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Rapid Interpretation of Chest X-Rays by Intensive Care Physicians And

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Rapid Interpretation of Chest X-Rays by Intensive Care Physicians And Introduction Acute pulmonary processes present a diagnostic challenge for intensivists and radiologist alike. Only when clinical data and radiographic findings are correlated can patient care be optimized. Although many acute pulmonary process are not unique to the ICU patient, these entities often have atypical presentations in the critically ill patient. Physicians caring for ICU patients must understand the role of the chest radiograph in diagnosing and following such processes. Despite the decreased sensitivity and specificity of ICU chest films they are the most commonly ordered radiologic examination for inpatients. Their use stems from the fact that studies have shown that up to 65% of ICU chest films may reveal a significant or unsuspected process. Currently, the American College of Radiology (ACR) suggests that daily chest radiographs be obtained on patients with acute cardiopulmonary problems and those receiving mechanical ventilation. Otherwise, only initial chest radiographs are needed for the placement or change of indwelling lines or devices. Indications: 1.Determining the placement of patient instrumentation- catheters, tubes, and monitoring devices. 2.To recognize the common normal and pathological appearances of portable chest x- rays in the postoperative or medically ill patient. 3.Identify complications of lines and tubes after insertion and removal. Technique: Routine chest films are obtained in the radiology department in a posteroanterior (PA) direction to minimize magnification of the heart. The optimal ICU chest radiograph is obtained in the anteroposterior (AP) view at a target-to-film distance of 72 inches with the patient in the upright position at maximum inspiration; alternatively a distance of 40 inches is used in the supine patient. Due to the decreased mobility of patients in the ICU, chest films are often taken while the patient is supine. Factors affecting the appearance of the ICU CXR: 1.AP view results in – the magnification of anterior structures such as the clavicle, sternum, and heart, often significantly up to a 15% difference between the width of the mediastinum in a 72-inch PA and a 40-inch AP view the medial border of the scapula is projected several centimetres further into the lung. 2.Supine positioning- widens the mediastinum and heart due to gravitational effects. changes the physiology of the pulmonary vasculature, putting more flow to the upper lobes and making diagnosis of cephalisation more difficult. make differentiating between pleural effusion and parenchymal processes difficult, and may make detecting a pneumothorax difficult or impossible due to unusual distribution. 3.Respiration- Incomplete inspiration can make differentiating basilar atelectasis and lung oedema more difficult. may cause significant changes in the apparent size of the heart and mediastinum. the diameter of a patient's mediastinum may differ by up to 50% between an expiratory supine AP and a erect inspiratory PA. Instrumentation: 1.Endotracheal Tubes- important to identify the location of the tip of the ETT. The rate of serious malposition of endotracheal tubes has been reported to be between 12-15%. The ideal position is in the midtrachea, 5 cm from the carina, when the head is neither flexed nor extended. This allows for movement of the tip with head movements. The minimal safe distance from the carina is 2 cm. The carina is often not visible. The carina can be assumed to be at the T4-T5 interspace, given that 95% of patients' carinas project over the T5, T6, or T7 vertebral bodies. Common malposition: the right main stem bronchus CXR with Endotracheal Tube insitu 2.Thoracostomy tubes- Ideal position-all of the fenestrations in the tube must be within the thoracic cavity. The last side-hole in a thoracostomy tube is indicated by a gap in the radiopaque line. If this interruption in the radiopaque line is not within the thoracic cavity or there is evidence of subcutaneous air, then the tube may not have been completely inserted. Tubes placed within fissures often cease to function when the lung surfaces become apposed. Determining whether a tube is anterior or posterior is often difficult with a single AP chest x-ray and may need CT scan. Complications: injury to adjacent structures. Often difficult to detect with a chest x- ray alone and may require a CT scan. Also useful when the location of the tube is important and unclear on plain radiographs. CXR showing Intercostal Catheter 3. Feeding tubes- Naso/Orogastric tubes- the tip of the tube should be below the level of the diaphragm. Malposition within the lung have serious consequences. Nasojejunal tubes-placed into the proximal small