Presentation is loading. Please wait.

Presentation is loading. Please wait.

Night Float Module Interpretation of Chest Radiographs

Similar presentations


Presentation on theme: "Night Float Module Interpretation of Chest Radiographs"— Presentation transcript:

1 Night Float Module Interpretation of Chest Radiographs
National Pediatric Nighttime Curriculum Written by LaToya S. Barber, MD and Francine D. Bynum, MD Childrens Hospital Los Angeles

2 Goals And Objectives Develop a comprehensive approach to reading chest x-rays Identify the following conditions on chest x-ray pneumonia and its complications pneumothorax atelectasis Describe two radiographic features for both pneumonia and pneumothorax ACGME Pediatric Milestones: Pediatric Core Competencies: Develop a comprehensive approach to reading Chest X-rays: Pediatric Milestone A. Patient Care and B. Medical Knowledge Pediatric Core Competencies Pneumonia, Radiographic Interpretation, Evidence Based Medicine Identify the following conditions on chest X-ray Pediatric Milestone B. Medical Knowledge and C. Practice based learning and improvement Pediatric Core Competencies Pneumonia, Radiographic Interpretation Describe two radiographic features for both pneumonia and pneumothorax

3 Case # 1 4 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 min Move on; this case will be re-visited later

4 Case # 2 12 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 patient He is complaining of a sharp, persistent chest pain and shortness of breath. On exam, you note long fingers and thin skin What 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 min Move on; this case will be re-visited later

5 Chest Radiography Proven and useful tool for the evaluation of…
Airways, lungs, pleura, and chest wall Heart, pulmonary vessels, and mediastinum Most common type is posteroanterior (PA) Anteroposterior (AP) and lateral films also common The most common cause for obtaining a Chest X-ray at night is 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 PA 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 bed The 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 apices Both costophrenic angles Mid-thoracic vertebral bodies, centered on film Left retro-cardiac pulmonary vessels Go Over Anatomy with residents; allow questions Technical 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 film Go 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 bronchograms Compare the right and left lung HHeart and Large Vessels: Evaluate heart size and shape Evaluate the location and prominence of vessels DDiaphragm: Look at elevation bilaterally Evaluate for free air underneath BBones: Look for fractures and deformities Evaluate bone density UUpper Abdomen: Look for stomach bubble Evaluate liver size Each person should come up with a consistent approach to reading chest X-rays; one commonly used method is Top to Bottom Another is the Mnemonic “ ABCDEFGH” A: Airway B: Bone C: Cardiac Silhouette D: Diaphragm E: Empty Space or Effusion F: Fields (Lungs) G: Gastric Bubble H: Hilar area/Hardware

10 Lobes and Fissures Go over anatomy of Lobes on Chest X-ray with Residents Evaluation of the lobes and fissures allows you to localize the pathology LUL RUL LUL RUL RML RLL RML LLL RLL LLL Left Lateral View Right Lateral View

11 Case # 1 4 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 atelectasis Bacterial pneumonia community acquired - abrupt onset usually following an URI, with fever, toxicity, cough (productive), tachypnea, crackles, retractions, nasal flaring Atypical - myalgias, fever, malaise, headache, dry cough Reactive Airways Disease- can also have focal areas of atelectasis Discuss 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 infection 3. What factors would support obtaining a Chest X-ray? Hypoxia, new onset fever and history of viral upper respiratory infection, increased work of breathing 4. 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 disease Lobar consolidation What Do You See?

12 Radiographic Findings in Pneumonia
Air bronchograms = most correlative New or worsening lung opacities Asymmetric focal findings Interstitial disease, especially in viral or atypical pneumonia Cavities, indicative of necrotizing pneumonia Here 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 alveoli Can be seen with : pulmonary consolidation pulmonary edema non-obstructive atelectasis severe interstitial disease neoplasm pulmonary infarction normal expiration Point 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 Pneumonia Atypical Pneumonia

15 Atelectasis Volume loss with displacement of fissures
White out of lobe or lung If large volume of lung involved, may get elevation of hemi- diaphragm and displacement of mediastinal structures Radiographic findings resolve within hours to days Atelectasis 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. Empyema Appears as solid white consolidate that blunts the costophrenic angle May not layer out on lateral decubitus Pleural Effusion Appears as white density within lung field If not loculated, will layer out on lateral decubitus film

17 Lateral Decubitus Assess volume of pleural effusion
Determine if effusion is mobile or loculated Note layering of fluid; in a loculated effusion; no layering will be noted

18 Case # 2 12 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 patient He is complaining of a sharp, persistent chest pain and shortness of breath. You note on exam long fingers and thin skin What 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 dissection 2. 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 dissection 3. 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 emergency What Do You See: Discuss Pneumothorax Note the lung is removed from borders of the pleural cavity and the Area of lucency around diaphragm What Do You See?

19 Pneumothorax on Chest X-ray
Consider if the X-ray is supine or erect Supine Air tends to accumulate in the posterior chest wall May appear near diaphragm first Erect Air accumulates near the apices Pneumothorax 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 Points A 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.

21 Thank You! Please tell us what you like and dislike about this module! Your anonymous feedback will help us continue to improve this curriculum. https://www.surveymonkey.com/s/Feedba ck-on-Modules

22 References Swischuk,E. Leonard. Emergency Imaging of the Acutely Ill or Injured Child. Lippencot Williams and Wilkins: Philidelphia, PA Pages 71-88 Behrman, Kliegman, Jenson. Nelsons Textbook of Pediatrics 17th edition. Atelectasis pp Koumbourlis, 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 2 Schechter, 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 ISSN Durbin, 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 References ACR Practice Guideline for the Performance of Pediatric and Adult Chest Radiography. Revised Acute Respiratory Illness. ACR Appropriateness Criteria. Revised Fever Without Source—Child. ACR Appropriateness Criteria. Revised Congestive Heart Failure. ACR Appropriateness Criteria. Revised Durbin, 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:


Download ppt "Night Float Module Interpretation of Chest Radiographs"

Similar presentations


Ads by Google