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

3. 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

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

5. 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)

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

8. Density – the key to x ray films

9. Normal chest X ray

10. Bacterial and Aspiration Pneumonia

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

12. 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”

13. Tip of ETT Carina T1 T2 T3 T4

14. Practice

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

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

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

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

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

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

21. Bonus – Look at the ET tube balloon

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

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

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

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

26. 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)

27. Appropriately placed IJ line?

28. 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

29. Which side is arterial, which is venous?

30. 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

31. Finding the tip can often feel like this

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

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

35. Arterial PICC

36. PICC Line Radiograph: Appropriate position or not?

37. 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!

40. Look at the carina