CORE - Chest Flashcards
Right or left ribs project more posteriorly on lateral chest x-ray
right ribs project more posteriorly (also slightly magnified); by convention lateral view is obtained with left side against the detector
“Black hole” on lateral chest x-ray
L mainstem bronchus (or LUL); left PA is both posterior and superior, right PA is anterior
Normal posterior wall thickness of bronchus intermedius
<3 mm
Raider’s triangle
a.k.a. retrotracheal space; anterior border is posterior trachea, posterior border is vertebral column
Opacity in Raider’s triangle
aberrant SCA (right or left), double aortic arch, substernal goiter, esophageal diverticulum
Most anterior and superior cardiac valves
tricuspid is most anterior, pulmonic is most superior; mitral valve is larger in size than the aortic valve (if two prosthetic valves are seen)
“Pointy” part of mechanical cardiac valves point toward or away from the direction of blood flow?
toward the direction of blood flow
Valve that would have a pacemaker wire running through it
tricuspid valve
Number of pleural layers in azygous fissure
4 layers of pleura; azygous vein displaced laterally during development
More anterior of the major fissures on lateral chest x-ray
right major fissure
Flat waist sign
LLL collapse
Segments of RUL (3) and LUL (4)
RUL = anterior, posterior, apical; LUL = anterior, apical-posterior, superior lingular, inferior lingular
Inferior border of superior mediastinum
sterno-manubrial junction
Posterior border of anterior mediastinum
pericardium
Contents of middle mediastinum
heart, pericardium, tracheal bifurcation
Mediastinal compartment containing thoracic duct
posterior mediastinum
Pig bronchus + associations
bronchus arises directly from trachea (prior to bifurcation); classically refers to RUL bronchus; assoc. with pulmonary sling and TEF
Most common anatomic variant of pulmonary veins
separate vein draining RML; typically only upper and lower pulmonary veins for each lung (4 total)
Findings in proximal interruption of the pulmonary artery
small hemithorax, oligemia (relative to other lung); distal vessels are present; occurs on side opposite of aortic arch
Proximal interruption of the pulmonary artery associations
PDA; interrupted left PA is also assoc. with ToF and truncus arteriosus
Location of mediastinal findings above the clavicles
posterior mediastinum (“cervicothoracic sign”)
Hilum overlay sign
vessels seen through hilar mass => mass is either in anterior or posterior mediastinum
Most common cause of pneumonia in normal patients and AIDS patients
S. pneumo for both
Bioterrorism + mediastinal widening
anthrax
“Bulging fissure”
Klebsiella; classically in alcoholics and aspirators; h/o “currant jelly” sputum
Patients who get pseudomonas pneumonia
vented ICU patients, CF and primary ciliary dyskinesia
Most common complication of aspiration
empyema (which can develop a bronchopleural fistula)
Infection associated with chest wall invasion and/or rib osteomyelitis
actinomyces; post-dental procedure, may also have mandibular osteomyelitis
Pulmonary findings post-BMT
<30 days = edema, hemorrhage, ARDS, aspergillosis; 30-90 days = PCP, CMV; >90 days = COP, bronchiolitis obliterans
Timing of GVHD affecting lungs (post-BMT)
> 100 days; manifests as bronchiolitis obliterans
Pulmonary infections with CD4 >200
bacterial infections, TB
Pulmonary infections with CD4 <200
PCP, atypical mycobacterial
Pulmonary infections with CD4 <100
CMV, disseminated fungal, mycobacterial
Chronic airspace opacity in AIDS patient
consider AIDS lymphoma
AIDS patient with CD4 <100 and GGO (PCP isn’t an option on this multiple choice question)
CMV
