CXR II Flashcards
ddx of opacities
Air Space or Interstitial dz
○ Patterns overlap, can have both
○ Visible on both CXR and chest CT
characteristics of air-space dz
Fluffy, hazy infiltrates ● Air bronchograms ● Opacities confluent (comes together), margins indistinct ● Segmental/lobar consolidation common ● “Bat wing” pattern ● Silhouette signs
volume loss and scaring otherwise known as
atelectasis
characteristics
Discrete “particles” of Dz ● Masses, honeycombing ● No air bronchograms ● No lobar margins ● If diffuse, usually bilateral ● Areas of normal lung may be present w/ good aeration
another name for air disease
alveolar disease
another name for infiltrative dz
interstitial
most PNA are airspace of interstitial
airspace
three ways to describe interstitial lung dz findings on a CXR
Reticular = too many lines
○ Nodular = too many dots
○ Reticulonodular = too many lines
Segmental/lobar patterns tend to be airspace of interstitial dz?
airspace
Silhouette signs is indicative of airspace of interstitial dz?
AIRSPACE
– Pneumococcal PNA is seen as airspace of interstitial dz?
LOBAR –> airspace
legionella PNA is a characteristically seen as airspace of interstitial dz?
airspace
PCP PNA (late)s characteristically seen as airspace of interstitial dz?
airspace
aspirations favorite lobe
Aspiration – favors RLL
bronchograms
airspace dz finding due to fluid around the bronchial tubes
aspiration is typically seen with airspace characteristics or interstitial?
airspace
RLL
LL in generally but RLL if pt is supine
silhouette sign of ascending aorta is indicative of a dz in the
RUL
silhouette sign of right heart border is indicative of a dz in the
RML
silhouette sign of RIGHT hemidiaphragm is indicative of a dz in the
rll
silhouette sign of descending aorta is indicative of a dz in the
LU or LLL
silhouette sign of L heart border is indicative of a dz in the
lingula of LUL
silhouette sign of LEFT hemidiaphragm is indicative of a dz in the
LLL
Silhouette sign is indicative of airspace or interstitial dz?
airspace
Pulmonary alveolar edema – cardiac (late
CHF) or non-cardiogenic is usually seen with airspace or interstitial CXR characteristics
airspace
Most TB ari or interst?
air
Pulmonary hemorrhage air or interst?
air
ARDS air or interst?
air
a form of non-cardiogenic
pulmonary edema seen with Delayed dyspnea, hypoxia, alveolar edema
this is a fatal systemic illness
ARDS
(Adult Respiratory Distress
Syndrome)
Chronic alveolar Dz air or interst CXR
air
alveolar edema is seen in what type of dz
lat CHF of non-cardeogenic
“Bat-wing” pattern - central distribution
alveolar edema
Viral or fungal seen as interst or air CXR findings ?
interstitial
Recall that the lingula is part of the _____
Recall that the lingula is part of the left upper lobe.
Systemic Dz seen as interst or air CXR findings ?
Systemic Dz – sarcoid, RA, etc – affect both
lungs
Cancer, mets seen as interst or air CXR findings ?
interst
Pulmonary fibrosis, Pneumoconiosis
(“dusty lung”) seen as interst or air CXR findings ?
interst
○ Asbestosis, silicosis, coal worker’s
lung, etc are all air or interstitial CXR findings?
interst
TB – miliary, cavitary lesion classified as air or interstitial CXR findings
interstitial
pulmonary edema seen with early CHF air or interstitial CXR findings
interstitial
Three great pretenders
syphillis
TB
appendicitis
reactivation TB favors which lobes
upper
milliary TB is air or interstitial?
interstitial
when to suspect TB based on HX
cough losing weight spit up blood short of breath from endemic area incarcerated homeless exposure
fever and elevated respiratory rate
or fever and low pulse OX
CXR!
ddx of cavitary lesions
(Reactivation TB, Staph and Strep pneumonias, Klebsiella and Coccidiomycosis, cancer, strep PNA
● Differential diagnosis of consolidation:
Pneumonia - airways full of pus
○ Cancer - airways full of cells
○ Pulmonary hemorrhage - airways full of blood
○ Pulmonary edema - airways full of fluid
T or F Consolidation means there is infection.
false!
