lower respiratory system and mediastinum part 2 Flashcards
what is Chilaiditi sign?
Is the anterior interposition of the colon to the liver reaching the under surface of the right hemi-diaphragm
One of the cause of pseudopneumoperitonuem
Can have Chilaiditi syndrome where patients experience pain
Breast implants- assumptions
Makes it look like patients got a chest infection on general x-ray whereas MRI shows it clearly.
What is Dextrocardia?
In dextrocardia, the heart is positioned on the right side of the chest instead of its normal position on the left side. Dextrocardia on its own does not usually cause problems, but it tends to occur with other conditions that can have serious effects on the heart, lungs and other vital organs.
Hiatus hernia: Description, causes, symptoms, diagnosis, complications, treatment and differential diagnosis
Occurs when there is herniation of the abdominal contents through the oesophageal hiatus of the diaphragm
Causes: Increases with age and slight female predilection
Symptoms: May be symptomatic
Chest / abdominal pain
Nausea and vomiting
Sometimes GORD (gastro-oesophagel reflux disease)
Diagnosis:
Plain film- retrocardiac opacity with air fluid level.
CT- fat collection in middle mediastinum, may see hernia or widened oesophageal hiatus
Complications: Volvulus of stomach
Treatment: Surgery in severe cases
Differential diagnosis: Can make the heart difficult to assess or look like a collection or abscess (mass behind the heart)
Pulmonary embolic disease: Description, causes, symptoms, diagnosis, complications, treatment and differential diagnosis
Description
Most commonly a blood clot (which oftenstarts in the leg), which travels through the circulatory system and then causes a blockage in the pulmonary artery – can be partial or complete
Stops blood getting to your lungs.
Lung tissue ventilated but no perfusion.
Struggle to breathe as there is no gas exchange which leads to breathing problems.
Less area of lung to oxygenate.
Which can lead to cardiac arrest.
Causes:
Recent surgery
Immobility
Diseases with a risk of thrombus formation e.g. lupus, HIV, Covid
Drugs such as the contraceptive pill,
Pregnancy
Malignancy
Symptoms:
History fitting any of the causes above
Tachycardia, dyspnea (difficulty breathing), chest pain, hemoptysis
Signs of a DVT
Treatment:
Anticoagulation
CPR if necessary
Differential diagnosis
Movement
Slow flow contrast – poor opacification
Diagnosis
Elevated d dimer
Positive scoring on Wells or other scoring system
Complications
PEA in the case of a cardiac arrest
Right ventricular strain
Pulmonary infarction
Pulmonary hypertension
What occurs in Pulmonary embolic disease?
In PE lung tissue is ventilated but not perfused, producing an intra-pulmonary dead space and resulting in impaired gas exchange
After several hours, alveolar collapse occurs which worsens hypoxemia
This leads to a reduction in the cross sectional area of the pulmonary arterial bed which results in elevation of pulmonary artery pressure and a reduction in cardiac output.
The area of lungs that is no longer perfused by the pulmonary artery may infarct but often doesn’t because oxygen is still supplied by the bronchial circulation and the airways
Large or multiple emboli can abruptly increase pulmonary arterial pressure to a level of afterload which cannot be matched by the right ventricle – sudden death may occur, or the patient may suffer from hypotension or syncope which can progress to shock or death due to acute right ventricular failure.
Most common source of PE is DVT in the lower limbs
Chronic thromboembolic pulmonary hypertension (CTEPH) occurs in 0.5-5% of people with treated PE – emboli are replaced by fibrous tissue which can lead to chronic obstruction of the pulmonary arterial vasculature. This leads to progressive increases in pulmonary arterial pressures leading to right heart failure.
Pulmonary oedema: Description, causes, symptoms, diagnosis, complications, treatment and differential diagnosis
Description: Accumulation of fluid in the interstitial and alveolar spaces – very broad term! it manifests in 2 types – alveolar and interstitial
causes:
Cardiogenic- (caused by heart)
Congestive heart failure
Cardiomyopathy
Arrythmias
Mitral regurgitation
Non cardiogenic (not caused by heart)
Near drowning
O2 (post intubation)
Trauma
CNS
Alveolitis (hypersensitivity pneumonitis)
Renal failure
Drugs
Inhaled toxins
Altitude- differences in oxygen levels if your high up
Contusion
symptoms: Breathlessness, distress, high heart rate due to fluid in the lungs- blocking gas exchange
diagnosis: CXR – increased cardio/thoracic ratio, upper lobe pulmonary venous diversion, alveolar signs (batwing shadowing, airspace shadowing, consolidation), interstitial signs (Kerley B lines, thickening of the fissures), pleural effusion.
CT – ground glass opacification, septal thickening
US – B lines
complications: Depends on underlying cause, but can result in large pleural effusions. Also leads to impaired gas exchange and can result in respiratory failure.
treatment: Depends on underlying cause
differential diagnosis: Pulmonary haemorrhage
pneumonia
Aortic dissection (Type A): description, causes, symptoms
Description
Separation in the aortic wall intima (tear), allowing blood to flow between the layers of the aortic wall (inner and outer walls of the media). Type A – ascending aorta with or without the aortic arch and descending aorta. Type B – mainly descending aorta and / or abdominal aorta.
