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Radiology > Radiology of the Chest #2 > Flashcards

Radiology of the Chest #2 Flashcards

1
Q

DDx: air-space disease

A

•Pneumonias (some overlap with interstitial)
–Pneumococcal (lobar), Leigionella, PCP (late), etc
•Aspiration
•Pulmonary alveolar edema
–Cardiac (late CHF), non-cardiac (drugs, drowning, etc)
•Tuberculosis (some overlap)
•Pulmonary Hemorrhage
•ARDS (adult respiratory distress syndrome -overlap)
•Chronic alveolar Dz

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2
Q

Miliary TB

A
  • miliary pattern: interstitial form of TB
  • Diffuse, bilateral hilar adenopathy
  • Good lung aeration maintained
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3
Q

Pneumothorax on US

A

Absence of:

  • Pleural Sliding
  • No comet tail artifact

M-Mode to confirm

  • ”Ocean + beach” is normal
  • No beach or “barcode” = pneumo

Lung Point
-Spot where lung moves in one area, not in adjacent area: 100% sensitive

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4
Q

ARDS

A

delayed dyspnea, hypoxia, alveolar edema

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5
Q

Congestive HF on CXR

A 
•Fluffy, hazy air space densities
•Fluid in fissures, effusions
•Kerley B’s, peribronchial cuffing
•Cardiomegaly –common
•Cephalization
–Vessels prominent toward apices
•Engorged, hazy, “plump”                                                      pulmonary vasculature 
–Due to pulmonary venous hypertension
•Either/mixed interstitial/alveolar
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6
Q

Emphysema characteristics

A
  • Hyperinflation: increased space between 7-10 ribs
  • Flat diaphragms
  • Narrow cardiac silhouette
  • Increased retrosternal space on lateral -“barrel chest”
  • +/-blunting of costophrenic angle
  • Bullae
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7
Q

Lung Cancer Patterns on CXR

A
  • Pulmonary nodule or mass
  • Mediastinal mass/hilar enlargement
  • Lobar atelectasis
  • Obstructive pneumonia
  • Malignant effusions
  • Chest wall mass
  • Metastases
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8
Q

Malignant pulmonary nodule characteristics and workup

A 
•Malignant characteristics
–>30yo, smoker, risks
–>3cm, recent growth
–Irregular shape
–Poorly defined edges or spiculated
–Asymmetric or no calcification
–Cavitary

•CT, PET scan, biopsy

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9
Q

Chest trauma imaging

A 
•eFAST–ultrasound immediately at bedside
–Lung, cardiac
•CXR -standard
–Portable supine or semi-recumbent AP
•CT -standard
–With IV contrast, high sensitivity
•MRI
–Spinal cord injury; when ptis stable
•Fluoroscopy
–Esophageal tears
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10
Q

Air space disease

A 
•Air-space Dz characteristics 
–Air Bronchograms (space around air-filled bronchi is filled w/ fluid making bronchi visible) 
–Fluffy, hazy infiltrate
–Confluent with ill-defined edges
–Consolidations, lobar
–DDx: most pneumonias, TB, late CHF
–Silhouette sign
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11
Q

Pneumoperitoneum

A
  • “Free Air” under the diaphragm
  • Right usually seen first, easier to see
  • Perforated viscous (hole in the bowel)
  • Trauma
  • Post-surgical
  • Post-procedural
  • Lateral CXR best for small perfs–see air under diaphragms
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12
Q

Pulmonary embolus

A 
•CXR first in all for alternate Dx
–Atelectasis, effusion, elevated hemidiaphragm
–Hampton’s hump, Westermark sign (late)
•CT scan with IV contrast 
–PE protocol
–Moderate to high risk
–New Gold Standard
•V/Q scan
–If cannot use contrast, consider if pregnant
•Pulmonary angiogram
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13
Q

Mediastinal Masses, enlargement

A

Hallmark = wide appearing mediastinum

Anterior (retrosternal) -4 Ts

  • Thyroid
  • (Terrible) Lymphoma
  • Thymoma
  • Teratoma

Middle

  • Lymphadenopathy
  • Cancers
  • Aortic Aneurysm

Posterior

  • Aortic Aneurysm
  • Neurogenic tumors
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14
Q

