“Must Know” chest RADIOGRAPH Radiology Joanna R. Fair, M.D., Ph.D. Vice Chair of Education Department of Radiology Many slides courtesy of UNM Radiology faculty and Petra Lewis, M.D. Associate Professor of Radiology Dartmouth Medical School

Objectives Review normal chest radiograph anatomy Describe findings of common emergent diagnoses on chest radiographs Identify proper and improper positioning of tubes and lines on chest radiographs

Normal Anatomy

Chest radiograph scan pattern “ABCDE” Airway Trachea R/L main bronchi Bones Shoulders Spine Ribs Cardiac Diaphragm and all below Everything else = Lungs B B A E E A A B C B B D

Chest radiograph scan pattern “ABCDE” Airway Trachea Bones Spine Sternum Cardiac Diaphragm and all below Everything else = Lungs A B B C E D

Common ER Diagnoses on Chest Radiographs

Where is the abnormality? No abnormality Left lung Right lung

Where is the abnormality? No abnormality Left lung Right lung

Lingular pneumonia

Silhouette sign Silhouette sign with diaphragm Well defined right lung opacity Surrounded by air Silhouette sign with diaphragm Silhouette sign with heart

Middle lobe pneumonia

The BEST interpretation of this CXR is: Normal Emphysema Left lower lobe pneumonia Pulmonary edema Interstitial edema

The BEST interpretation of this CXR is: Normal Emphysema Left lower lobe pneumonia Pulmonary edema Interstitial edema Kerley B lines

Interstitial pulmonary edema Distension/blurring of upper lobe pulmonary veins Peribronchial cuffing/indistinct hilar “fuzziness” Kerley B lines Pleural effusions +/- Enlarged cardiac silhouette

Baseline

- Enlarged cardiac silhouette - Superior redistribution of vessels - Early interstitial edema (See next image for close-up)

Baseline Early CHF Vascular redistribution to upper lobes. Fuzzy vessels Sharp vessels Sharp vessels Baseline Early CHF Vascular redistribution to upper lobes. Vessels less distinct, larger caliber.

CHF with lymphatic engorgement: Kerley B lines Another patient with CHF Mag of RLL

Interstitial & alveolar pulmonary edema.

The MOST likely dx is: A. Pneumonia B. Pulmonary hemorrhage C. Pulmonary edema D. Aspiration E. ARDS Pulmonary edema but could be any

The MOST likely dx is: A. Pneumonia B. Pulmonary hemorrhage C. Pulmonary edema D. Aspiration E. ARDS Pulmonary edema but could be any Could be any of these!

Bilateral Airspace Opacification Edema Pneumonia/aspiration Hemorrhage ARDS Unusual conditions such as alveolar proteinosis

Asymmetric pulmonary edema

Pulmonary hemorrhage goodpastures

ARDS

Pneumonia (aspiration)

Best diagnosis for the LEFT thorax is: Pleural effusion Hydropneumothorax Pneumonia Atelectasis Left hydropneumothorax

Best diagnosis for the LEFT thorax is: Pleural effusion Hydropneumothorax Pneumonia Atelectasis Left hydropneumothorax

Pleural Effusions Best seen on CT or ultrasound CXR: Lat > PA upright > AP supine Confirm presence/mobility with ipsilateral decubitus film/US Horizontal line = air/fluid level = hydropneumothorax Supine Diffuse ground glass opacity lower zones Diaphragm obscured Very large effusions  mass effect

Pleural Effusions Huge left pleural effusion,.supine left effusion

Pleural Effusions Decub view s PA Left effusion Left lateral decubitis

What is the MOST likely diagnosis? Left pneumothorax Right pneumothorax Left lower lobe pneumonia Right lower lobe pneumonia Right pneumothorax

What is the MOST likely diagnosis? Left pneumothorax Right pneumothorax Left lower lobe pneumonia Right lower lobe pneumonia Right pneumothorax

Pneumothorax Expiratory or upright or lateral decubitus film more sensitive White line with absent lung markings distally Apex on upright film Play with contrast/brightness Skin folds may confuse Look for signs of tension

Pneumothorax inspiratory/expiratory films Inspiratory –expiratory pair (expiratory on right) left ptx. Notice how the expiratory film shows the ptx better Inspiratory Expiratory Easier to see

BEST diagnosis for the RIGHT is: Middle lobe pneumonia Tension pneumothorax Upper lobe atelectasis Aortic rupture Right tension ptx

BEST diagnosis for the RIGHT is: Middle lobe pneumonia Tension pneumothorax Upper lobe atelectasis Aortic rupture Right tension ptx

Tension pneumothorax Medical emergency Often total lung collapse Pneumothorax plus Mediastinal shift Diaphragmatic depression Hypotension, pulsus paradoxus, hypoxia

Tension pneumothorax

Trauma film. Your most IMMEDIATE concern would be for: Left lower lobe pneumonia Fractured clavicle Left pleural effusion Aortic injury Case courtesy of Dr Andrew Dixon, Radiopaedia.org, rID: 31553

Trauma film. Your most IMMEDIATE concern would be for: Left lower lobe pneumonia Fractured clavicle Left pleural effusion Aortic injury Case courtesy of Dr Andrew Dixon, Radiopaedia.org, rID: 31553

Mediastinal Hematoma Wide mediastinum Left apical pleural cap Abnormal aortic contour Deviation of trachea or NGT to right

Where is all that air? subQ emphysema pneumomediastinum possible pneumothorax

Lines and tubes

Which of these lines is NOT inserted correctly? Dobhoff (feeding) tube ET tube PICC line Subclavian line

Which of these lines is NOT inserted correctly? Dobhoff (feeding) tube ET tube PICC line Subclavian line

NG tube Incorrect Coiled in esophagus Correct Tip and side port below GE junction Incorrect Coiled in esophagus

Dobhoff (feeding) tube Correct Tip in duodenum Tip in stomach (may be OK) Must be below GE junction; prefer duodenum

Dobhoff (feeding) tube Dobhoff both main bronchi Dobhoff tip in esophagus Incorrect In both main bronchi Incorrect Tip in distal esophagus

Central line Correct Right IJ tip mid-distal SVC Incorrect Normal right IJ; LIJ in aorta, Correct Right IJ tip mid-distal SVC Incorrect Left IJ in aorta

Central line Incorrect IJ into right subclavian Incorrect PICC coiled Right subclav in IJ Incorrect IJ into right subclavian Incorrect PICC coiled

Right subclavian line placement What happened here? Right subclavian line placement with PTX

Chest tube Chest tube OK Side port inside thorax Chest tube ports outside thorax Chest tube OK Side port inside thorax Side port outside thorax

ET tube ETT position OK Best at level of aortic arch Incorrect ETT normal ETT RMB ETT position OK Best at level of aortic arch Incorrect In right main bronchus

Line placements: Summary NG Both ports in stomach Dobhoff tube Tip must be below GE junction, pref. in duodenum ET Few cm above carina in adult At level of aortic arch

Line placements: Summary (2) PICC/IJ/SCV Tip in distal SVC Chest tubes Both ports in chest Basal and posterior for effusions Anterior and apical for ptx

Radiology Ordering Tips More history = better interpretation Radiologists available 24/7 (check AMION) Call with ?s about protocols or interpretations Some studies (nuc med, fluoroscopy, IR) require a phone call if after hours or on weekends