Intro to Chest imaging Matthew Bentz, MD OHSU Diagnostic Radiology Assistant Professor 2015

Objectives Remember your search pattern and use it on every CXR Learn appropriate positioning of ET tubes and central lines List the six commonly encountered radiographic patterns on CXR

Concepts 1)Density differences form the image 2)Pattern and distribution are key 3)Diffuse versus focal reflects systemic versus local 4)Wide mediastinum

Concept #1 Organ boundaries are seen only when the densities are different between the tissues – Pulmonary vessels are sharply seen in normal lungs (Soft tissue – air interface) – Airways are not seen in normal lung (Air – Air interface)

Tissue Appearance on Radiographs The Contrast in Densities is Essential Air Fat Densities Water/tissue Bone Metal

Density – the key to x ray films

Normal chest X ray

Bacterial and Aspiration Pneumonia

More airways are visible due to the increased density of the pneumonia

ETT Position Ideal is 3-4 cm above carina – Carina located ~ T6 Position ETT between T4 and T6 ETT Tube follows the chin (up / down) – “The Hose goes with the Nose”

Tip of ETT Carina T1 T2 T3 T4

Practice

A.High B.Low C.Just Right D.Not in the trachea E.They aren’t intubated

A.High B.Low C.Just Right D.Not in the trachea E.They aren’t intubated

A.High B.Low C.Just Right D.Not in the trachea E.They aren’t intubated

A.High B.Low C.Just Right D.Not in the trachea E.They aren’t intubated

A.High B.Low C.Just Right D.Not in the trachea E.They aren’t intubated

A.High B.Low C.Just Right D.Not in the trachea E.They aren’t intubated

Bonus – Look at the ET tube balloon

A.High B.Low C.Just Right D.Not in the trachea E.They aren’t intubated

A.High B.Low C.Just Right D.Not in the trachea E.They aren’t intubated

A.High B.Low C.Just Right D.Not in the trachea E.They aren’t intubated

A.High B.Low C.Just Right D.Not in the trachea E.They aren’t intubated

Central lines Our perspective on most central lines – Is it central? Yes = good – Is it flopping around hitting the AV Valve? Yes = bad – Close to the CavoAtrial Junction (CAJ) is fine – CAJ landmarks About 2 cm below the bulge of the right atrial appendage About 2 vertebral bodies below the carina (better for peds)

Appropriately placed IJ line?

Subclavian artery vs vein The subclavian vein is below the clavicle The subclavian artery may extend above the clavicle So if a subclavian line goes above the clavicle (on a technically good CXR), you must have a high suspicion that it is arterial

Which side is arterial, which is venous?

PICC lines Goal for the tip is the same, i.e. central Make sure it doesn’t take a wrong turn! – Make sure to look at the arms and neck

Finding the tip can often feel like this

If you truly can’t see the tip, repeat the film in a different position

Do not assume it’s ok if you don’t see it

Arterial PICC

PICC Line Radiograph: Appropriate position or not?

Feeding tubes Make sure they travel downward along the midline Should terminate below the diaphragm Make sure to locate the proximal sidehole Look at the carina!

Look at the carina