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CLASP Radiology > Chest Imaging > Flashcards

Chest Imaging Flashcards

1
Q

what are the different densities on CXR

A 
air- black 
fat- grey 
soft tissue/ muscle- grey/ white
bone- white 
metal - bright white
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2
Q

is the cardiothoracic ratio (CTR) measure on a PA or AP CXR

A

PA (not done on AP as makes heart look bigger)

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3
Q

what is the CTR

A

ratio of maximal horizontal cardiac diameter to maximal horizontal thoracic diameter

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4
Q

what is a normal CTR

A

less than 0.5 (heart half of thoracic width)

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5
Q

how many ribs should be present on CXR when fully inspired

A

the anterior ends of at least 6 ribs should be visible

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6
Q

how do you know a CXR is correctly centred

A

the medial ends of the clavicles should be equidistant form the spinous processes of the upper thoracic vertebrae

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7
Q

what are the mediastinal borders

A 
aorta
pulmonary artery 
left auricle 
left ventricle 
right atrium 
trachea 
hemidiaphragm 
stomach bubble 
horizontal fissure
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8
Q

what are the pulmonary hila

A

junctions between the heart and the lungs

where pulmonary arteries and bronchi enter and the pulmonary veins exit the lungs

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9
Q

which hilum is higher

A

the left

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10
Q

what is the dominant structure in the hilum

A

pulmonary artery

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11
Q

which diaphragm is higher

A

right side 1.5cm higher than left

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12
Q

what are the zones of the lung

A

each has upper (to 2nd rib), middle (2nd to 5th rib) and lower- not the same as lobes

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13
Q

which lung has only two lobes

A

left- although has lingula

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14
Q

how do you tell the anterior from posterior part of ribs

A

anterior curved, posterior straight (horizontal)

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15
Q

what pathologies occur in the lung apices

A

masses (pancoast tumour), pneumothorax

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16
Q

what pathologies occur behind the heart

A

consolidation, masses, hiatus hernia

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17
Q

what pathologies occur below the diaphragm

A

free gas, misplaced lines and tubes, gastric distention, bowel obstruction

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18
Q

what in the bones and soft tissues is often misses on CXR

A

fractures, masses, mastectomy, subcutaneous emphysema, evidence of previous surgery

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19
Q

what are the review areas on CXR

A

common areas for missed findings- lung apices, behind heart, below the diaphragm, bones and soft tissues

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20
Q

what causes lobar collapse

A

obstruction of a lobar bronchus (tumours, foodstuffs, mucus impaction)
lobe no longer ventilated, air gets resorbed, volume loss, collapses

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21
Q

what does a collapsed lobe look like on CXR

A

density increases

adjacent major fissure dragged out of position

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22
Q

what does a left lower lobe collapse look like on CXR

A

volume loss on left, elevation of the hemidiaphragm
increased density in left retrocardiac region (white sail sign)
loss of clarity in medial aspect of left hemidiaphragm
left hilum displaced downwards
left hemithorax looks smaller

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23
Q

what does a left upper lobe collapse look like on CXR

A

volume loss on the left, elevation of the left hemidiaphragm
loss of clarity of heart shadow
veil like diffuse opacification of the left hemithorax

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24
Q

what does a right upper lobe collapse look like on CXR

A

volume loss on the right
loss of clarity of the upper right mediastinum
density in the right upper zone
elevation of the horizontal fissure

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25
Q

what does a right middle lobe collapse look like on CXR

A

loss of clarity of the right heart border
density in the right lower zone
right hemidiaphragm PRESERVED
(small lobe)

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26
Q

what does a right lower lobe collapse look like on CXR

A 
volume loss on the right 
loss of clarity of the right hemidiaphragm 
density in right lower zone 
depression of the horizontal fissure 
(can still see right heart border)
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27
Q

what does the bronchus intermedius mean for lobar collapse

A

is the common origin for bronchus to both the middle and lower right lobes, if obstructed both will collapse

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28
Q

what does a combined right middle and lower lobe collapse look like on CXR

A

volume loss on the right
loss of clarity of the right hemidiaphragm and right heart border
density in right lower zone
depression of the horizontal fissure and oblique fissue

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29
Q

what pattern does consolidation follow

A

same positions and obscuring same borders as lobar collapse but without the volume loss

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30
Q

what is the lingula adjacent to

A

the left heart border

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31
Q

what does right middle lobe consolidation look like

A

increased density in tight lower zone
loss of clarity of the right heart border
right hemidiaphragm preserved

32
Q

what does consolidation of the lingula look like

A

obscures the left heart border

left hemidiaphragm preserved

33
Q

what does left upper lobe consolidation look like

A

increased density in left upper zone
loss of clarity of the left upper mediastinum
volume preserved
air bronchograms

34
Q

what is an air bronchogram

A

where the bronchus contains air but the surround lung doesnt- is filled with blood/ pus/ etc

air filled bronchi running through fluid filled alveoli

35
Q

when can you see the pleural cavity on CXR

A

only when it is filled with air (pneumothorax) or fluid (pleural effusion)

36
Q

what does fluid in the pleural space look like

A

collects at lung bases
forms curved appearance of a meniscus at the lung edges
blunts the costophrenic angles

37
Q

what causes a pneumothorax

A

rupture of the visceral pleura

38
Q

what do pneumothoraxes look like on CXR

A

small- dark cresent without lung markings bounded medially by the lung edge, often at epex

larger- will have larger black air space with no lung markings

normally lung markings go all the way to the edge of the thorax

39
Q

what does a tension pneumothorax look lik

A

displaced mediastinum
large air space in thorax with no lung markings
depressed hemidiaphragm
collapse lung (squashed by the air, unable to be ventilated)

