(1) Lung Anatomy
Anterior Posterior
Right Left
2 Approaching a CXR
1. Patient and clinical details 2. Technical adequacy 1. Projection 2. Inspiration 3. Rotation 3. ABCDE 1. Airway – position of trachea 2. Breathing – lungs 3. Circulation – cardiac and mediastinal contours 4. Diaphragm – contours and below the diaphragm 5. Everything else – lines and tubes 4. Review areas 1. Lung apices 2. Costophrenic angles 3. Behind the heart 4. Behind and below the diaphragm
3 Case-based discussion: 1
History A 35-year-old gentleman presents with PLEASE INSERT IMAGE HERE a fever and cough. He has a (if appropriate) background of HIV and his most recent CD4 count was normal.
On examination, he has bronchial breathing and dull percussion on the left.
Observations HR 101, BP 130/86, RR 22, SpO2 93%, Temp 38.8
4 Question: 1
What radiographic feature is most suggestive of consolidation?
1) Loss of the left heart border 2) Ill-defined opacification 3) Air bronchograms 4) Interstitial shadowing 5) Bronchial wall thickening
5 Question: 1
What radiographic feature is most suggestive of consolidation?
1) Loss of the left heart border 2) Ill-defined opacification 3) Air bronchograms 4) Interstitial shadowing 5) Bronchial wall thickening
6 7 8 (1) Lung Anatomy
Anterior Posterior
Right Left
9 Lung Anatomy
Anterior Posterior
Right Left
10
Silhouette sign
Definition: loss of a normal thoracic contour (e.g. heart border or diaphragmatic border) as a result of pathology that is contiguous with that border.
Useful in lots of contexts! • Lobar collapse • Mediastinal masses • Consolidation
12 Case-based discussion: 1
History A 35 year old gentleman presents PLEASE INSERT IMAGE HERE with a fever and cough. He has a (if appropriate) background of HIV and his most recent CD4 count was normal.
On examination, he has bronchial breathing and dull percussion on the left.
Observations HR 101, BP 130/86, RR 22, SpO2 93%, Temp 38.8
13 Question: 2
What is the most likely causative organism?
1) SARS-CoV-2 2) Streptococcus pneumoniae 3) Mycobacterium tuberculosis 4) Pneumocystis jirovecii 5) Staphylococcus aureus
14 Question: 2
What is the most likely causative organism?
1) SARS-CoV-2 2) Streptococcus pneumoniae 3) Mycobacterium tuberculosis 4) Pneumocystis jirovecii 5) Staphylococcus aureus
15 16 Case-based discussion: 2
History PLEASE INSERT IMAGE HERE A 30-year-old man presents to the (if appropriate) Emergency Department with pleuritic chest pain and shortness of breath. He is usually fit and well however is a smoker.
On examination, he appears dyspneic but is not in respiratory distress. There is reduced air entry at the left apex.
Observations HR 85, BP 110/80, RR 22, SpO2 95%, Temp 37.3 17 Question: 3
What is the most likely cause for the patient’s clinical presentation?
1) Pneumonia 2) Pulmonary embolism 3) Spontaneous pneumothorax 4) Tension pneumothorax 5) Costochondritis
18 Question: 3
What is the most likely cause for the patient’s clinical presentation?
1) Pneumonia 2) Pulmonary embolism 3) Spontaneous pneumothorax 4) Tension pneumothorax 5) Costochondritis
19 Pneumothorax
Definition • Presence of gas within the pleural cavity
(3) (2)
20 21 22 Case-based discussion: 2
History PLEASE INSERT IMAGE HERE A 30-year-old man presents to the (if appropriate) Emergency Department with pleuritic chest pain and shortness of breath. He is usually fit and well however is a smoker.
On examination, he appears dyspneic but is not in respiratory distress. There is reduced air entry at the left apex.
Observations HR 85, BP 110/80, RR 22, SpO2 95%, Temp 37.3 23 Question: 4
How should you manage this patient? (Pneumothorax measures 1 cm at the hilum)
1) Pleurodesis 2) Aspirate and repeat imaging 3) Chest drain insertion 4) Observe for 24 hours 5) Discharge and review as outpatient
24 Question: 4
How should you manage this patient? (Pneumothorax measures 1 cm at the hilum)
1) Pleurodesis 2) Aspirate and repeat imaging 3) Chest drain insertion 4) Observe for 24 hours 5) Discharge and review as outpatient
25 Approaching a CXR
1. Patient and clinical details 2. Technical adequacy 1. Projection 2. Inspiration 3. Rotation 3. ABCDE 1. Airway – position of trachea 2. Breathing – lungs 3. Circulation – cardiac and mediastinal contours 4. Diaphragm – contours and below the diaphragm 5. Everything else – lines and tubes 4. Review areas 1. Lung apices 2. Costophrenic angles 3. Behind the heart 4. Behind and below the diaphragm
26 Case-based discussion: 3
History PLEASE INSERT IMAGE HERE A 75-year-old man who was admitted (if appropriate) earlier in the day with an ischaemic stroke has developed increasing shortness of breath and a cough.
