Signs in Chest Imaging
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Surgical Management of Empysema
Surgical Management of Empysema John A Odell MB ChB, FRCS(Ed), FACS Emeritus Professor of Surgery Mayo Clinic College of Medicine Previously Surgical Director Lung Transplantation ©2013 MFMER | slide-1 Problem case. How would you manage? • 64yr male • Previous RLL bullectomy. • Recent left pneumothorax managed elsewhere with chest tube placement. • Because of continued air-leak talc pleurodesis. • Air-leak continues. ©2013 MFMER | slide-2 • On nasal oxygen. Dyspneic on walking • Significant air-leak. More dyspneic when suction applied to chest drain. • FEV1 40% predicted. DLCO 12% predicted. Options? • Thoracotomy and close air leak surgically • Videothoracoscopy and closure of air-leak • Thoracotomy and decortication • Remove chest drain • List for transplantation Historical Treatment of Emphysema • Abdominal compression belts. The stimulus was the observation that emphysematous patients lean forward when breathing. • Pneumoperitoneum. In an attempt to restore diaphragmatic curvature. • Lungs too large for the chest – costochondrectomy or transverse sternotomy to provide more room. Multiple wedge excisions. • Chest grown too large – thoracoplasty • Pleurodesis. Emphysema results from alveolar wall ischemia. • Phrenectomy. Overvigerous inspiration was ripping alveolar walls. • Hilar denervation. To decrease bronchoconstriction and mucous production mediated by the parasympathetic nervous system. • Whole lung irradiation. To increase elastic recoil by inducing fibrosis. ©2013 MFMER | slide-7 Variants of Emphysema that may be Surgically -
X-Ray Interpretation
Objectives Describe a systematic method for interpretation of chest and abdomen x-rays List findings to accurately identify common X-ray Interpretation pathology in chest & abdomen x-rays Describe a systematic method to approach the Denise Ramponi, DNP, FNP-C, ENP-BC, FAANP, FAEN important components in interpretation of upper & lower extremity x-rays Chest X-ray: Standard Views Lateral Film Postero-anterior (PA): (LAT) view can determine th On inspiration – diaphragm descends to 10 rib the anterior-posterior posteriorly structures along the axis of the body Normal LAT film Counting Ribs AP View - Portable http://www.lumen.luc.edu/lumen/MedEd/medicine/pulmonar/cxr/cxr_f.htm When the patient is unable to tolerate routine views with pts sitting or supine No participation from the patient Film is against the patient's back (supine) 1 Consolidation, Atelectasis, Chest radiograph Interstitial involvement Consolidation - any pathologic process that fills the alveoli with Left and right heart fluid, pus, blood, cells or other borders well defined substances Interstitial - involvement of the Both hemidiaphragms supporting tissue of the lung visible to midline parenchyma resulting in fine or coarse reticular opacities Right - higher Atelectasis - collapse of a part of Heart less than 50% of the lung due to a decrease in the amount of air resulting in volume diameter of the chest loss and increased density. Infiltrate, Consolidation vs. Congestive Heart Failure Atelectasis Fluid leaking into interstitium Kerley B 2 Kerley B lines Prominent interstitial markings Kerley lines Magnified CXR Cardiomyopathy & interstitial pulmonary edema Short 1-2 cm white lines at lung periphery horizontal to pleural surface Distended interlobular septa - secondary to interstitial edema. -
Effect of an Indwelling Pleural Catheter Vs Talc Pleurodesis On
This supplement contains the following items: 1. Original protocol, final protocol, summary of changes. 2. Original statistical analysis plan. There were no further changes to the original statistical analysis plan. Downloaded From: https://jamanetwork.com/ on 10/02/2021 The Australasian Malignant Pleural Effusion Trial (AMPLE) A Multicentre Randomized Study Comparing Indwelling Pleural Catheter vs Talc Pleurodesis in Patients with Malignant Pleural Effusions Ethics Registration number 2012-005 Protocol version number 1.0 Protocol date 10/01/2012 Authorised by: Name: Prof YC Gary Lee Role: Chief Investigator Signature: Date: 10/01/2012 Downloaded From: https://jamanetwork.com/ on 10/02/2021 General Information This document describes the Western Australian Randomised Malignant Effusion trial for the purpose of submission for review by the relevant human research and ethics committees. It provides information about procedures for entering patients into the trial and this protocol should not be used as a guide for the treatment of other patients; every care was taken in its drafting, but corrections or amendments may be necessary. Questions or problems relating to this study should be referred to the Chief Investigator or Trial Coordinator. Compliance The trial will be conducted in compliance with this protocol, the National Statement on Ethical Conduct in Human Research, data protection laws and other guidelines as appropriate. It will be registered with the Australia and New Zealand Clinical Trials Registry, once ethical approval is secured. -