40
Q

what results from heart failure in the lungs

A

pulmonary oedema

41
Q

what are the radio-logical signs of pulmonary oedema due to heart failure in order of occurrence/ severity

A
  1. dilation of upper lobe vessels/ cardiomegaly
  2. interstitial opacities (peribronchovascular cuffing (doughnut sign, haziness around bronchioles) and septal line (kerly B lines- peripheral lines usually at lung bases)
  3. airspace opacification (alveoli fill with fluid, when severe and acute has a perihilar/ batwing appearance, air bronchograms)
  4. pleural effusion
42
Q

what is the mnemonic for the x rays signs of heart failure

A 
ABCDE
A- alveolar oedema (bat wing opacities) 
B- kerly B lines 
C- cardiomegaly 
D- dilated upper lobe vessels 
E- pleural effusion
43
Q

what is the correct placement for an endotracheal tube

A

tip 5 cm above the carina
width 2/3rds trachea diameter
cuff should not expand the trachea

44
Q

when is an endotracheal tube malpositioned

A

if extends beyond carina - commonly goes into right main bronchus (more vertical than left) (causes early collapse of unventilated lung)
may have entered oesophagus

45
Q

what is the correct position of an nasogastric tube

A

subdiaphragmatic
in stomach (overlying gastric bubble on CXR)
at least 10 cm from gastro-oesophageal junction
passes carina in the midline

46
Q

how might an NG tube be misplaced

A

tip remaining in oesophagus
in bronchus or lung
coiled in upper airway
intracranial insertion (skull base trauma/ surgery)

47
Q

where are central venous lines inserted

A

right and left internal jugular/ subclavian veins

48
Q

where are peripherally inserted central catheters inserted

A

cephalic, basilic or brachial veins

49
Q

where should the tip of a central venous catheter be

A

at the cavoatrial function- right side

bend in line should be at 2nd anterior intercostal space

50
Q

how can a central venous catheter be misplaced and what might this cause

A

tip too high- proximal SVC- risk of thrombus formation

tip too low- distal right atrium/ right ventricle- increased risk of arrhythmia

coiled or displaced in another vein

51
Q

where should a peripherally inserted central catheter go

A

up arm towards axilla
under clavicle
towards heart
tip ends at cavoatrial junction/ in central vein

52
Q

how might a peripherally inserted central catheter be misplaced

A

tip too high:superficial upper limb vein
tip too low:distal right atrium or right ventricle
tip in the right internal jugular vein
tip in the azygos vein

53
Q

what are the different types of sizes of pulmonary masses

A

miliary nodules: <2 mm
pulmonary micronodule: 2-7 mm
pulmonary nodule: 7-30 mm
pulmonary mass: >30 mm

54
Q

what are the morphologies of pulmonary nodules

A

solid pulmonary nodules
- calcified pulmonary nodules
partly solid pulmonary nodules
ground glass pulmonary nodules

55
Q

what are the possible distribution of pulmonary nofules

A

perilymphatic pulmonary nodules
- perifissural pulmonary nodules
centrilobular pulmonary nodules
random pulmonary nodules

56
Q

what does a basal predominance of pulmonary modules suggest

A

cancer- mets

57
Q

does calcification of nodules suggest cancer

A

no

58
Q

where in lung do primary lung cancers tend to be

A

apical- smoker

59
Q

what does TNM stand for in lung cancer staginf

A

tumour size
intrathoracic lymph Node staging
metastases

60
Q

what does a contrast enhanced CT do in lung cancer

A

assess tumour size
shows mets
guides biopsy of peripheral lesions

61
Q

what does a FDG-PET CT do in lung cancer

A 
shows nodal mets 
distant mets (not brain) 
delineated tumour in an area of collapse
62
Q

what is a pneumoperitoneum

A

when perforation of a hollow viscous (stomach, duodenum, small/ large bower) causes gas in the peritoneal cavity

63
Q

what is seen on CXE in penumoperitoneum

A

when patient in erect position
gas rise up under the diaphragm - think black line between diaphragm and subdiaphragmatic structures
(easier to see on right)

64
Q

what is the presentation of a PE

A

dyspnoea either at rest or on exertion
pleuritic chest pain, cough, orthopnoea and haemoptysis
if caused by deep vein thrombosis,calf/thigh pain and swelling may occur

65
Q

what Ix for a PE

A

D-dimers can be useful in low-risk patients to rule out a VTE
Chest radiographs are often performed to look for alternative causes for symptoms and to decide on appropriateness of V/Q scan (only if CXR normal)
CTAP to visualise the clot
V/Q scan (ventilation perfusion scan) to look for mismatched perfusion defect caused by clot

66
Q

what might be seen on CXR in PE

A

non specific findings- plerual effusion, cardiomegaly, atelectasis (collapse of lung due to reduced/ absent gas exchange)

67
Q

how do you tell CXR is PA not AP

A

scapular will not be over the film

68
Q

how can you tell a CXR has good exposure

A

(enough radiation)

can see spine behind heart, left hemidiaphragm is visible to the spine

69
Q

what is a silhouette sign

A

loss of a silhoutte e,g loss of heart borders

70
Q

if you can see all the heart borders where must a lesion be on the left side

A

lower lobe

71
Q

is blood white on CT

A

no- unless clotted

if blood white on CT then will have had contrast/ be clotted

72
Q

what is white on CT

A

bones and metal

73
Q

what is black on CT

A

air

74
Q

what is seen in lung on CT in COPD

A

emphysema- seen as black holes: smokers in apices, alpha def in bases

75
Q

what lymph nodes should be check in lung cancer

A

tracheobronchial- bronchopulmonary- supraclavicular

CLASP Radiology (6 decks)

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