Difference in CXR for atelectasis vs pneumonia

A

Atelectasis: volume loss, ipsilateral shift of mediastinal structures, linear wedge shaped opacification, in lobar collapse apex is at the hilum

Pneumonia: normal or increased volume, no shift in mediastinal structures, air space dz, no apex

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15
Q

Benign pulmonary nodule characteristics and workup

A 
•Benign characteristics
–<30yo, no risks
–Small <3cm
–Round, solid
–Well defined edges
–No growth in 2 yrs
–Central calcification

•Work-up -old CXR
–Repeat q 3mos first yr
–Q 6mos in 2nd yr

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16
Q

Aspiration pneumonia

A

usually favors lower lobes (if pt was supine)

17
Q

Foreign body

A 
•Children < 5 most common
•In the bronchi, trachea or esophagus?
•CXR: PA +lateral -to locate
–Collapse of lung/atelectasis
–Aspiration 
–FB must be radiopaque to see it 
•Bronchoscopy
18
Q

Interstitial disease

A 
•Interstitial Dz: 
•Supportive structures of air-spaces affected
•Usually bilateral
•Masses, dots, lines, thickening
•Discrete “particles” of Dz
•No lobar margins
•DDx:
–Some pneumonias, usually atypical: viral, fungal, etc
–Systemic Dz –sarcoid, RA, etc
–Cancer, mets
–Pulmonary fibrosis, occupational 
–TB –cavitary lesion, milliary
19
Q

Atelectasis

A

•Incomplete aeration/expansion of the lung –no air there
•Volume loss causes “collapse” –white on CXR
•Structures shift to sameside, fissures displaced
•Major Types:
•Subsegmental:“discoid”, “plate-like”, linear
–Common condition: pleuritic pain; post surgery, trauma, scarring
•Compressive: with effusion, pneumothorax, mass
•Obstructive: partial or complete
–Lobar collapse, opacified hemithorax
•Round: pleural based, post effusion/dz

20
Q

Thoracic aortic aneurysm

A

High suspicion w/:

  • Chest, back pain
  • Risks, presentation

CXR suspicious:

  • wide mediastinum
  • tortuous aorta
  • L pleural effusion common

CT angio, echo

21
Q

Pulmonary edema on US

A

Normal lung:

  • See the pleural line move with respiration
  • See horizontal A-lines, “comet tail” artifact

Pulmonary Edema:

  • See B-lines
  • Bright, vertical, obliterate the A-lines, fill the screen, bilateral

Pneumonia: unilateral or one area of B-lines and “hepatization”

22
Q

Silhouette sign - structure obscured and location of dz

A
  • Ascending aorta - RUL
  • R heart border - RML
  • R hemidiaphragm - RLL
  • Descending aorta - LUl or LLL
  • L heart border - Lingula of LUL
  • L hemidiaphragm - LLL
23
Q

Pneumothorax

A

•Lucent lung, no lung markings (not symmetric!)
•Visceral pleura line visible
•Check apices and edges!
•Expiratory upright filmor Lateral decubfilm if subtle
•Deep sulcus sign in supine ptor with tension pntx
-CT best for small pntx

24
Q

Obstructive lobar atelectasis

A

•Lobar collapse -obstructing tumor, FB, etc
•Opacificationwith evidence of volume loss
–Tracheal deviation
–Mediastinal deviation
–Elevated hemidiaphragm
–Upward bowing of fissures
–Hyperinflation remaining lung on same side
–Rib cage narrowing

25
Q

Identifying opacities

A 
•Opacities are dense (white) areas on CXR that represent Dz
•DDxdepends on it’s characteristics
•Consider your patient
•Major categories = 
–Air Space or Interstitial dz
–Patterns overlap, can have both
–Visible on both CXR and chest CT
26
Q

Opacified hemithorax: ddx

A 
•“White out” of one side of chest
•Are structures pushed or pulled? (trachea, etc)
•Atelectasis of entire lung
–Structures shift toward opacified side
•Large pleural effusion or mass
–Structures shift away from opacified side
•Pneumonia of entire lung
–No shift, maybe air-bronchograms
•Pneumonectomy of entire lung
–Missing ribs, surgery clues
27
Q

