Abnormal CXR Flashcards
objectives
1
Q
Typical (lobar or segmental): MC type of pneumonia
A
- Pneumococcal pneumonia – Strep pneumoniae
- Infection contained within a single lobe or part of a lobe
- Affected tissue is more opaque aka infiltrate
- May contain air bronchograms
- Silhouette sign: helps localize the lobe
- Airspace dz, fluffy, cloudlike, indistinct borders
2
Q
Bacterial Pneumonia
A
- Typically lobar, single consolidation
3
Q
Bad Lobar Pneumonias: worse bacterial pathogens = bronchopneumoina
A
- Staph aureus …. Also gram negative bacteria (klebsiellae and pseudomonas)
- Patchy airspace dz involving several segments of lung, exudate may fill bronchi so may not have air bronchograms
- How to dx:
- Sputum gram stain
- Blood cultures
- PCR for respiratory viruses
- Legionella urinary antigen
4
Q
Air Bronchogram
A
- normally you can’t see airways>> as they get more stuff on the outside (consolidation) you can see the air going through the airway
5
Q
Atypical Pneumonia: “walking”
A
- MC mycoplasma pneumoniae
- No focal consolidation like bacterial, more diffuse and patchy
- Fine, reticular interstitial pattern in lungs
6
Q
Atypical: PCP/PJP: always multi-lobar
A
- MC infection in pts with AIDS
- Fine, reticular interstitial pattern in lungs
7
Q
Tuberculosis
A
- Parenchymal lung disease with Cavitary lesion
- CXR of active TB:
- Classic: focal infiltration of upper lobes (apical/posterior) or lower lobe (apical/superior)
- Can be unilateral or bilateral
- Cavitation may be present and inflammation/tissue destruction causing fibrosis
- Caseous granulomas
- Enlargement of hilar and mediastinal lymph nodes
8
Q
Pleural effusion
A
- fluid trapped between visceral and parietal pleura
- Normally contains 5-20 mL of pleural fluid
- The rate of formation may be increased due to
- inc hydrostatic pressure- Left HF
- dec colloid osmotic pressure- hypoproteinemia
- inc capillary permeability- infection
- The rate of resorption can decrease by:
- Decreased absorption of fluid by lymphatics- tumor
- The rate of formation may be increased due to
- Normally contains 5-20 mL of pleural fluid
9
Q
pleural effusion etiology
A
- Etiology: cbc, protein and LDH level inc (get serum sample), gram stain, cytology
- Transudates: bilateral, low protein low LDH
- CHF MCC
- Cirrhosis
- Nephrotic syndrome
- Exudates: unilateral, inc protein, inc LDH
- Malignancy and infection MCC
- Contains frank pus = empyema
- Rheumatic dz can cause bilateral or unilateral –older ppl
- Transudates: bilateral, low protein low LDH
10
Q
free pleural effusion
A
- You can see a meniscal line with free pleural effusions
- Will have blurred costophrenic angles most of the time; will be white
- The fluid will move with gravity when a lateral decubitus is taken.
- You may need a lateral view to see the small effusion in the posterior mediastinum
11
Q
loculated pleural effusion
A
- can mimic pneumonia/consolidation
- When you get a lateral decubitus and the fluid does not move with gravity.
- If fluid is in a position where it could not normally hold itself up – adhesions are holding it up
12
Q
CXR view for pleural effusion
A
- Lateral decubitus with affected side down
- A pleural effusion can cause an atelectatic lung where the two layers are separated by fluid so the lung decreases in size but remains its shape.
13
Q
Pneumothorax
A
Air trapped in pleural space
14
Q
pneumothorax cause
A
- Trauma/iatrogenic- through a communication in the chest wall
- Spontaneous/COPD- thorugh lung parenchyma across visceral pleura
- Copd- blebs that burst
15
Q
pneumothorax CXR
A
- look at the lining of the pleura at the periphery – they will be separated
- Absence of vessels outside the pleural line
- If it is a small pneumothorax, look at the apices first- up near clavicle!
- Which one?
- Expiratory Lateral decubitus with affected side up because air rises!
16
Q
Tension pneumothorax
A
- “so much air outside that is pushes everything to other side of chest”
- Positive pressure that displaces the mediastinal structures (shifts them) to the opposite side of the pneumothorax
- Impair venous return and compromise cardiopulmonary function
- Can cause cardiac arrest if venous return sucks so BP will drop
- On CXR:
- Trachea deviated
- Flattening or inversion of diaphragm w/partial or complete collapse of lung
- You need to decompress this immediately if large enough….
- Mainstay of tx: chest tube if large enough; inserted at apices since air rises
- Body can absorb the air if it is a small one.