Consolidation does not always mean there is infection. The small airways may fill with material other than pus.
occupational lung dz are almost always air or interstitial?
interstitial
typically CXR finding with sarcoidosis
bilateral mediastinal lymphadenopathy
Diffuse, bilat
hilar adenopathy seen as innumerable nodules
miliary TB
cardiomegaly common is common with what CXR finding
CHF cardiopulmonary edema
non cardiogenic pulmonary edema
Heart +/- normal; less commonly see Kerley B, effusions
Near drowning, inhalation injury
Drug hypersensitivity, overdose (heroin)
Fluid overload - renal failure/uremia
High altitude pulmonary edema (HAPE)
cardiogeni pulmonary edema is characterized by
● Fluid in fissures (major and minor)
● Kerley B lines (Kerley A lines too)
● Pleural effusions
● Peribronchial cuffing
pleural based straight lines coming right off of the edge
kerley B’s
what is peribronchial cuffing
bronchus on end seen b/c of fluid aroudn the bronchus like in CHF
Incomplete aeration/expansion of the lung – no air there
Atelectasis
incomplete aeration or expansion of the lung because there is no air there
the lung collapses
why does atelectasis appear white
because collapsed lung is denser
Causes of atelectasis
obstructing neoplasm such as a bronchogenic carcinoma, asthma mucus plugs, aspirated FB
what do we see in with structures and fissures
sructures shift to SAME side (being PULLED), fissures displaced
what do we see in the unaffected lung with at atelectasis
○ Compensatory overinflation of thasis e unaffected ipsilateral lobes or the contralateral lung
Lobar collapse d/t occluding lesion of the bronchial tree
obstuctive lobar atelect
diaphragm on obstructure atelectasis
elevated (being pulled)
Tracheal deviation, mediastinal deviation, elevated hemidiaphragm (tenting), upward bowing of
fissures, hyperinflation remaining lung on same side, rib cage narrowing
all common findings with
obstructive atelectasis
common causes of obstructive atelectasis
Tumors – includes bronchogenic carcinoma (especially squamous cell), endobronchial
metastases, carcinoid tumors
● Mucus plug – esp in bedridden, post-op, asthma or cystic fibrosis patients
● FB aspiration – esp peanuts, toys, or following a traumatic intubation
● Inflammation – as in scarring caused by TB
Normal or increased volume
No shift
Air space disease
No apex
all classic CXR findings for
PNA
key to pleural effusions on CXR
meniscus sign or blunting of costophrenic angles
you can see small effusions better on what type of CXR
lateral
Meniscus sign
upward sloping of fluid in cfa
○ The beam must be _______ to fluid to see meniscus or fluid level
○ The beam must be horizontal to fluid to see meniscus or fluid level
Plural effusion _____things away and atelectasis ____
pleural effusions pushes
atelectasis pulls
causes of plural effusions
: infection, malignancy (chest or abdominal), CHF, trauma/toxic, renal failure, chronic lung disease
effusions in the lung can be foun
fluid in thorax, around the lung; in the potential space between the visceral and parietal pleura
fissure finding with effusions
Look for “opacified” fissures – effusion fluid likes to collect here
It takes _____ of fluid to opacify an entire hemithorax
It takes 2 liters of fluid to opacify an entire hemithorax
– easy to mistake for a mass/infiltrate; btw layers of fissure; will disappear with tx
Round effusion –
luid collects beneath the lung, between the hemidiaphragm and the lung base
→ elevated hemidiaphragm, no meniscus on PA, lateral is the money shot, silhouettes the diaphragm
Subpulmonic effusion
both air and fluid in pleural space; produces an air-fluid level w/ horizontal beam
Hydropneumothorax
Blunting of costophrenic angle – seen earliest on lateral (___ necessary to see it)
Blunting of costophrenic angle – seen earliest on lateral (75ml necessary to see it)
blunting of costophrenic angle can be seen with ____ml of fluid on PA
200-300
if plural effusion does not layer out
If it does not “layer out” on lateral decubitus film – it is loculated and cannot be tapped simply
Failure of an effusion to change location with changes in the patient’s position is a clue that the
effusion is unable to flow freely or is __________
Failure of an effusion to change location with changes in the patient’s position is a clue that the
effusion is unable to flow freely or is loculated
On CT – effusions settle _______-
On CT – effusions settle posteriorly as pt is supine
how to differentiate opacified hemithorax from PNA or pneumonectomy
no deviation of structures
exam your effin pt if they don’t have a lung you should know (or their ribs are missing)
what should we be able to see with a pneumothorax that you can’t see normally
Visceral pleura line must be visible
○ *The pleura only become visible when there is an abnormality present.
