Respiratory - finished

Question 1

What are the normal projections of the Chest

Answer 1

PA Lateral - usually Left

Question 2

When is an inspiration and expiration study taken?

Answer 2

For pneumothorax

Question 3

Are other chest films taken on inspiration or expiration?

Answer 3

Full Inspiration

Question 4

What is the system for interpreting chest xrays?

Answer 4

1. Request form
   - name, age, sex, date and clinical information
2. Technical
   - centering, position, degree of inspiration, exposure (finger held behind black area should just be visible)
3. Trachea
   - Position (midline?), outline
   - Bifurcation
4. Heart and Mediastinum
   - Size, shape and displacement
   - Check great vessels (arch and asc. aorta)
   - Cardiac diameter=less than half width of chest
5. Diaphragms:
   - Right side is 2.5cm higher than left (liver)
6. Pleura:
   - Costo-phrenic and cardiophrenic angles (sharp and clear bilat and in both PA and lateral
7. Lung fields:
   - Compare bilat for markings and translucency
8. Hidden areas:
   - apices of the lungs
   - diaphragms, mediastinum and bones
9. Hila:
   - Left is higher than right
   - Should be able to see individual vessels
10. Below diaphragm
    - gas shadows
    - any calcification
    - splenomegaly/hepatomegaly
11. Soft tissues:
    - density changes
12. Bones:
    - should see 9-10 ribs above the diaphragm
    - check for scoliosis

Question 5

What colour is an overexposed film

Answer 5

Blacker

Question 6

What colour is an underexposed film?

Answer 6

Paler

Question 7

What are the 2 types of metastatic carcinoma in the chest

Answer 7

Haematogenous metastasis

Lymphangitic metastasis

Question 8

What is the commonest type of primacy malignant cancer in the lungs?

Answer 8

Bronchogenic carcinoma

Question 9

What % of primary lung tumours does bronchogenic carcinoma account for?

Answer 9

90%

Question 10

What is the clinical presentation of bronchogenic carcinoma?

Answer 10

90% of male and 70% female patients (35% of cause of death in males)

Cough or wheezing

Sputum may be bloody

Weight loss and weakness are late signs

Beware of pneumonia that clears with antibiotic treatment but then reoccurs.

Question 11

What are the radiographical features of bronchogenic carcinomas?

Answer 11

Most are endobronchial - apical primary carcinoma = Pancoast

Atelectasis is the most common sign
- collapse or closure of a lung resulting in reduced or absent gas exchange

Opacity of non-aerated lung tissue

May alter size/shape of lobes or segments

May cause an elevated hemidiaphragm

May see a solitary mass of nodule almost always without calcification

Often assoc. with unilateral hilar enlargement.

Question 12

Describe pneumonia

Answer 12

A viral or bacterial infection of the alveolar epithelium

Many types of pneumonia - commonest = lobar pneumonia.

May spread to entire lobe

Question 13

What % of pneumonias are caused by Streptococcus pneumonia?

Answer 13

75%

Question 14

What is the clinical presentation of pneumonia?

Answer 14

Acute onset (days to week) with a productive cough, haemoptysis common, with pleuritic chest pain, chills and high fever. Often features tachycardia (120bpm), headaches and malaise. Percussion of dullness, tactile fremitus and bronchial breath sounds.

Question 15

What are the radiographical features of lobar pneumonia?

Answer 15

Confluent airspace opacification

Focal spherical consolidation

Lobar enlargement - caused by oedema

Fissue bulges away from the involved lobe

Lobar pneumonia superimposed on emphysema resemble necrosing pneumonia (numerous small lucencies within consolidated area of lung.

Question 16

Define tuberculosis

Answer 16

Infectious agent is the mycobacterium. Incidence declined in 80’s but since then has slowly increased. Children, elderly and immuno-compromised populations vulnerable to primary TB.