17
Q
Hilar enlargement
A
- Hilar adenopathy: prominent hilar border that is lobulated or polycyclic in contour- GRAPES
- Aortopulmonary window is not clear
- Enlarged Lymph Nodes
- Lymph nodes have a lobular grape-cluster appearance on PA film
- Sarcoidosis most common cause: “bilateral hilar lymphadenopathy”
- Unilateral:
- Mets from bronchial CA
- Malignant Lymphoma-neoplasmas
- Infections - esp TB and Histoplasmosis
18
Q
Bronchogenic Tumors
A
- Usually presents as solitary nodule
- If metastatic dz to lungs: multiple nodules
- Four types:
- Squamous cell carcinoma
- Central growing, in bronchi
- Adenocarcinoma
- Bronchoalveolar cell carcinoma
- Peripheral
- Small cell: centrally
- Large cell carcinoma
- Squamous cell carcinoma
19
Q
Enlarged Pulmonary Arteries
A
- Pulmonary arteries have a branching pattern
20
Q
Discuss the characteristics that help distinguish benign from malignant solitary pulmonary nodules
A
- Calcified nodule:
- The more calcium the more radiopaque that it is going to look
- Most likely benign
- Shape:
- Irregular = bad
- Speculated border- malignancy
- Nodules/masses: more sharply marginated than airspace dz and produce clear demarcation btwn nodule and lung tissue
- Nodule < 3 cm
- Mass > 3 cm
- Malignant mass: > 5 cm
- Change in size over time =malignant
21
Q
Recognize the classic appearance of pulmonary metastases
A
- See more bilateral nodules – they can be large or small
- They can look like whatever they want no matter what type of cancer
- No size restriction/ not uniform- would be all over a lot of the time
22
Q
Severe Emphysema / COPD
A
- COPD: lung disease characterized by persistent respiratory symptoms and airflow limitations that is due to airway or alveolar abnormalities (noxious particle exposure= cigarettes)
- On CXR: hyperinflation, flattening of diaphragm, inc retrosternal air space
- Long, narrow, vertical, hanging heart
- Hyperlucency of lungs (dec markings)
- On CXR: hyperinflation, flattening of diaphragm, inc retrosternal air space
- Emphysema is destruction of the alveoli à as they are destroyed there is a pocket of dead air
- Bullae/bleb formation w/emphysema
- Radiolucent CXR – ribs may look bigger, heart may look smaller, flattened diaphragm
- More barrel chested on lateral view
23
Q
Pulmonary infarction (Hamptons Hump and Westermark sign)
A
- Pulmonary emboli
- CXR findings:
- Westermark Sign
- Truncated pulmonary artery
- Collapse of the distal vasculature creating the appearance of a sharp cut off on chest radiography.
- You are going to see this more centrally
- Hampton’s Hump
- Wedge shaped pleural based consolidation (mimics pneumonia)
- Will see a large obstruction further out into the lung
- Caused by Pulmonary Infarction associated with PE
- Wedge shaped pleural based consolidation (mimics pneumonia)
- Pleural effusion
- Elevated diaphragm
- CXR is usually normal - a normal film does NOT rule out a PE!!!
- Westermark Sign
- CXR findings:
24
Q
Interstitial Lung Disease, e.g. idiopathic pulmonary fibrosis
A
- Has discrete reticular, nodular, or reticulonodular patterns
- Usually diffuse
- No air bronchograms present
- What causes ILD:
- Pulmonary fibrosis
- Drugs/ct dz, environmental
- Sarcoidosis
- Early edema from HF
- CT: “ground glass opacities” or “honeycombing” – starts in the periphery and have thick scarred vessels (scarring in the interstitium highlights vessels), more advanced can be seen more centrally
- CXR: Lacy, reticular pattern typically involving most lung fields but can be apical or basilar predominate
25
Q
Bullae
A
- Thin-walled Air-filled space
- Contained within the lung
- Walls may be formed by pleura, septa, or compressed lung tissue
26
Q
Recognize cardiomegaly. Describe the classic radiographic appearance of congestive heart failure.
A
- Measure the cardiac width and divide by the thoracic width à should be under 50% for a normal pt
- Above 50% is cardiomegaly on a PA film
- Heart is enlarged
- “water bottle sign”
- the fluid is backing up in CHF and causing the heart to be enlarged due to inc blood stasis due to poor pumping out or hypertrophy of the muscles
- CHF: most common dz of hospitalized pts over 65 yo
- Pulmonary interstitial edema- early CHF
- Pulmonary alveolar edema- later CHF
- Batwings/butterfly distribution, bilateral
- Fluffy, indistinct airspace densities
- May also show:
- Pleural effuisons
- Kelry B
- Cardiomegaly
- Goes towards head and stays centrally
27
Q
Describe the classic radiographic appearance of a pericardial effusion
A
- Pericardial effusion:
- Water bottle shape or water bottle sign
29
Q
Endotracheal tubes
A
- Want it to stop below the clavicles and above the carina
- Mostly clear but have a radiopaque line so you can find it
30
Q
Central venous catheters
A
- Under the clavicle into the internal jugular
- Want it to end as close to the SVC and right atrium as you can – don’t want it to go through the tricuspid
- You can have a left sided one that goes in subclavian down to SVC
31
Q
Nasogastric tubes
A
- This should go below the diaphragm down esophagus
- Requires CXR after you insert!!!