MCC of pneumothorax
MCC is trauma, with laceration of the visceral pleura by a fractured rib
what film finding would you see with a subtle pneumothorax
Expiratory upright film or Lateral decub film if subtle
Inspiratory film expands your lungs vs. expiratory film makes them smaller!
○ Lateral decubitus film b/c air rises!
what film finding would you see with a subtle pneumothorax
why?
Expiratory upright film or Lateral decub film if subtle
Inspiratory film expands your lungs vs. expiratory film makes them smaller!
○ Lateral decubitus film b/c air rises!
● Deep sulcus sign is seen in ______ or ______- with pntx
● Deep sulcus sign in supine pt or tension pntx
Deep sulcus sign
used to recognizing pneumothorax in the supine pt. The air of a pneumothorax will collect
anteriorly and inferiorly, displacing the costophrenic angle inferiorly. The angle becomes “deeper” and
more lucent
Tension pneumothorax
is a clinical Dx, usually after trauma. Sudden tachycardia/hypotension/hypoxia,
pain, resp distress, agitation, tracheal deviation AWAY from affected side, distended neck veins, absent lung sounds, pntx on ultrasound. Immediate lung re-expansion is life-saving – no time for a chest X-ray.
“Free Air” under the diaphragm is called_____ usually from
Pneumoperitoneum
perforated viscous (hole in the bowel), trauma, post-surgical, post-procedural
best film for recognizing a pneumoperitoneum
Lateral CXR good for small perfs – see air under diaphragms
○ Really small crescent of air seen separating the liver and diaphragm
tomach slides upward through diaphragmatic hiatus (opening in diaphragm for the esophagus).
● Diaphragmatic/Hiatal Hernia
History/patient presentation is key – may be completely asymptomatic (painless!)
○ Air-fluid level in stomach commonly seen through heart – straight lines are abnormal…
“Free air” around the mediastinum; seen as area of lucency around the heart and great vessels
Pneumomediastinum
Pneumomediastinum . caused by
Pulmonary interstitial emphysema is caused by rupture of an alveolus (d/t increased alveolar pressure)
Mechanical ventilation can also cause pneumomediastinum, as can ruptured bleb (COPD) or barotrauma
Air dissecting into the neck and chest wall can produce subcutaneous emphysema. Air dissecting along
muscle bundles produces a characteristic comblike, striated appearance that superimposes on the
underlying lung, often making it difficult to evaluate the lungs by CXR.
● Subcutaneous Emphysema
Hyperinflation ○ Flat diaphragms ○ Narrow cardiac silhouette ○ Increased retrosternal space on lateral - “barrel chest” ○ +/- blunting of costophrenic angle
all findings seen with
Emphysema
why do we see barrel chest on CXR of pt with COPD
increased retristernal air
what are Bullae on CT chest
Bullae measure more than 1 cm in size. They are usually associated with emphysema. They
occur in the lung parenchyma and have a very thin wall (<1 mm) that is frequently only partially
visible on CXR but well seen on CT.
what are the characteristics of bullae
Characteristically, they contain no blood vessels, but there
may be septae that appear to traverse the bulla. On conventional radiographs their presence is
often inferred by a localized paucity of lung markings.
CXR findings of lung cancer
○ Pulmonary nodule or mass
○ Mediastinal mass/hilar enlargement
○ Lobar atelectasis, obstructive pneumonia, malignant effusions, chest wall mass, metastases
CXR can mirror
effusions or PNA
– central, obstructive – rapid progression lung cancer
Squamous cell
peripheral, solitary – slow growing
Adenocarcinoma
central, Cushing’s, SIADH – fastest
Small cell/oat cell
– peripheral, dx of exclusion – fast
Large cell
Diagnostic tool you want to do first if suspecting lung cancer and why?