Hypervascular lymph nodes (AIDS patient)
Castleman disease, Kaposi sarcoma
Ranke complex
Ghon focus + ipsilateral calcified hilar node; represents healed primary TB; Ghon focus = calcified caseating granuloma (tuberculoma)
Primary TB in peds and immunocompromised patients
consolidation, effusion, lymphadenopathy; cavitation is uncommon; lymph nodes demonstrate central low density
Post-primary TB
a.k.a. reactivation TB; cavitary lesion in upper lobe(s); lymphadenopathy uncommon
Miliary TB
represents hematogenous dissemination; can occur in primary or reactivation TB
Patient with TB and AIDS started on HAART, now doing worse
immune reconstitution inflammatory syndrome (IRIS); treatment is steroids
MAC infection (cavitary form)
thin-walled cavitary lesion(s) in upper lobe with fibrosis, +/- tree-in-bud nodules in other areas (endobronchial spread); seen in COPD, CF, immunocompromised patients
Hot tub lung
hypersensitivity pneumonitis in response to mycobacteria; no active infection; UL GGO + centrilobular nodules; occurs in otherwise health patients
Infection with propensity to invade mediastinum, pleura, or chest wall
mucormycosis; actinomyces may also invade chest wall
Timing of CMV in patients post-BMT
30-90 days; occurs due to reactivation of latent infection or from CMV-infected marrow products
SARS findings
lower lobe predominant GGO; SARS = severe acute respiratory syndrome
Diffusely scattered small calcified lung nodules
healed varicella; occurs most commonly in immunocompromised adults
Feeding vessel sign DDx
hematogenous mets, septic emboli, pulmonary infarcts, invasive aspergillosis
Bacteria implicated in Lemierre syndrome
Fusobacterium necrophorum
USPSTF recommendations for lung cancer screening
low dose CT for asymptomatic adults 55-80 y/o with a 30 pack-year history and who currently smoke (or quit within 15 years)
Size cutoff for a solitary pulmonary nodule
<3 cm (>3 cm = mass)
Most suspicious SPN calcification pattern
eccentric calcification
SPN findings suggestive of malignancy
spiculated margins, air bronchogram through nodule (AIS), part-solid part-GGO nodules
SPN morphology (most to least suspicious)
part-solid part-GGO > pure GGO > pure solid
GGO nodule on PET
cold suggests malignancy, hot suggests infection; SPN should be >1 cm to evaluate on PET
Paraneoplastic syndromes associated with lung cancer
PTH in SCC; SIADH, ACTH, limbic encephalitis, and Lambert-Eaton in small cell lung cancer
Most common type of lung cancer
adenocarcinoma; also most common type to present as SPN; assoc. with pulmonary fibrosis and smoking (less than SCC)
Well-differentiated adenocarcinoma with lepidic growth
AAH/AIS/invasive mucinous adenocarcinoma (a.k.a. BAC)
Chronic consolidation DDx
endobronchial tumor (post-obstructive), mucinous BAC, lymphoma, organzing pneumonia, eosinophilic pneumonia
BAC on PET
cold
Stage of lung cancer that is unresectable
stage 3B or higher (see ‘SPECIAL - Staging’ notes for more info)
Radiation changes (lungs)
early (1-3 months) = geographic GGO; late = bronchiectasis, fibrosis, consolidation, volume loss
Increasing air in pneumonectomy cavity (post-op)
bronchopleural fistula; should become progressively more fluid-filled
Xenon in pneumonectomy cavity on V/Q scan
bronchopleural fistula
“Cannonball mets”
RCC or choriocarcinoma mets (classically)
Most common cause of unilateral lymphangitic carcinomatosis
bronchogenic carcinoma
Heart valves affected by endobronchial carcinoid
mitral and aortic valves
Most common tracheal malignancy + 2nd most common
SCC > adenoid cystic carcinoma; both generally arise in lower trachea; ACC is NOT assoc. with smoking
Primary pulmonary lymphoma
