Pulm Flashcards
What does the heart look like on PA and AP?
PA vs AP: heart size-looks larger in AP
Lateral: use the spine and heart for orientation
Describe anatomical structures of the thorax
What do the carina and bronchi look like on CXR?
Where should the trachea be?
Over the vertebrae with the division of the carina.
An aspiration from the right bronchus will end up in what lobe?
RLL
What do the lungs look like on chest x-ray?
The lung fields: left upper and lower, right upper, middle, lower, and posterior lower lung extends superiorly and inferiorly. Usually need 2 views a AP and PA view.
What is the anatomy of the diaphragms on x-ray?
Liver elevates right side just a little. Sometimes we can see gastric bubbles from the stomach
1= right hemidiaphragm-higher because it is right under the heart.
2= left hemidiaphragm-higher at spine
You should be able to define the costophrenic angles and cardiophrenic angles
The costophrenic angles are in yellow, green, and blue
The cardiophrenic angles are in red.
Angles should be sharp
If in cardiophrenic-may be sticky like pneumonia. Usually gets rapped in costophrenic fluid collects at lowest portion and we will get a small sign
What does the heart and blood vessel anatomy look like on chest x ray?
What parts of the heart can we see on chest x ray?
On the PA view, how does heart size look?
Heart diameter should be less than ½ of the chest diameter. If they have a bigger heart than this in this view it indicates CHF
What does the aorta and other vessels look like on chest x ray?
The aorta has a small area that may be visible on the right side. The aortic knob is on the left and the descending aorta along the thoracic vertebrae. There is also the pulmonary trunk and the aortopulmonary window.
What is the aortopulmonary window?
In fetal development it is called the ductus arteriosum which will degrade into the ligamentum arteriosum. it helps develop the aortopulmonary window.
If the ductus arteriosum does not close, what happens?
It will cause a congenital heart defect
Describe the structures of the aorta, pulmonary trunk, and aortopulmonary window
Aorta in red, pulmonary trunk in yellow, and aortopulmonary window in blue
Describe the structure of the pulmonary arteries
L/R pulmonary arteries and L/R hilum
Define these vessels (aortic knob, aorta, pulmonary trunk, right pulmonary artery, and left pulmonary artery) in this picture.
Define these heart areas: aorta (ascending arch, descending), pulmonary trunk, aortopulmonary window.
The circle is the aortopulmonary window
The aortopulmonary window is easier to see on what view of chest x ray?
Lateral
What are the 3 lateral spaces and how do they look on a lateral chest x-ray?
Retrosternal (red), retrocardiac (yellow), and retrotracheal (blue). Vertebrae become darker inferiorly. Spinal processes are whiter as we go down, there is an infiltrate.
How does the scapula look on chest x-ray and how can it be confusing?
When looking at vertebrae on chest x-ray what should we be looking for?
Should see brighter white of spinous process in center of trachea and look for alignment of the vertebrae.
What do the clavicles look like on chest x-ray?
Medial portions of the clavicles should be aligned and acromioclavicular joints should be equidistant to clavicles. The bottom of the clavicle should line up with the bottom of the acromioclavicular joint
Can you identify these things in the following chest x ray?
Trachea and L/R bronchi
L/R hemidiaphragms and costophrenic angles
heart areas and heart borders
Aortic knob, aorta, aortopulmonary window
L/R pulmonary arteries/hila
Vertebrae and spinous processes
Count the ribs
Clavicles, scapula
Any other organs-liver, stomach
Correctly identify an artifact on a chest x-ray.
Breast shadows for an objects, artifacts from clothing, jewelry, pacemakers, wires, or tubes, external or internal hardware from prior surgeries and subcutaneous air. Breasts, pacemakers/defibrillators, sternotomy wires, heart valves, EKG wires and electrodes, metal snaps from a gown, jewelry, hair, hair bands
Accurately count anterior and posterior ribs on a chest x-ray.
Ribs-anterior vs posterior
Vertebrae-spinous processes, body, transverse processes
Clavicles, Scapulae, Humeruses
Posterior (dorsal) portion runs horizontalish
Anterior (ventral) portion runs at angle
The 1st rib-smaller and broader and the 2nd rib right under 1st
Can you identify these things on the following lateral chest x-ray?
Trachea
L/R hemidiaphragms and costophrenic angles
Heart areas
Aorta, pulmonary trunk, aortopulmonary window
Lateral spaces
vertebrae
This is not a good retrotracheal space and we should be worried mass/abscess right there
What are the indications for a CXR?
This is often the initial imaging modality. Indic: SOB, dyspnea on exertion, chest pain (aortic dissection), Hemoptysis (lung mass, cancer, CXR), increased sputum production
List the things that need to be assessed to determine the quality of a chest x-ray.
Rotation
Inspiration
Position
Exposure
Left hemidiaphragm should be visible to the spine. Thoracic vertebrae should be barely visible behind the heart. Lung markings should extend to the edges (vessels inside the lungs we’re seeing). CXR has the most quality markers. Make sure there is good exposure.
Look at rotation of spinous processes and these should be midway between the medial ends of the clavicles. Make sure positioning is good and the spinous processes should be equidistant from the medial end of each clavicle. Check degree of inspiration and rib counting- should see 9-10 posterior ribs/ 6-7 anterior ribs
Explain the appearance of a chest x-ray if it is over-exposed versus under-exposed.