Causes
Risk factors include:
Hypertension
Marfan syndrome- connected tissue disorder
Ehlors-Danlos syndrome- connected tissue disorder
Symptoms
Acute severe chest pain
Left right blood pressure differential
Pulse deficit
Dyspnoea
Aortic dissection: Diagnosis __- imaging is essential to classify the dissection and decide on a treatment plan
CXR - _not specific and may appear normal. However, you may see:
Widened mediastinum
Irregular aortic contour
Deviation of the mediastinum and / or trachea
CT - _Investigation of choice. Sensitivity and specificity of nearly 100%. Needs to be a contrast scan, preferably a CT angiogram. Will see
Dilation of the aorta due to aortic insufficency
Double lumen
MRI - _mainly used in follow ups, but useful in patients with poor renal function. Issues with an acutely unwel patient. Similar snesitivity to CTA
US- _not often used due to availability of CT but can perform transoesophageal echocardioraphy
Aortic dissection: complications, treatment and differential diagnosis
Complications __
Organ ischaemia
Stroke
Paraplegia
Aortic rupture
Mortality of 10-35% in hospital
Treatment__
Aggressive blood pressure control with beta blockers to reduce blood pressure and heart rate
Immediate surgical repair
Differential diagnosis_
CXR – any cause of mediastinal widening
CT – pseudo dissection – motion artifact, adjacent adjacent infection
Symptoms – PE, pneumonia, acute coronary syndrome (STEMI, NSTeMI, unstable angina)
Pneumonia: Description, causes, symptoms, diagnosis, complications, treatment and differential diagnosis
Description: Broad term to describe acute infection on the lung parenchyma (functional tissue e.g. alveoli)
causes: Infection e.g. COVID 19, bacteria, viral or fungal
symptoms: Productive cough / breathlessness / chest pain
High temperature (pyrexia), sometimes associated with tachycardia
Malaise
diagnosis: CXR – air space opacification
CT – not generally used as the initial diagnostic tool, but useful in cases with complications or for follow up
complications: Empyema
Pulmonary abscess
Bronchopleural fistula- tract between lung and pleura
treatment: Antibiotics
Potentially follow up imaging
differential diagnosis: Consolidation Mass
Primary lung cancer: Description, causes, symptoms, diagnosis, complications, treatment and differential diagnosis
Description
Broad term referring to primary lung malignancy. You may also see the term bronchogenic.
Causes
Tobacco smoking
Asbestos
COPD
Symptoms
Patients may be asymptomatic in up to 50% of cases
Hemoptysis- coughing up blood
Cough and dyspnoea
Pleural effusion
Pneumonia
Diagnosis
CXR – may see a lung nodule – rounded or irregular area of increased attenuation. May also see a widened mediastinum, pleural effusion or consolidation
CT – nodule or mass with spiculated or irregular margins. Mat see cavitation. Or metastases.
PET-CT – assists with staging and assessment of nodal and distant metastatic spread. The Role of PET Scan in Diagnosis, Staging, and Management of Non‐Small Cell Lung Cancer - Schrevens - 2004 - The Oncologist - Wiley Online Library
MRI - Magnetic Resonance Imaging in Lung Cancer - ScienceDirect
Complications
Metastatic spread
Pleural effusions and infections leading to difficulty in breathing
Treatment
Surgery, chemotherapy, radiotherapy depending on status of tumour
Molecular testing can help with targeted treatments
Differential diagnosis
Consolidation
TB
Pleural effusion: Description, causes, symptoms, diagnosis, complications, treatment and differential diagnosis
Description: Is any accumulation of fluid in the pleural cavity – this could be simple fluid, blood, pus etc. Results from many pathological processes which overwhelm the pleura’s ability to reabsorb fluid.
causes: Most common are cardiac failure and malignancy
symptoms: Small amount may have no symptoms
As volume increases symptoms include breathlessness especially when active
Causes are generally split into transudate and exudate. See next slide
diagnosis: US – allows detection of small amounts (3-5ml) and can help guide for pleural taps or drainage.
CT – excellent in detecting small amounts.
CXR – most commonly used imaging method. BUT needs as much as 250mls – 600mls of fluid to see.
Will see blunting of the costo and cardiophrenic angles, fluid within the horizontal fissure, fluid level and may see some mediastinal shift if large.
complications: Lung collapse
Fibrotic changes- scarring
treatment: Targeted to underlying cause
May drain- if it is large
differential diagnosis: Elevated hemidiaphragm
Collapse or conslidation
Pleural thickening
Pleural effusion: transudate and exudate
Transudate
Lower protein content (<30g/L)
Occurs when there is an increase in hydrostatic pressure
Cardiac failure
Cirrhosis
Trauma
Post coronary surgery
Exudate
Higher protein content (>30 g/L)
Occurs due to an alteration in the pleural space drainage to lymph nodes
Bronchial cancer
Lung metastases
PE
Pneumonia
TB
Mesothelioma
Pleural effusion – AP / Pa erect
Erect films are insensitive to small amounts of fluid
May see blunting of the costophrenic angle
Blunting of the cardiophrenic angle
Fluid within the horizontal or oblique fissure
Eventually a meniscus will be seen, (not with a hydropneumothorax)
Lateral images can identify a smaller amount of fluid