- low sensitivity; fast, inexpensive, low radiati
if you find something on your CXR what would you do next?
CT
evaluate CXR abnormalities; staging, screening
when would you use MRI for cancer?
MRI- not common for lung itself; good for cancer involving spinal cord, soft tissue of neck
probably use it more in the future
tests you would do after CT
PET scan - staging, diagnosis
○ Fluoroscopy- biopsy, diagnosis, staging of lesion
shoulder pain + older + smoker
typical presentation of
pancoast tumor
Typically destroy adjacent ribs
○ Usually squamous cell carcinoma or adenocarcinoma
pancoast tumor
Can invade the brachial plexus or cause a Horner’s syndrome on the affected side
○ On the right side, they can also lead to _____-through obstruction of the ____
pancoast tumor
Can invade the brachial plexus or cause a Horner’s syndrome on the affected side
○ On the right side, they can also lead to superior vena cava syndrome through obstruction of the SVC
Solitary Pulmonary Nodules
what size would indicate benign
<3cm
what age and risk factor would indicate a malignant pulmonary nodule
> 30 smoker
Poorly defined edges or “spiculated”
Asymmetric or no calcification
Cavitary
usually indicative or benign or malignant?
malignant nodule
Well-defined edges
No growth in 2 years
Central calcification
usually indicative or benign or malignant?
benign
Work-up for benign pulmonary nodule
Repeat CXR q3 mos for 1st year,
then q6 mos in 2nd year
what would you want to do if you see what you suspect malignant pulmonary nodule
CT, PET scan, biopsy
★★★Wide Mediastinum DDx: anterior
Anterior (retrosternal): “4 T’s” – Thyroid, (Terrible) Lymphoma, Thymoma, Teratoma
★ Wide Mediastinum DDx: middle
Middle: Lymphadenopathy, Cancers, Aortic Aneurysm
★ Wide Mediastinum DDx: posterior
Posterior: Aortic Aneurysm, Neurogenic tumors
spiculation
starburst border incredibly suspicious of cancer
hallmark of mediastinal mass
● Hallmark = wide appearing mediastinum
Chest, back pain
○ Risks, presentation
high suspicion
Thoracic Aortic Aneurysm
● CXR suspicious: of Thoracic Aortic Aneurysm
○ Wide mediastinum
○ Tortuous aorta :doesn’t do the arch thing
○ Left pleural effusion common
what is the difference b/w a aortic dissection and aortic anuerysm
intima (part of the lining of the vessel ) tears apart and away, blood will dissect down
viewed as little black line in an axial view
usually v painful
CXR in PE
CXR first in all for alternate Dx (but NOT diagnostic!!!)
○ Atelectasis, effusion, elevated hemidiaphragm
almost always normal
hamptons hump
: late finding (develops in 3-4 days), ipsilateral pleural-based infiltrate
Westermark sign:
late; oliguria (decreased vascular markings) distal to site of embolic blockage
if you want to RULE OUT a PE
CT scan with IV contrast – PE protocol
if you can not use a CT to dx because of renal failure or pregnancy
V/Q scan – if cannot use contrast, consider if pregnan
when would we use pulmonary angiogram to rule out a PE
probably never
would inject dye this would see westermark
Oligemia distal to the affected segment on pulmonary angiography
○ Used to be gold standard 6-8 yrs ago, but now rarely used
oliguria
decreased vascular markings
what can you see with US following trauma
Pneumothorax
- Fluid in chest (blood)
- Rib Fracture
indications for ULS
- Pulmonary Edema (CHF)
- Pulmonary Effusions
- Pneumonia
B LINES on ULS
obliterate A-lines
can dx pulmonary edema DONE
normally you would see acoustic shadow of the ribs and then A lines. B lines look like little sunshine rays coming down everywhere
besides pulmonary edema what else would cause B lines?