defined as lack of extra-thoracic involvement for 3 months; usually NHL (80% are MALT)
Secondary pulmonary lymphoma - NHL vs. HL
NHL is 80-90% of secondary pulmonary lymphoma, but HL more commonly involves the lungs; NHL often occurs in the absence of mediastinal disease (unlike HL)
Timing of pulmonary PTLD
usually occurs within 1 year; typically B-cell type (assoc. with EBV)
AIDS patient with lung nodules, pleural effusions, lymphadenopathy
AIDS lymphoma
AIDS lymphoma
high-grade NHL, assoc. with EBV; CD4 <100
Most common lung tumor in AIDS patients
Kaposi sarcoma > AIDS lymphoma
Bloody pleural effusion in AIDS patient
Kaposi sarcoma; CD4 <200 for Kaposi’s; most common hepatic neoplasm in AIDS
Pulmonary lesion with “popcorn calcification”
hamartoma; often with intra-lesional fat; may be PET hot
Most common location for bronchial atresia
apical-posterior segment of LUL
Finger-in-glove DDx
ABPA, bronchial atresia, bronchial carcinoid, bronchogenic carcinoma, CF
Indication to treat pulmonary AVM
afferent vessel >3 mm
Left SVC drainage
coronary sinus; rarely to LA (resulting in right-to-left shunt)
Extralobar sequestration associations
CCAM, CDH, vertebral anomalies, congenital heart disease, pulmonary hypoplasia; extralobar type is less common
Potential complication of CCAM
malignant transformation to pleuopulmonary blastoma and rhabdomyosarcoma; treatment of CCAM is excision
CCAM with a systemic arterial feeding vessel
sequestration (NOT CCAM)
Lung disease(s) that spare costophrenic angles
pulmonary LCH, hypersensitivity pneumonitis
Cystic lung disease with thin-walled oval cysts
Birt-Hogg-Dube; also get skin stuff and RCCs/oncocytomas
LIP associations
Sjogren’s, HIV, RA, SLE, Castleman’s; LIP in peds => think HIV
Increased size of the retrosternal clear space
empyshema
Causes of panlobular emphysema
a.k.a. panacinar emphysema; alpha-1 antitrypsin, Swyer-James, ritalin lung
Central dot sign
centrilobular emphysema; most common type; upper lobe predominant
Paraseptal emphysema findings
subpleural distribution; 1 row of cysts thick (vs. honeycombing which is 2-3 rows thick)
Main PA greater than aorta in size in the setting of emphysema
assoc. with worse outcomes; represents pulmonary HTN due to COPD
Vanishing lung syndrome
a.k.a. idiopathic giant bullous emphysema; occupies >1/3 of hemithorax by definition; young males usually
Vanishing lung syndrome associations
alpha-1 antitrypsin, Marfan’s, Ehlers-Danlos
Pattern of nodularity in pneumoconioses
centrilobular and/or perilymphatic
Asbestosis (definition)
fibrotic changes assoc. with asbestos exposure; UIP-esque changes + pleural thickening
Earliest pleural-based phenomenon associated with asbestos exposure
pleural effusion (lag time of 5 years); pleural plaques and mesothelioma have a lag time of >20 years
Cavitary upper lobe lesion in the setting of silicosis
suspect TB; PMF can also cavitate
Pattern of nodularity with subpleural sparing
centrilobular
Upper lobe fibrosis DDx
end-stage sarcoidosis, chronic HSP, end-stage silicosis, ankylosing spondylitis
Lower lobe fibrosis DDx
IPF, NSIP (fibrotic form), end-stage asbestosis, rheumatoid arthritis, scleroderma
Occupational history of working on aircraft or space shuttles
Berylliosis; hilar adenopathy + upper lobe reticular opacities
Findings in talcosis
GGO, micronodules, +/- PMF
Consolidation vs. GGO
consolidation obscures vessels, GGO does not
Centrilobular nodules DDx
endobronchial spread of infection (pneumonia, TB), HSP, RB-ILD, silicosis; “airway stuff”
Perilymphatic nodules DDx
sarcoidosis, pneumoconioses, lymphangitic carcinomatosis
RB-ILD findings
GGO + centrilobular nodules; typically upper lobe predominant; RB-ILD = RB + clinical symptoms