Diagnosing Pulmonary Embolism M Riedel
309 Postgrad Med J: first published as 10.1136/pgmj.2003.007955 on 10 June 2004. Downloaded from REVIEW Diagnosing pulmonary embolism M Riedel ............................................................................................................................... Postgrad Med J 2004;80:309–319. doi: 10.1136/pgmj.2003.007955 Objective testing for pulmonary embolism is necessary, embolism have a low long term risk of subse- quent VTE.2 5–7 because clinical assessment alone is unreliable and the consequences of misdiagnosis are serious. No single test RISK FACTORS AND RISK has ideal properties (100% sensitivity and specificity, no STRATIFICATION risk, low cost). Pulmonary angiography is regarded as the The factors predisposing to VTE broadly fit Virchow’s triad of venous stasis, injury to the final arbiter but is ill suited for diagnosing a disease vein wall, and enhanced coagulability of the present in only a third of patients in whom it is suspected. blood (box 1). The identification of risk factors Some tests are good for confirmation and some for aids clinical diagnosis of VTE and guides decisions about repeat testing in borderline exclusion of embolism; others are able to do both but are cases. Primary ‘‘thrombophilic’’ abnormalities often non-diagnostic. For optimal efficiency, choice of the need to interact with acquired risk factors before initial test should be guided by clinical assessment of the thrombosis occurs; they are usually discovered after the thromboembolic event. Therefore, the likelihood of embolism and by patient characteristics that risk of VTE is best assessed by recognising the may influence test accuracy. Standardised clinical presence of known ‘‘clinical’’ risk factors. estimates can be used to give a pre-test probability to However, investigations for thrombophilic dis- orders at follow up should be considered in those assess, after appropriate objective testing, the post-test without another apparent explanation. -
Chest and Abdominal Radiograph 101
Chest and Abdominal Radiograph 101 Ketsia Pierre MD, MSCI July 16, 2010 Objectives • Chest radiograph – Approach to interpreting chest films – Lines/tubes – Pneumothorax/pneumomediastinum/pneumopericar dium – Pleural effusion – Pulmonary edema • Abdominal radiograph – Tubes – Bowel gas pattern • Ileus • Bowel obstruction – Pneumoperitoneum First things first • Turn off stray lights, optimize room lighting • Patient Data – Correct patient – Patient history – Look at old films • Routine Technique: AP/PA, exposure, rotation, supine or erect Approach to Reading a Chest Film • Identify tubes and lines • Airway: trachea midline or deviated, caliber change, bronchial cut off • Cardiac silhouette: Normal/enlarged • Mediastinum • Lungs: volumes, abnormal opacity or lucency • Pulmonary vessels • Hila: masses, lymphadenopathy • Pleura: effusion, thickening, calcification • Bones/soft tissues (four corners) Anatomy of a PA Chest Film TUBES Endotracheal Tubes Ideal location for ETT Is 5 +/‐ 2 cm from carina ‐Normal ETT excursion with flexion and extension of neck 2 cm. ETT at carina Right mainstem Intubation ‐Right mainstem intubation with left basilar atelectasis. ETT too high Other tubes to consider DHT down right mainstem DHT down left mainstem NGT with tip at GE junction CENTRAL LINES Central Venous Line Ideal location for tip of central venous line is within superior vena cava. ‐ Risk of thrombosis decreased in central veins. ‐ Catheter position within atrium increases risk of perforation Acceptable central line positions • Zone A –distal SVC/superior atriocaval junction. • Zone B – proximal SVC • Zone C –left brachiocephalic vein. Right subclavian central venous catheter directed cephalad into IJ Where is this tip? Hemiazygous Or this one? Right vertebral artery Pulmonary Arterial Catheter Ideal location for tip of PA catheter within mediastinal shadow. -
Cardiothoracic Fellowship Program
Cardiothoracic Fellowship Program Table of Contents Program Contact ............................................................................................ 3 Other contact numbers .................................................................................. 4 Introduction ........................................................................................................... 5 Goals and Objectives of Fellowship: ..................................................................... 6 Rotation Schedule: ........................................................................................ 7 Core Curriculum .................................................................................................... 8 Fellow’s Responsibilities ..................................................................................... 