An airborne infection which favourites sites for seeding are

1) in lungs (lower lobes first then spread to apices),
2) in the skeleton (long bone metaphyses and vertebral bodies) and
3) in other organs (as kidneys and brain cortex).

Question 17

What is the clinical presentation of tuberculosis

Answer 17

Often asymptomatic, may see general malaise, night sweats, cough (early morning, minimal productive), dyspnoea may result from spontaneous pneumothorax or pleural effusion, haemoptysis is a late manifestation.

Question 18

What are the radiological features of tuberculosis?

Answer 18

Primary:

• parenchymal consolidation (usually lower lobe)
• hilar and mediastinal lymphandenopathy
• pleural effusion (rare), with healing consolidation may regress to a clearly defined nodule, which may be resorbed or which may calcify
• Ghon tubercle: calcified tubercular granuloma in the lung field (coin lesion), and
• Rhanke complex: enlarged hilar lymph node with ipsilateral calcified granuloma (Ghon tubercle) in the peripheral lung field.

Question 19

What is a pneumothorax?

Answer 19

Free air between the visceral and parietal pleura

Question 20

What are the aetiologies for pneumothorax

Answer 20

1) Trauma (penetrating injury to chest wall, fracture rib)
2) Pulmonary barotrauma from mechanical ventilators
3) Spontaneous (no antecedent trauma, may be due to localised disease)
4) Tension pneumothorax where air can enter the pleural space but not leave unless the pressure within the spaces rises above atmospheric pressure

Question 21

What is a primary pneumothorax? How does it differ from a secondary

Answer 21

is one that occurs without an apparent cause and in the absence of significant lung disease, while a secondary pneumothorax occurs in the presence of existing lung pathology.

Question 22

What is an open pneumothorax

Answer 22

occurs when there is a pneumothorax associated with a chest wall defect, such that the pneumothorax communicates with the exterior.

Question 23

What is a closed pneumothorax?

Answer 23

results when the chest wall is punctured or air leaks from a ruptured bronchus (or a perforated oesophagus) and eventually ruptures into the pleural space.

Question 24

What is the clinical presentation of pneumothorax?

Answer 24

Varies depending on extent of involvement and aetiology.

May see sudden:

• sharp chest pain
• dry hacking cough
• may develop severe dyspnoea
• shock
• respiratory failure
• circulatory collapse

Referral of pain to shoulder, chest and abdomen, diminished voice and breath sounds, hyperresonant percussion sounds, diminished absent tactile fremitus, and diminished chest excursion on affected side.

Question 25

What is the radiological appearance of a pneumothorax?

Answer 25

• Mediastinum shifts to unaffected side with large pneumothorax
• Tension pneumothorax results in complete lung collapse and contralateral mediastinal shift, with hemi-diaphragm depressed or inverted.
• Pneumothorax is usually at lung apex, and lateral to lung; but air may accumulate medially or inferior to lungs.
• PA film taken on full expiration may detect a small pneumothorax. Lateral decubital with affected side uppermost (display air along lateral borders).

Sail sign**

Question 26

Define COPD

Answer 26

Emphysema is a lung disease that involves damage to the air sacs (alveoli) in the lungs.

Question 27

What are the causes, incidence and risk factors of COPD

Answer 27

Cigarette smoking is the most common cause of emphysema. Tobacco smoke and other pollutants are thought to cause the release of chemicals from within the lungs that damage the walls of the air sacs.

This damage becomes worse over time. Persons with this disease have air sacs in the lungs that are unable to fill with fresh air. This affects the oxygen supply to the body.

Question 28

What is the radiological appearance of COPD

Answer 28

• Hyperinflation
• Hyperlucency
• Low set flat diaphragm
• Vertical heart
• Pre and infracardiac lungs
• Barrel shape chest
• Hyperlucent lung fields
• Multiple blebs (small air-containing space - radiolucent)
• Avascular zones
• Prominent pulmonary arteries