DIP findings
lower lobe predominant GGO (more extensive than RB-ILD); +/- small cysts
Most common interstitial lung disease
UIP/IPF
“Heterogeneous histology”
UIP/IPF
NSIP subtypes
cellular (GGO only) and fibrotic (GGO + traction bronchiectasis + reticulation); posterior lower lobes with subpleural sparing; Tx is steroids
Biochemical markers in sarcoidosis
elevated ACE, hypercalcemia
Stage 2 of sarcoidosis
lymphadenopathy + parenchymal disease; stage 1 is only nodes, stage 3 is only parenchymal, stage 4 is fibrosis; based on x-ray
Stage of CHF: cephalization of vessels, big heart
stage 1 (redistribution); PCWP 13-18 mmHg
Stage of CHF: peribronchial cuffing, Kerley B lines
stage 2 (interstitial edema); PCWP 19-25 mmHg
Stage of CHF: airspace opacity, pleural effusion
stage 3 (alveolar edema); PCWP >25 mmHg
Most common cause of right heart failure
left heart failure; other causes include chronic PE and tricuspid regurgitation
Cause of hyperacute rejection following lung transplant
HLA and ABO antigen mismatch; massive homogeneous infiltration
Time frame for acute rejection following lung transplant
8 days to 2 months; GGO + interlobular septal thickening; treatment is steroids
Findings in chronic lung transplant rejection
bronchiolitis obliterans (bronchiectasis, air trapping, bronchial wall thickening); affects 50% at 5 years; may progress to fibrosis
Organizing pneumonia in lung transplants
seen in both acute and chronic rejection (more common in acute); treatment is steroids
Air trapping in a lung transplant at or after 6 months
chronic rejection
Most common recurrent primary disease after lung transplant
sarcoidosis
Increased infection risk related to PAP
Nocardia
PAP in a child <1 y/o
assoc. with alymphoplasia
Most common type of lipoid pneumonia
endogenous; due to a post-obstructive process (e.g. cancer)
Atoll sign
a.k.a. reverse halo sign; organizing pneumonia; may be secondary to infection, drug reaction, inhalation, acute/chronic rejection; treatment is steroids
Peripheral GGO or consolidation DDx
organizing pneumonia, chronic eosinophilic pneumonia, non-cardiogenic pulmonary edema, atypical/viral pneumonia
Phase of HSP with patchy GGO, centrilobular nodules, and air trapping
subacute
Findings of chronic HSP
subacute findings + fibrosis
Causes of focal tracheal stenosis
post-intubation/tracheostomy, Behcet’s, Crohn’s
Circumferential tracheal thickening with calcifications
amyloidosis
Kartagener syndrome
primary ciliary dyskinesia + situs inversus; 50% of PCD patients have Kartagener’s
Tracheal diameter >3 cm
Mounier-Kuhn (a.k.a. tracheobronchomegaly); normal tracheal size is <2.5 cm
Air trapping on CT (no additional findings)
bronchiolitis, often viral or asthma in kids; may see assoc. centrilobular nodules; consider RB in smokers and chronic rejection in lung transplants
Follicular bronchiolitis associations + findings
Sjogren’s, RA, HIV; lower lobe predominant ground-glass centrilobular nodules +/- tree-in-bud nodules
Constrictive bronchiolitis
a.k.a. bronchiolitis obliterans; bronchiectasis, air trapping, bronchial wall thickening, GGO
Causes of bronchiolitis obliterans
post-viral, inhalational, post-transplant, drug-induced, Swyer-James
Findings in ankylosing spondylitis
upper lobe fibrosis and bullous changes
Pulmonary manifestations of RA
lower lobe fibrosis; presence of rheumatoid nodules help distinguish from UIP; may see pleural thickening and/or effusion
Upper lobe lung nodules in a coal miner with RA
Caplan syndrome
“Shrinking lung”
progressive volume seen in SLE; involves both lungs; may also see pleural and pericardial effusions
Shortness of breath when sitting up