22 Resources ........................................................................................................... 23 Facilities ....................................................................................................... 23 Educational Program .......................................................................................... 26 Duty Hours .......................................................................................................... 29 Evaluation ........................................................................................................... 30 Table of Appendices .................................................................................... 31 Appendix A -
Screening Chest X-Ray Interpretations and Radiographic Techniques IOM GUIDELINES FIRST EDITION Iii
FIRST EDITION 2015 Screening Chest X-Ray Interpretations and Radiographic Techniques IOM GUIDELINES Global Radiology Coordination and Teleradiology Centre Migration Health Division International Organization for Migration (Manila Administrative Centre) 24th floor Citibank Tower, Paseo De Roxas 8741, Makati city 1226 Metro Manila, Philippines Email: [email protected] • [email protected] Tel: +632 230 1674 The opinions expressed in the report are those of the authors and do not necessarily reflect the views of the International Organization for Migration (IOM). The designations employed and the presentation of material throughout the report do not imply the expression of any opinion whatsoever on the part of IOM concerning the legal status of any country, territory, city or area, or of its authorities, or concerning its frontiers or boundaries. IOM is committed to the principle that humane and orderly migration benefits migrants and society. As an intergovernmental organization, IOM acts with its partners in the international community to: assist in meeting the operational challenges of migration; advance understanding of migration issues; encourage social and economic development through migration; and uphold the human dignity and well-being of migrants. Author Sifrash Meseret GELAW, MD Radiologist, MPH; Global Radiology Coordinator IOM, Manila Administrative Centre, Manila, Philippines Major Contributor Anthony MACDERMOTT, MD former Global HAP Quality Coordinator, IOM, Regional Office for Asia and the Pacific, Bangkok, Thailand Additional -
Pediatrics-EOR-Outline.Pdf
DERMATOLOGY – 15% Acne Vulgaris Inflammatory skin condition assoc. with papules & pustules involving pilosebaceous units Pathophysiology: • 4 main factors – follicular hyperkeratinization with plugging of sebaceous ducts, increased sebum production, Propionibacterium acnes overgrowth within follicles, & inflammatory response • Hormonal activation of pilosebaceous glands which may cause cyclic flares that coincide with menstruation Clinical Manifestations: • In areas with increased sebaceous glands (face, back, chest, upper arms) • Stage I: Comedones: small, inflammatory bumps from clogged pores - Open comedones (blackheads): incomplete blockage - Closed comedones (whiteheads): complete blockage • Stage II: Inflammatory: papules or pustules surrounded by inflammation • Stage III: Nodular or cystic acne: heals with scarring Differential Diagnosis: • Differentiate from rosacea which has no comedones** • Perioral dermatitis based on perioral and periorbital location • CS-induced acne lacks comedones and pustules are in same stage of development Diagnosis: • Mild: comedones, small amounts of papules &/or pustules • Moderate: comedones, larger amounts of papules &/or pustules • Severe: nodular (>5mm) or cystic Management: • Mild: topical – azelaic acid, salicylic acid, benzoyl peroxide, retinoids, Tretinoin topical (Retin A) or topical antibiotics [Clindamycin or Erythromycin with Benzoyl peroxide] • Moderate: above + oral antibiotics [Minocycline 50mg PO qd or Doxycycline 100 mg PO qd], spironolactone • Severe (refractory nodular acne): oral -
2019 Coding and Payment Information Pleural Effusions and Ascites Management
2019 coding and payment information Pleural effusions and ascites management The information contained in this document, including Reimbursement rates shown are Medicare national the codes supplied, is provided for informational payments for 2019 and do not reflect actual payments purposes only. BD makes no statement, promise or made to individual providers, as payments are adjusted guarantee concerning the appropriateness of any codes specific to particular geographic regions. for a particular procedure, actual levels of All information is subject to change without notice. In reimbursement, payment or charge or that addition, payers or local carriers may have their own reimbursement will be made. coding and billing requirements. Consult your payer This is not intended to be a comprehensive guide to all organization with regard to local reimbursement policies. coding and payment information. 2019 Medicare outpatient facility rates CPT® 2019 APC OPPS 2019 ASC Description APC Status code base rate* base rate Pleural catheter procedures 32550 Insertion of indwelling tunneled pleural catheter 5341 J1 $2,947 $1,790 32552 Removal of indwelling tunneled pleural catheter with cuff 5181 Q2 $620 $319 32560 Instillation via chest tube/catheter, agent for pleurodesis 5181 T $620 N/A 32650 Thoracoscopy, surgical, with pleurodesis (e.g., mechanical or chemical) N/A; inpatient procedure Peritoneal catheter procedures Insertion of tunneled intraperitoneal catheter (e.g., dialysis, intraperitoneal chemotherapy instillation, management of ascites), 49418 -