PNA but not throughout
only in pulmonary edema would we see B lines everywhere
fluid is what color on ULS
BLACK
allows you do dx plural effusion by looking at the costophrenic angel
in trauma you send this pt to the ER because that is blood
if you have an absence of Pleural Sliding WITH ULS
-No comet tail artifact
Pneumothorax
M-Mode to confirm PNX seen as
waves with no beach
aka barcode PNX
lung-point
Spot where lung moves in one area, not in adjacent area:
100% sensitive
infant normal variants on a CXR
Thymus
Cardiomegaly - in infants, cardiothoracic ratio can be up to 65% (not 50% as in adults)
CXR in peds are helpful for dx
Congenital heart disease
Infections
Foreign bodies
Tetrology of Fallot
cardiac defect that allows for dx w/ CXR in peds
steeple sign on CXR is indicative of
Croup – “steeple sign”
most common cause of a mediastinal mass overall.
Lymphadenopathy
__________ frequently presents with a border that is lobulated or polycyclic in contour owing to the conglomeration of multiple enlarged nodes.
Lymphadenopathy frequently presents with a border that is lobulated or polycyclic in contour owing to the conglomeration of multiple enlarged nodes.
_______is most common in Hodgkin’s Disease, especially the nodular sclerosing variety, which was this patient’s diagnosis.
Anterior mediastinal lymphadenopathy is most common in Hodgkin’s Disease, especially the nodular sclerosing variety, which was this patient’s diagnosis.
aneurysms are defined as enlargement of a vessel greater than ____- of its original size.
aneurysms are defined as enlargement of a vessel greater than 50% of its original size.
_____ is the most common cause of a thoracic aortic aneurysm. Most patients are asymptomatic and the aneurysm is discovered serendipitously.
Atherosclerosis is the most common cause of a thoracic aortic aneurysm. Most patients are also hypertensive. Most patients are asymptomatic and the aneurysm is discovered serendipitously.
a thick-walled cavity (dotted line) with a nodular inner margin (white arrow) characteristic of a _
a thick-walled cavity (dotted line) with a nodular inner margin (white arrow) characteristic of a cavitating bronchogenic carcinoma,
Solitary pulmonary nodules that are found on mass screenings of asymptomatic patients prove to be cancer less ____ of the time.
Solitary pulmonary nodules that are found on mass screenings of asymptomatic patients prove to be cancer less than 5% of the time.
Masses larger than 5 cm have a ___ chance of malignancy.
Masses larger than 5 cm have a 95% chance of malignancy.
_______is the most important determinant in distinguishing benign from malignant.
Calcification is the most important determinant in distinguishing benign from malignant. The presence of calcification is usually determined by CT.
Squamous cell carcinomas of the lung are primarily _____in location.
Squamous cell carcinomas of the lung are primarily central in location.
why would we want to do a left decubitus xray in a pt withe pleural effusion
(1) to establish if the fluid is free-flowing in the pleural space (which has implications for its successful drainage), or, on occasion
(2) to visualize the underlying lung if the patient lies on the side opposite from the pleural fluid for the radiograph.
acute airspace disease
Pneumonia
Pulmonary alveolar edema
Hemorrhage
Aspiration
Near-drowning
chronic airspace disease
Bronchoalveolar cell carcinoma
Alveolar cell proteinosis
Sarcoidosis
Lymphoma
reticular interstitial disease
Pulmonary interstitial edema
Interstitial pneumonia
Scleroderma
Sarcoid
nodular interstitial diseae
Bronchogenic carcinoma
Metastases
Silicosis
Miliary tuberculosis
Sarcoid
why don’t you see air bronchograms in pulmonary alveolar edema?
because fluid fills the lungs AND the airways themselves
what makes up the lung’s interstitium
The lung’s interstitium consists of connective tissue, lymphatics, blood vessels, and bronchi.
where does atelectasis most frequently occur in a critically ill patient
In the critically ill patient, atelectasis occurs most frequently in the left lower lobe.
only a pneumonia in this portion of the lung can be seen to extend above and below the minor fissue
but only a pneumonia in the superior segment of the LOWER LOBE can seem to extend both above and below the minor fissure