PE Dx gold standard test

A

Chest CT w/ Contrast, PE protocol

28
Q

Tuberculosis

A
  • Air space disease and/or interstitial
  • Patchy or consolidated
  • Primary TB: infiltrate anywhere w/ ipsilateral hilar adenopathy
  • Reactivation TB: upper lobes/apices -infiltrate, cavitation, effusion, hilar adenopathy
  • Miliary TB is considered primary –interstitial pattern
29
Q

Causes of interstitial disease

A

•Pulmonary interstitial edema
–Precursor to alveolar edema, overlaps air-space
–Cardiac (CHF) and non-cardiac
•Cancer, metastases
•Pneumonia (special ones)
–PCP, influenza, varicella, histo-, coccidio-, crypto-
•Sarcoidosis, RA
•Pneumoconioses -“dusty lung”
–Asbestosis, silicosis, coal worker’s lung, etc(top photos)
•Pulmonary fibrosis
•TB – milliary, cavitary

30
Q

Pulmonary edema causes

A

•Cardiogenic, CHF (cardiomegaly common)
•Non-cardiogenic
–Heart +/-normal; less commonly see KerleyB, effusions
–Near drowning, inhalation injury
–Drug hypersensitivity, overdose (heroin)
–Fluid overload -renal failure/uremia
–High altitude pulmonary edema (HAPE)
•Considerable overlap in patterns –look at the patient

31
Q

Pediatric chest

A 
•Normal variants
–Thymus
–Cardiomegaly -in infants, cardiothoracic ratio can be up to 65% (not 50% as in adults)
•Congenital heart disease
•Infections
•Foreign bodies
32
Q

Ultrasound of the lung indications

A
  • Pulmonary Edema (CHF)
  • Pulmonary Effusions
  • Pneumonia

In Trauma:

  • Pneumothorax
  • Fluid in chest (blood)
  • Rib Fracture
33
Q

Interstitial (infiltrative) characteristics on CXR

A
  • Thin white lines: reticular
  • Dots (nodules): nodular
  • Dots & lines: reticulo-nodular •Masses, honeycombing
  • No air bronchograms
  • No lobar margins
  • If diffuse, usually bilateral
  • Areas of normal lung may be present w/ good aeration
34
Q

Pleural dz: effusion

A 
•Infection
•Malignant
–Chest or abdominal
•CHF
•Trauma, toxic
•Renal failure
•Chronic lung disease
•KEY: blunting of costophrenic angles
–concave meniscus sign
35
Q

Large pleural effusions

A
  • Large effusions shift chest structures awayfrom effusion
  • No air bronchograms, fluid “crawls up” pleural edge (concave meniscus)
  • Cannot estimate cardiac size in either patient above as effusion obscures the cardiac border
  • Cause? Can it be tapped for analysis? Does it “layer out”?
  • Can use a lateral decubitus view to see if it “layers out”
36
Q

Air-space (alveolar) characteristics on CXR

A
  • Air bronchograms
  • Fluffy, hazy infiltrates
  • Opacities confluent, margins indistinct
  • Segmental/lobar consolidation common
  • “bat wing”pattern
  • Silhouette sign
37
Q

Pleural effusion on US

A

Normal R side

  • No black area between the liver and/or spleen and the diaphragm
  • Curvilinear probe

Pleural Effusion

  • Look at costophrenic angle (position 4 L&R)
  • Black on US = fluid
  • See black in space = effusion (or blood)
  • Ultrasound guided thoracentesis now standard
38
Q

Imaging suspected lung CA

A 
•CXR-low sensitivity
–But...is fast, inexpensive, low radiation
–Screening tool
•CT-evaluate CXR abnormalities
–Staging, screening
•MRI-not common for lung itself
–Cancer involving spinal cord, soft tissue of neck -yes
•PET scan -staging, diagnosis
•Flouroscopy/Broncoscopy/VATS procedure
–biopsy, diagnosis, resection

Radiology (4 decks)

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