bowel, and confirmed by an abdominal film. CXR of Nasogastric Tube 4.Central venous catheters- either through the subclavian veins or the internal jugular veins. Ideally the catheter tip should lie between the most proximal venous valves of the SVC and the right atrium as placement beyond the superior vena cava may be detrimental. Malposition: the internal jugular vein, right atrium, and right ventricle. Pneumothorax, occur in as many as 6% of cases. Damage may also be caused by guidewires causing injury to the endothelium. This may result in thrombus formation or possibly vessel perforation. CXR showing R) sided Subclavian Central Line 5. The intraaortic counter pulsation balloon pump (IABP)- Introduced percutaneously through the right femoral artery. Ideally the catheter should be in the region of the aortic isthmus or left main bronchus and above the origins of the celiac trunk and superior mesenteric artery. During systole the balloon may appear as a fusiform air (helium) containing radiolucency. CXR showing IABP 6.Transvenous pacemakers- Transvenous pacers are introduced through the internal jugular or subclavian vein into the apex of the right ventricle. The pacer tip should be at the apex with no sharp angulations throughout its length. The integrity of the pacer wire should be inspected along its entire length. A CXR of an ICU patient with ETT, NGT, CVC, Vascath and ICC The Abnormal CXR- 1.Extra-alveolar air - manifest as pulmonary interstitial emphysema, pneumothorax, pneumomediastinum, pneumopericardium or subcutaneous air. When searching for lucencies which may represent air on the chest x-ray, be aware of the Mach effect. The Mach effect is caused by lateral inhibition of light receptors in the eye. The eye enhances the contrast between objects by increasing the brightness of objects near dark borders and decreasing the brightness of dark objects near bright borders. This optical illusion can deceive a person interpreting a chest x-ray into believing that a lucent streak exists when it does not. A.Subcutaneous emphysema: usually occurs due to an air leak from the lung into the chest cavity and out into the subcutaneous tissues. It may also result from poorly positioned chest tubes or a non-occlusive dressing around a thoracostomy site. In the absence of pneumomediastinum, patients with cervical subcutaneous emphysema should be examined for upper airway injury, especially following a difficult intubation or the placement of a new nasogastric tube. CXR showing Subcutaneous Emphysema B.Pneumothorax: In the erect patient, air will rise to the apicolateral surfaces of the lung. An apicolateral pneumothorax appears as a thin, white pleural line with no lung markings beyond. The presence of lung markings beyond this line, though, does not exclude pneumothorax. This is especially true in the patient with parenchymal disease which may alter the compliance of affected lobes, making their collapse more difficult to detect radiographically. Parenchymal disease may also make visualization of the pleural line more difficult or impossible. Skin folds on a patient can mimic a pleural edge and a pneumothorax. One can sometimes differentiate the two by noting that the skin fold line continues outside of the chest. In the supine patient, intrapleural air rises anteriorly and medially, often making the diagnosis of pneumothorax difficult. The anteromedial and subpulmonary locations are the initial areas of air collection in the supine patient. An apical pneumothorax in a supine patient is a sign that a large volume of air is present. Subpulmonic pneumothorax occurs when air accumulates between the base of the lung and the diaphragm. Anterolateral air may increase the radiolucency at the costophrenic sulcus. This is called the deep sulcus sign. Other signs of subpulmonic pneumothorax include a hyperlucent upper quadrant with visualization of the superior surface of the diaphragm and visualization of the inferior vena cava. Occasionally, a posterior subpulmonary pneumothorax will result in visualization of the more superior anterior diaphragmatic surface and the inferior posterior diaphragmatic surface, resulting in the double-diaphragm sign. Anteromedial pneumothoraces are differentiated into those which are superior or inferior to the pulmonary hilum. A superior anteromedial pneumothorax may result in visualization of the superior vena cava or azygos vein on the right. An inferior anteromedial pneumothorax may be evidenced by delineation of the heart border and a lucent cardiophrenic sulcus. This is the key sign of a pneumothorax as this is the highest point in the supine patient, where the air will accumulate first. A tension pneumothorax in the ICU patient is a clinical diagnosis based on ventilatory and cardiac compromise. Radiographically, a tension pneumothorax in an ICU patient can be an extremely challenging
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