7. Chest X-ray abnormalities, scintigraphy, ultrasound

Question 1

CXR findings suggestive of Thoracic emergencies

Answer 1

1. Tracheal or mediastinal deviations [Tension PTX, Large hemothorax or Pleural effusion, Aortic dissection]
2. Multiple Rib fractures [Flail chest]
3. Increased cardiothoracic ratio [Large pericardial effusion, Cardiac tamponade]
4. Mediastinal widening [Aortic aneurysm, Aortic dissection]
5. Westmark sign and/or Hampton hump [PE]
6. Hemidiaphragm depression [Tension PTX]
7. Abrupt radiolucency and decreased lung markings [Tension PTX]
8. Subdiaphragmatic free gas [GI perforations or post laparoscopy]
9. Bilateral diffuse opacities, Kerley B lines and increased lung markings [PE]

Question 2

Main types of pathologic changes on CXR

Answer 2

1. Masses
2. Consolidations
3. Covering/Shadowing
4. Free air

Question 3

Hazy or cloudy inflitrations/cosolidations on the X-ray - Radiopaque or less transparent than surrounding lung and can involve small or large areas and entire lobes, unilateral or bilateral

Answer 3

Pulmonary infiltrates caused by Pneumonia, TB, ILD, Lobar Pneumonia

Question 4

Covering or shadowing/whitening of small or large areas of chest such that sinuses or lung marking not visible, if covering almost entirety of chest then shifting of trachea or midline structures to unaffected side may also be seen

Answer 4

Pleural effusions or hemothorax caused from CHF, pneumonia, mesothelial cancers, pleuritis or pleural infections

Question 5

Absence of lung markings uni or bilaterally, increased intracostal distance, shifting of mediastinum to unaffected side

Answer 5

Tension Pneumothorax

Question 6

homogenous shadowing covering half or more than half of a wall, no visible sinuses or lung markings, the visible radiolucent area show a flat horizonatal line separating homogenous shadow and radiolucent part

Answer 6

Pneumothorax + Pleural effusion [Nevo line]

Question 7

Nevo line + Mediastinum/central structures shift to affected side + no lung markings on radiolucent area

Answer 7

Atelectasis + Pleural effusion + Pneumothorax, could be caused by central tumours or pneumectomy and post surgical fluid accumulation in pleural space

Question 8

No nevo line, homogenous consolidation follows chest wall and has no horizontal separation lines and lung consolidations on radiolucent area

Answer 8

Hydrothorax

Question 9

Basket sign mass within homogenous consolidation

Answer 9

Lung Abscess

Question 10

Solitary or multiple, varying size homogenous mass, round or irregular shaped

Answer 10

Tumour masses

Question 11

Widening of mediastinum and hilar area consolidations

Answer 11

Hilar lymphadenopathy from TB, Sarcoidosis, malignancy

Question 12

How do we use Scintigraphy in Pulmonology?

Answer 12

Ventilation-Perfusion Scan [V/Q scan]
- Used to assess the matchin of ventilation and perfusion in lungs
- Inhaled radionuclides to detect ventilation and IV radionuclides to detect perfusion
- In suspected PE [but current standard is CT with contrast], chronic thromboembolic Pulmonary HTN, evaluation of lung function

Gallium Scintigraphy
- Assessing pulmonary infections and Inflammatory lung diseases

Technetium Scintigraphy
- Lung Cancer staging, lung diseases, detect abnormalities in function

Question 13

How is Ultrasound used in Pulmonology?

Answer 13

1. Examine pleural spaces
2. Evaluate diaphragm function
3. US guided biopsy for lung lesions or lymph nodes
4. Endobronchial US used with bronchoscopy to locate masses and enlarged lymph nodes
5. Echocardiography to note chronic pulmonary HTN [not routinely done], for ddx of chest pain and dyspnea