On examination, he appears distressed. There are bibasal crepitations.
Observations HR 90, BP 110/80, RR 28, SpO2 95%, Temp 37.8
27 Question: 5
How would you manage this patient?
1) IV antibiotics 2) IV diuretics 3) Discuss radiograph with seniors/radiology 4) Remove NG tube 5) None of the above
28 Question: 5
How would you manage this patient?
1) IV antibiotics 2) IV diuretics 3) Discuss radiograph with seniors/radiology 4) Remove NG tube 5) None of the above
29 30 Question: 6
Which of the following is NOT correct when assessing the position of an NG tube?
1) It is safe to feed a patient through an NG tube with its tip in the duodenum 2) The NG tube must bisect the carina 3) The tip of the NG tube must be seen below the diaphragm 4) It is safe to feed a patient through an NG tube with its tip in the oesophagus 5) Measuring the pH of the aspirate is the first-line test
31 Question: 6
Which of the following is NOT correct when assessing the position of an NG tube?
1) It is safe to feed a patient through an NG tube with its tip in the duodenum 2) The NG tube must bisect the carina 3) The tip of the NG tube must be seen below the diaphragm 4) It is safe to feed a patient through an NG tube with its tip in the oesophagus 5) Measuring the pH of the aspirate is the first-line test
32 NG Tube Assessment
An NG tube must:
1. Pass through the middle of the chest/mediastinum 2. It must bisect the carina 3. It must cross the diaphragm in the midline 4. Its tip must be clearly visible below the diaphragm (10 cm below the GOJ)
33 34 Case-based discussion: 4
History A 57 year-old man presents with a cough and weight loss. He is an ex- PLEASE INSERT IMAGE HERE (if appropriate) smoker and uses inhalers for COPD. He attends A&E with worsening shortness of breath.
On examination, he is dyspneic.
Observations HR 88, BP 101/78, RR 25, SpO2 87%, Temp 37.1
ABG Shows a type 1 respiratory failure
35 Question: 7
What is the most likely cause for the patient’s type 1 respiratory failure?
1) Bronchogenic carcinoma 2) Exacerbation of COPD 3) Lobar collapse 4) Pneumonia 5) Heart failure
36 Question: 7
What is the most likely cause for the patient’s type 1 respiratory failure?
1) Bronchogenic carcinoma 2) Exacerbation of COPD 3) Lobar collapse 4) Pneumonia 5) Heart failure
37 38 Lung Anatomy
Anterior Posterior
Right Left
39 40 41 Approaching a CXR
1. Patient and clinical details 2. Technical adequacy 1. Projection 2. Inspiration 3. Rotation 3. ABCDE 1. Airway – position of trachea 2. Breathing – lungs 3. Circulation – cardiac and mediastinal contours 4. Diaphragm – contours and below the diaphragm 5. Everything else – lines and tubes 4. Review areas 1. Lung apices 2. Costophrenic angles 3. Behind the heart 4. Behind and below the diaphragm
42 Question: 8
The loss of the left hemidiaphragm in this case is known as which sign?
1) Felson’s sign 2) Mach effect 3) Luftsichel sign 4) Silhouette sign 5) Sail sign
43 Question: 8
The loss of the left hemidiaphragm in this case is known as which sign?
1) Felson’s sign 2) Mach effect 3) Luftsichel sign 4) Silhouette sign 5) Sail sign
44 Summary of Left Lower Lobe Collapse
Aetiology: • Endobronchial obstruction • Mucus plug in young asthmatic • Endobronchial carcinoma until proven otherwise in older patient or smoker • Foreign body in children
Radiographic features: • Triangular retrocardiac opacity (sail sign) represents the collapsed left lower lobe • Loss of most of the left hemidiaphragm (silhouette sign) – due to loss of the air-tissue interface • Loss of the left hilum (pulled down due to volume loss) • Tracheal deviation towards the side of the collapsed lung (not seen in this case) which is also due to volume loss • Increased lucency within the remaining left lung (hyperinflation of the left upper lobe)
45 46 Case-based discussion: 5
History A 40-year-old woman who was PLEASE INSERT IMAGE HERE admitted with osteomyelitis in her (if appropriate) foot is due to be discharged with long term outpatient antibiotic therapy. She has a past medical history of type 2 Diabetes Mellitus.
