkins: Philidelphia, PA Pages 71-88Behrman, Kliegman, Jenson. Nelsons Textbook of Pediatrics 17th edition. Atelectasis ppKoumbourlis, AC. Albert Einstein College of Medicine, and Division of Pulmonary Medicine. Schneider Childrens Hospital, New Hyde Park, New York. Scoliosis and the Respiratory System. Paediatric Respiratory Review Jun: 7(2): Epub Jun 2Schechter, MS. Airway Clearance Applications in infants and children. Respiratory Care October: 52(10):Ilrena M. Tocino, M.D. Pneumothorax in the Supine Patient: Radiographic Anatomy. Radiographics Tocino 5 (4):Byung Gil Choi, MD. Seog Hee Park, MD. Eun Hee Yun, MD. Kyung Ok Chae, MD. Kyung Sub Shinn, MD Pneumothorax Size:Correlation of Supine Anteroposterior with Erect Posteroanterior Chest Radiographs. Radiology 1998; 209:Dick, Elizabeth, specialist registrar in radiology, North Thames Deanery. Chest Xrays Made Easy. studentBMJ 2000;08: September ISSNDurbin, WJ and Stille, C Pneumonia. Pediatr. Rev. 2008; 29;Zaoutis, LB, Chiang, VW. Comprehensive Pediatric Hospital Medicine, Philadelphia, Elsevier.Kliegman, RM, Behrman, RE, Jenson, HB, Stanton, BF. Nelson Textbook of Pediatrics, Philadelphia, Elsevier.
23 ReferencesACR Practice Guideline for the Performance of Pediatric and Adult Chest Radiography. RevisedAcute Respiratory Illness. ACR Appropriateness Criteria. RevisedFever Without Source—Child. ACR Appropriateness Criteria. RevisedCongestive Heart Failure. ACR Appropriateness Criteria. RevisedDurbin, WJ and Stille, C Pneumonia. Pediatr. Rev. 2008; 29;Zaoutis, LB, Chiang, VW. Comprehensive Pediatric Hospital Medicine, Philadelphia, Elsevier.Kliegman, RM, Behrman, RE, Jenson, HB, Stanton, BF. Nelson Textbook of Pediatrics, Philadelphia, Elsevier.Pediatric Hospital Medicine Education Resource Page: