Abnormal CXR Flashcards
Identify the main “things” to look at when looking at a CXR.
A Airway B Breathing (i.e. lungs) C Cardiac (heart) D Diaphragm E External Structures & Equipment F Fat & soft tissue G Great vessels H Hidden areas
What are possible abnormalities in the airway on a CXR?
- Endotracheal tube too close to the carina (i.e. needs to be withdrawn)
- Mediastinal shift (i.e. trachea moves to one side)
- Angle of the bronchi increased by pressure from enlarged lymph nodes (Sarcoid, Tumour) or by local tumour.
What are possible pathologies which may lead to mediastinal shifts ?
Pathologies pushing mediastinum AWAY:
- Too black = tension pneumothorax
- Too white = massive pleural effusion (or any mass effect, i.e. effect of a growing mass that results in secondary pathological effects by pushing on or displacing surrounding tissue e.g. tumour)
Pathologies pulling mediastinum TOWARDS
-Too white = Atelectasis (=lobar collapse, i.e. something obstructing a main bronchus, no air can get into the lung, lung shrivels up and pulls mediastinum towards it), or pleural fibrosis, or pneumonectomy/lobectomy
Give the CXR appearance of a pneumothorax.
- Black on one side
- Mediastinal shift away from blacker area
- Visceral pleural line, with no lung markings seen peripheral to this line (abnormal)
What are possible causes of pneumothorax ?
Penetrating chest injury
Iatrogenic (e.g. dialysis central line)
What signs of pneumothorax would you find upon clinical examination ?
- Inspection: Chest pain, diminished respiratory rate (and shortness of breath), possibly cyanosed
- Palpation: Limited expansion on the R inside of the pneumothorax
- Percussion: Hyper resonance
- Auscultation: Decreased breath sounds on the right
What are possible abnormalities in breathing (i.e. lungs) on a CXR ?
1) Consolidation (i.e. opacification due to replacement of normal air space gas with fluid or solid material).
- Characteristic sign of consolidation is air bronchogram (i.e. large airways are spared so become visible (black) against the white background)
2) Atelectasis
Some opacification, mediastinal shift (TOWARDS) and a loss of V (dragging diaphragm/fissures superiorly)
3) Pleural effusion
Mediastinal shift AWAY, lower zone uniformly white (on one side or the other), concave upper border (meniscus), no evidence of air bronchograms
4) Asbestos Exposure
- Calcified plaque (not malignant itself) on pleural cavity
- Mesothelioma (present as pleural effusion, but with holly leaf opacification)
5) Pneumothorax
- Black on one side
- Mediastinal shift away from blacker area
- Visceral pleural line, with no lung markings seen peripheral to this line (abnormal)
What are the clinical findinds of pneumonia ?
Inspection: Productive cough Fever Shortness of breath Tachycardia
Percussion: Dull to percussion over the left lower lung
Auscultation: breath sounds are harsh
What are the main substances of consolidation ? What causes each ?
Pus - infection (pneumonia) Blood - Pulmonary haemorrhage Fluid - Pulmonary oedema, drowned lung Cells - Lung cancer Protein - Alveolar proteinosis
How do we know which lobe is affected by consolidation ?
On L side:
- L heart border clearly defined then LLL (opacification lower than that)
- If opacification directly adjacent to L heart margin, causing blurring of heart border then LUL (/lingula)
On R side:
- If opacification above horizontal fissure, RUL
- If opacification directly adjacent to R heart margin, causing blurring of heart border then RML
- If opacification lower than RUL and does not cause blurring of heart border, then RLL
What might we be unsure of the location of the consolidation ?
What can we do to figure out which lobe is affected ?
Due to the presence of the oblique fissure on the R lung (so can have UL anteriorly but LL posteriorly)
By using a lateral X Ray
Can we know the substance in a consolidation based on the CXR ?
No, but possibly have a guess using patient history
Distinguish atelectasis from consolidation.
Consolidation involves opacification
Atelectasis involves some opacification, mediastinal shift (TOWARDS) and a loss of V (dragging diaphragm/fissures superiorly)
What are the clinical findings of consolidation ?
- Dull to percussion
- Increased vocal resonance
- Bronchial breathing
Define atelectasis. Which features of a CXR may hint at an atelectasis ?
Reduction in inflation of all or part of the lung.
Suspect this on X-ray if:
-Volume loss
-Some opacification
-Displacement of trachea
-Displacement of diaphragm (raised)
-Displacement of lung fissures (superiorly)
-Compensatory over inflation of non collapsed lung (blacker)
-Crowding of vessels & bronchi
Often do not have all abnormalities, but some.