You are are reviewing her most recent chest XR with your consultant before discharging her.
47 Question: 9
How should you manage the patient?
1) Request a chest CT 2) Insert a cannula and discharge patient home for OPAT 3) Discharge patient for OPAT 4) Insert a chest drain 5) None of the above
48 Question: 9
How should you manage the patient?
1) Request a chest CT 2) Insert a cannula and discharge patient home for OPAT 3) Discharge patient for OPAT 4) Insert a chest drain 5) None of the above
49 50 (4)
51 Case-based discussion: 6
History A 31-year-old woman presents to the PLEASE INSERT IMAGE HERE Emergency Department with acute (if appropriate) shortness of breath and wheeze. She has a past medical history of asthma.
On examination, she has a widespread wheeze. Dullness to percussion at the right apex
Observations HR 90, BP 110/80, RR 25, SpO2 100%, Temp 37.8
52 Question: 10
Based on the clinical findings and chest radiograph, what is the most likely diagnosis?
1) Right upper lobe collapse secondary to mucus plugging 2) Right upper zone primary lung carcinoma 3) Right upper lobe collapse secondary to an endobronchial carcinoma 4) Right upper zone pneumonia 5) Acute exacerbation of asthma
53 Question: 10
Based on the clinical findings and chest radiograph, what is the most likely diagnosis?
1) Right upper lobe collapse secondary to mucus plugging 2) Right upper zone primary lung carcinoma 3) Right upper lobe collapse secondary to an endobronchial carcinoma 4) Right upper zone pneumonia 5) Acute exacerbation of asthma
54 55 56 Question: 11
Which of the following is not a sign of loss of volume in right upper lobe collapse?
1) Elevation of the right hemidiaphragm 2) Decreased spacing between the right ribs 3) Right upper zone opacification 4) Rightward tracheal deviation 5) Elevation of the right hilum
57 Question: 11
Which of the following is not a sign of loss of volume in right upper lobe collapse?
1) Elevation of the right hemidiaphragm 2) Decreased spacing between the right ribs 3) Right upper zone opacification 4) Rightward tracheal deviation 5) Elevation of the right hilum
58 Signs of volume loss
1. Deviation of structures: 1. Trachea 2. Hila 3. Mediastinum 2. Elevation of the diaphragm 3. Decreased spacing between the ribs
59 Case-based discussion: 7
History A 45-year-old man presents to the PLEASE INSERT IMAGE HERE Emergency Department with central (if appropriate) chest pain. He is normally fit and well but has been taking regular NSAIDs following an injury a month ago.
On examination, the lungs are clear.
Observations HR 103, BP 98/62, RR 25, SpO2 94%, Temp 38.1
A blood gas reveals a lactate of 3.2
60 Question: 12
What finding is present on the chest radiograph?
1) Bilateral hilar enlargement 2) Pneumoperitoneum 3) Right apical pneumothorax 4) Left apical pneumothorax 5) Widened mediastinum
61 Question: 12
What finding is present on the chest radiograph?
1) Bilateral hilar enlargement 2) Pneumoperitoneum 3) Right apical pneumothorax 4) Left apical pneumothorax 5) Widened mediastinum
62 63 References
1) By David Richfield and Mikael Häggström, M.D.- Author info- Reusing images, CC BY-SA 4.0, https://commons.wikimedia.org/w/index.php?curid=76719949 2) By OpenStax College - Anatomy & Physiology, Connexions Web site. http://cnx.org/content/col11496/1.6/, Jun 19, 2013., CC BY 3.0, https://commons.wikimedia.org/w/index.php?curid=30148380 3) By BruceBlaus. When using this image in external sources it can be cited as:Blausen.com staff (2014). "Medical gallery of Blausen Medical 2014". WikiJournal of Medicine 1 (2). DOI:10.15347/wjm/2014.010. ISSN 2002-4436. - Own work, CC BY 3.0, https://commons.wikimedia.org/w/index.php?curid=27924395 4) By OpenStax College - Anatomy & Physiology, Connexions Web site. http://cnx.org/content/col11496/1.6/, Jun 19, 2013., CC BY 3.0, https://commons.wikimedia.org/w/index.php?curid=30148288
64 Further information
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