hepatopulmonary syndrome; arteriovenous shunting seen in cirrhosis; dilated subpleural vessels in peripheral lower lobes; uptake in brain and kidneys on Tc-99m MAA
Goodpasture syndrome findings
patchy GGO and/or consolidation; may progress to fibrosis; h/o hemoptysis
Pleural calcification DDx
abestos-related plaques, old hemorrhage, old infection/TB, extra-skeletal osteosarcoma
Pleural mass with extension into pulmonary fissure
suggestive of mesothelioma; most common pleural malignancy (lipoma is the most common benign pleural tumor)
Fibrous tumor of the pleural associations
hypoglycemia, hypertrophic osteoarthropathy; 20% are malignant; 6th-7th decade
Most common pleural mets
lung cancer (adenocarcinoma most commonly) > breast > lymphoma; pleural effusion is the most common manifestation
Volume of pleural effusion to be visible on frontal and lateral x-rays
175 cc for frontal and 75 cc for lateral
Lateralization of diaphragmatic peak
subpulmonic effusion (between lung base and diaphragm)
Most common pathogens associated with empyema necessitans
TB > actinomyces; “BATMAN”
Most common location of traumatic diaphragmatic hernia (not congenital)
left-side also (liver is protective)
Paradoxial movement of diaphragm on sniff test
diaphragmatic paralysis; hemidiaphragm is elevated on inspiration and does not change on expiration; must consider malignancy causing phrenic nerve compression (arises from C3-5 nerve roots)
Elevated hemidiaphragm with negative sniff test
eventration (congenital weakening); DDx is diaphragmatic paralysis, diaphragmatic hernia, subpulmonic effusion
Pancoast tumor definition
superior sulcus tumor + Pancoast syndrome (shoulder pain, hand pain/atrophy, Horner syndrome); most commonly SCC
Reasons for superior sulcus tumor unresectability
C8 or higher brachial plexus involvement, diaphragmatic paralysis, >50% vertebral body involvement, distant nodes or mets
Multiple pleural lesions with slurred speech, double vision, and arm weakness
thymoma with drop mets (in the setting of myasthenia gravis)
Thymoma vs. thymic carcinoma
lymphadenopathy and mets are more common in thymic carcinoma
Thymoma associations
myasthenia gravis, pure red cell aplasia, hypogammaglobulinemia
Anterior mediastinal soft tissue mass DDx
thymic hyperplasia, thymoma, thymic carcinoma, malignant germ cell tumor, lymphoma
Thymic hyperplasia vs. thymic malignancy (MR)
thymic hyperplasia demonstrates signal dropout on out-of-phase (thymic malignancies do not)
Most common mediastinal germ cell tumor
teratoma (cystic +/- fat and calcs); seminoma is homogeneous, NSGCTs are heterogeneous; all assoc. with Klinefelter’s
Causes of fibrosing mediastinitis
histoplasmosis, TB, radiation, sarcoidosis
Anterior mediastinal mass with calcification(s) DDx
teratoma, treated lymphoma, thymoma, thymic carcinoma
Aortic nipple
left superior intercostal vein
Fissure separating medial-basal segment from other lower lobe segments
inferior accessory fissure; more common on right
Fissure separating superior segment from other lower lobe segments
superior accessory fissure
Thoracic duct course
arises from cisterna chyli (L1) => passes through aortic hiatus => crosses midline at T5 (right-to-left) => empties into LSCV/LIJV
Size limit for bleb vs. bulla
bleb is <1 cm, bulla is >1 cm; giant bulla occupies >30% of hemithorax
Westermark sign
regional oligemia (due to PE)
Fleischner sign
enlarged pulmonary artery (due to PE)
Pulmonary artery aneurysm DDx
iatrogenic, Behcet’s, chronic PE
Recurrent thrombophlebitis + pulmonary artery aneurysms
Hughes-Stovin syndrome (vasculitis); aneurysms may rupture
Rasmussen aneurysm seen in primary or post-primary TB?