Make sure there is good exposure.
Too dark means there is over penetration and overexposure. Too bright it is underpenetrated and underexposed.
What is this pathology?
tram tracks
Bronchiectasis is often described as “tram tracks” more severe inflammation in the walls of the bronchus. These are pts that we initially think have COPD and it doesn’t get better. Walls of bronchi are thickened, inflamed, and floppy. Seen better on CT. Two parallel white lines= tram tracks
What is this pathology?
Steeple sign: Kids croup
A narrowing at the start of the trachea and is characterized by laryngotracheal inflammation.
What is this pathology?
Trachieal deviation. Both of these pictures are masses. Masses like lymphoma, sarcoidosis, enlarged mediastinal lymph nodes
Tension Pneumothorax (collapsed lung)
Prior pneumonectomy (where they have taken out a lobe of the lung, now there are pressure differences between the lungs)
What is this pathology?
Bronchial occlusion. Left main bronchus occlusion on left and right upper bronchus occlusion with superior lobe occluded on right image. If it is along the lines of the lobes, this gives a clue that it is not an infection, but an occlusion. Often causes collapse of lung tissue distal to obstruction. Examples include the left main bronchus obstruction and the right upper bronchus obstruction. The collapse will appear brighter and if you see whiteness, this is most likely an occlusion of the bronchus. Can happen in single lobes as well like seen in image 2. Follows lines of fissure of the lobes. Can be caused by thick mucus secretions and plugs (bronchoscopy)
What does fungal pneumonia look like on CXR?
Often bilateral because we are inhaling fungal spore. scattered denser areas in more diffuse ground glass opacities
What is this pathology?
gGroung class opacities. Bottom left is normal. Viral pneumonia-tends to be bilateral and less dense on xray (“ground glass”), Covid, flu
What is this pathology?
peribronchial cuffing
Inflammation of walls of smaller bronchi/mucus plugging of small bronchi. Common causes are: bronchiolitis (RSV), cystic fibrosis. Developmental disorders in premature infants. Look like a bright ring with a dark center. We are seeing the ring of the wall inflamed.
What is this pathology?
Bacterial pneumonia- tends to be lobar, unilateral, consolidation, wont follow lines of the lobes. Can often see a consolidation of dense area of fluid/inflammation
‘lobar’= confined to a lobe
What is this pathology?
Aspiration pneumonia -more likely in lower lobes and more common to end up in the right than left.
What is this pathology?
costophrenic angle blunting
PLEURAL EFFUSION. Blunting of the costophrenic angles (bilateral vs unilateral)
Fluids work with gravity and therefore collect at the lowest point. Supposed to be able to see costophrenic angles.
Bilateral: heart problems, backup of fluid. heart failure, liver cirrhosis, nephrotic syndrome, and pancreatitis. Usually non-pulmonary reasons
Unilateral: masses, lung issues-pneumonia and cancer. Usually pulmonary causes.
Bilateral on the left. Unilateral on the right.
Effusions can take up the whole lung, we would just see a little white around the encasing of the lungs.
What is this pathology?
Cavitary lesion in the right lung is fluid filled. cancers can cause this. We can figure out sometimes based on sx and CT, but we will most likely need to biopsy it.
What is this pathology?
Cavitary lesion in the left lung inferior lobe that is not fluid filled.
Compare and contrast the advantages and disadvantages of a CT chest versus a chest x-ray.
Advantages to chest CT: No superimposed structures, high definition of structures, better visualization of nodular opacities, can image vasculature with contrast, high resolution, thin slices, 3D reconstruction often available.
Disadvantages to chest CT: Radiation exposure increased, not portable and there is risk of contrast with allergies
CXR: accessible, cost effective, less radiation, quick
What is the gold standard for visualization of pulmonary arteries?
Pulmonary angiography and fluoroscopy x-ray
Dye injected into pulmonary arteries individually and images taken. Minimally invasive-right heart catheterization. Gold standard for blood clots, but rarely done
What is this pathology?
This would be going to the left lung. Will usually go into either the radial artery or femoral artery. There are risks for perforation.
They can dissolve the clot by dripping TPA on it or they can go in and physically pull the clot out.
Describe the appearance of the following on an ultrasound:
pleural effusion
US done at the bedside. Blood or fluid is black. Guiding the needle for thoracentesis.
Pleural effusion- dark area between lung and liver/diaphragm
Describe the appearance of the following on an ultrasound:
pneumothorax
Normal pleural line- bright white where movement of pleura is noted in normal lung-sliding and PTX air space if noted, no sliding of pleura
The visceral and parietal pleura slide against each other. Pneumothorax will not slide, looks like a barcode.
Describe the appearance of the following on an ultrasound:
pneumonia
Areas of consolidation appear more heterogenous and bronchograms are noted as bright
Describe the Allen test and how to interpret it.
To assess adequate blood flow of the hand. We would hold/occlude both the radial and ulnar arteries and we will ask the patient to make a fist and then release and we will release pressure form the ulnar artery. If the hand gets its red color back, the test is positive, and this means there is good blood flow through the ulnar artery. If it is negative, it will look like the picture on the right. Right side picture is a negative allen test
Positive means good blood flow and this means we are good to proceed
Describe what an anion gap is, and how to calculate it.
Anion gap= Na - (Cl+ CO2) = 8-16 meq/L when we dont use potassium
When the gap is over 20: this is concerning for an extra acid present
