Chest radiology - masterclass

Question 1

How to tell if a CXR is adequately inspired?

Answer 1

If a CXR is adequately inspired, the anterior ends of at least 6 ribs should be visible

Question 2

What are the pulmonary hila?

Answer 2

The hila are the junctions between the heart and lungs, where the pulmonary arteries and bronchi enter and the pulmonary veins exit the lungs
•The left hilum normally lies higher than the right

Question 3

On a normal CXR, the right diaphragm lies about 1.5cm above the left diaphragm. True/false?

Answer 3

True

Major deviations from this usually indicate disease

Question 4

When looking at the lungs, divide into upper mid and lower zones. Should be roughly same size and density. True/false?

Answer 4

True

Major deviations from this usually indicate disease

Question 5

What to look for in CXR of lung apices?

Answer 5

lung apices: masses (e.g. Pancoast tumour), pneumothorax

Question 6

What to look for in CXR behind the heart?

Answer 6

behind the heart: consolidation, masses, hiatus hernia

Question 7

What to look for in CXR below diaphragm?

Answer 7

below the diaphragm: free gas, lines and tubes (e.g. nasogastric tube), gastric distension, bowel obstruction

Question 8

What to look for in CXR of bones and soft tissues?

Answer 8

bones and soft tissues: fractures, masses, mastectomy, subcutaneous emphysema, evidence of previous surgery (e.g. axillary clips)

Question 9

What is the lingula?

Answer 9

the tip or tongue-like projection of the upper lobe of the left lung

Question 10

Causes of bronchial obstruction?

Answer 10

tumours, aspirated foodstuffs, mucus impaction etc.

Question 11

Appearance of left lower lobe collapse on CXR?

Answer 11

Volume loss on the left with elevation of the hemidiaphragm, left hemithorax looks small

Increased density in left retrocardiac region (region on left side behind heart).

Loss of clarity medial aspect left hemidiaphragm
•Left hilum displaced downwards

Question 12

Appearance of left upper lobe collapse on CXR?

Answer 12

Volume loss on the left, elevation of the left hemidiaphragm
•Loss of clarity of the heart shadow
•‘veil like opacity’ diffuse opacification of the left hemithorax

Question 13

Consolidation follows the same patterns in terms of position/obscuring borders, but without the volume loss. True/false?

Answer 13

True

Question 14

Infection of the lingula causes the right heart border to become obscured. True/false?

Answer 14

False

Obscuring left heart border.since lingula on left lung

Question 15

What is the pleural cavity?

Answer 15

The pleural cavity is a potential space visible on chest radiographs when it is filled by fluid (pleural effusion) or air (pneumothorax).

Question 16

What are the costophrenic angles?

Answer 16

formed by the points at which the chest wall and diaphragm meet.

Bottom edges where lungs meet sides of chest wall.

Question 17

How does pleural effusion affect costophrenic angles?

Answer 17

On an erect CXR dense pleural fluid is seen to collect at the lung bases and often forms the curved appearance of a ‘meniscus’ at the lung edges, blunting the costophrenic angles

Question 18

How to spot a small pneumothorax on CXR?

Answer 18

A small pneumothorax is subtle – look for a dark crescent without lung markings bounded medially by the lung edge. It is often at the lung apex.

Question 19

How to spot a large pneumothorax on CXR?

Answer 19

A larger right pneumothorax, note the lung edge and the black air filled pleural space with no lung markings

Question 20

Appearance of heart failure on CXR?

Answer 20

A good mnemonic to remember these principles is ABCDE:
•A - alveolar oedema (bat wing opacities)
•B - Kerley B lines
•C - cardiomegaly
•D - dilated upper lobe vessels
•E - pleural effusion

Question 21

Doctors often have to insert lines and tubes into patients in order to monitor treatment, provide nutrition. What are some examples?

Answer 21

Endotracheal (ET) tubes
Nasogastric tubes
Central venous lines

Question 22

Normal position of ET tubes?

Answer 22

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

Question 23

Malposition of ET tubes?

Answer 23

tip may extend past the carina
malposition most commonly seen is the tip in the right main bronchus
May have entered the oesophagus