post-primary (reactivation); pseudoaneurysm (not a true aneurysm)
Signs of pulmonary hypertension
> 25 mmHg (pulmonary artery); PA >29 mm or larger than the aorta, mural calcifications, RV diltation and/or hypertrophy
Causes of secondary pulmonary hypertension
chronic PE, cor pulmonale (emphysema/asthma/CF), left heart failure, mitral valve stenosis, pulmonary veno-occlusive disease
Location of tracheobronchial injury (trauma)
within 2 cm of carina; injury close to the carina causes pneumomediastinum rather than pneumothorax
Criteria for flail chest
≥3 segmental rib fractures or >5 adjacent rib fractures; “paradoxical motion of chest wall with breathing”
Persistent fluid collection after chest tube placement (trauma)
extra-pleural hematoma; look for displaced extra-pleural fat
Timing of pulmonary contusion
appears within 6 hours, disappears in 72 hours; represents alveolar hemorrhage without alveolar disruption
Most common site of aortic injury (trauma)
isthmus > root > diaphragm
Altered mental status, rash, and shortness of breath (trauma)
fat emboli (classically 1-2 days after fracture); GGO in lungs (looks like edema); may not see pulmonary artery filling defects
Abrupt bend in tip of a central line near cavo-atrial junction
terminates in azygous vein
Central line on left side of heart
left-sided/duplicated SVC or arterial placement
Ideal endotracheal tube positioning
5 cm from carina; neck flexion => tip moves caudal; neck extension => tip moves cephalad
Function of IABP
decrease LV afterload, increase myocardial perfusion; should be just below origin of LSCA
ACR Appropriateness Criteria: suspicion for metastatic disease
CXR
ACR Appropriateness Criteria: patients on mechanical ventilation
daily CXR
ACR Appropriateness Criteria: chest pain with high suspicion for aortic dissection
CXR
PMF assocations
silicosis, CWP, talcosis, sarcoidosis
Frozen hemithorax
mesothelioma; lack of expected contralateral mediastinal shift with massive pleural effusion
Hemorrhagic lymph nodes
anthrax; mediastinal widening also
Tulip bulb aorta
annulo-aortic ectasia (Marfan’s, Ehlers-Danlos)
Reverse batwing pulmonary opacities
chronic eosinophilic pneumonia; high serum eosinophils, normal BAL eosinophils
Migratory pulmonary consolidations
pulmonary eosinophilia (Loeffler syndrome); normal serum eosinophils, high BAL eosinophils
Angiofollicular lymph node hyperplasia
a.k.a. Castleman disease
Location of acute HSP
lower lobe predilection, patchy GGO
Erdheim-Chester syndrome
classic triad of osteosclerosis + perirenal soft tissue + pleural or diffuse septal thickening; may see GGO and centrilobular nodules
Normal relationship of bronchi and PAs
right bronchus is eparterial (bronchus above artery); left bronchus is hyparterial (bronchus below artery) then anterior to the left PA
Relationship of PAs to trachea on lateral chest x-ray
right PA is anterior to the trachea, left PA is posterior to the trachea
Which hilum is higher on a frontal radiograph?
left
Lenticular subscapular soft tissue mass with fatty streaks
elastofibroma; seen in elderly patients; biopsy unnecessary with classic appearance; resection is curative
Amiodarone toxicity
peripheral consolidations +/- interstitial fibrosis; treatment discontinue + steroids
Wandering vein
single vein collects all pulmonary venous return from a lung and drains to LA
Scimitar syndrome associations
pulmonary hypoplasia, ASD, horseshoe lung, absence/interruption of IVC, systemic arterial supply to right lung
Thymic carcinoid association
MEN1; most commonly assoc. hormonal syndrome is Cushing’s
p-ANCA vasculitides
Churg-Strauss, PAN; Goodpasture’s is non-ANCA
Increased risk of pneumothorax in lung biopsy
lesion size <2 cm, depth >4 cm, COPD, non-perpendicular pleural entry site, multiple pleural punctures
Lower lobe segments - right and left
right = PALMS; left = SLAP (anteromedial)
Intermediate probability for PE with negative D-dimer - NEXT STEP
CXR; if intermediate probability + positive D-dimer => CTA or CXR; pregnant patients with suspicion for PE should start with CXR