The Supine Pneumothorax
Annals of the Royal College of Surgeons of England (1987) vol. 69 The supine pneumothorax DAVID A P COOKE FRCS Surgical Registrar, Department ofSurgery, St Thomas' Hospital JULIE C COOKE FRCR* Radiological Senior Registrar, Department ofDiagnostic Radiology, Brompton Hospital, London Key words: PNEUMOTHORAX; COMPUTI ED TOMOGRAPHY; TRAUMA Summary TABLE I Causes of a pneumothorax The consequences of an undiagnosed pneumothorax can be life- threatening, particularly in patients with trauma to the head or Broncho-pulmonay pathology Traumatic injuy and in those mechanical ventilation. Yet multiple requiring Asthma it is these patients, whose films will be assessed initially by the Bronchial adenoma surgeon, who are more likely to have a chest X-ray taken in the Bronchial carcinoma Penetrating trauma supine position. The features of supine pneumothoraces are de- Emphysema Blunt trauma scribed and discussed together with radiological techniques used to Fibrosing alveolitis Inhaled foreign body confirm the diagnosis, including computed tomography (CT) Idiopathic which may be ofparticular importance in patients with associated Marfan's syndrome fatrogenic cranial trauma. Pulmonary abscess Pulmonary dysplasia CVP line insertion Introduction Pulmonary infarct Jet ventilation Pulmonary metastases Liver biopsy In a seriously ill patient or the victim of multiple trauma Pulmonoalveolar proteinosis Lung biopsy the clinical symptoms and signs of a pneumothorax may Radiation pneumonitis Oesophageal instrumentation be overshadowed by other problems. Usually in these Sarcoid PEEP ventilation circumstances a chest X-ray will be taken at the bedside Staphylococcal septicaemia Pleural aspiration with the patient supine and the appearances of a Tuberculosis Pleural biopsy pneumothorax will be different from those seen when the Tuberose sclerosis patient is upright. -
Pulmonary Embolism (Pe), Suspected Acute Algorithm
CLINICAL PATHWAY PULMONARY EMBOLISM (PE), SUSPECTED ACUTE ALGORITHM Start · Room air pulse oximetry Inclusion Criteria: · Consider supplemental oxygen · IV access and STAT CBC and DIC screen Patient presents with · Urine β-HCG, if appropriate suspected Pulmonary · CXR (PA + lateral), EKG and call the Cardiology Embolism (PE) Fellow for Echo review · Review criteria* for urgent imaging for possible PE Exclusion Criteria based on age-specific risk factors (see green boxes) No suspected PE < 18 Patient 18 years years old age? or older *Criteria for Urgent Imaging: *Criteria for Urgent Imaging: Patients < 18 years old For patients ≥ 18 years old · Painful leg swelling or known recent diagnosis of deep vein thrombosis (DVT) Please refer to the Wells Criteria · Family or personal history of DVT or PE Algorithm on page 7. · Known clotting disorder predisposing to DVT or PE · Recent or current indwelling central venous catheter · Elevated systemic estrogen (e.g., oral contraceptive pill use, pregnancy) · Recent immobility · Recent major or orthopedic surgery or trauma · Acute or chronic inflammatory condition · Obesity Does patient Is the No to meet 1 or more Yes to Yes to Wells Criteria No to ALL criteria for urgent ANY EITHER Score > 4 points BOTH criteria imaging OR is d-dimer criteria criterion OR is d-dimer criteria > 0.5ug/mL? > 0.5ug/mL? Discuss CXR findings and optimal Consider non-urgent imaging for subsequent imaging modality (e.g., CT Consider non-urgent imaging for PE, consider alternative angiogram, ventilation perfusion PE, consider -
CHEST RADIOLOGY: Goals and Objectives
Harlem Hospital Center Department of Radiology Residency Training Program CHEST RADIOLOGY: Goals and Objectives ROTATION 1 (Radiology Years 1): Resident responsibilities: • ED chest CTs • Inpatient and outpatient plain films including the portable intensive care unit radiographs • Consultations with referring clinicians MEDICAL KNOWLEDGE: • Residents must demonstrate knowledge about established and evolving biomedical, clinical, and cognitive sciences and the application of this knowledge to patient care. At the end of the rotation, the resident should be able to: • Identify normal radiographic and CT anatomy of the chest • Identify and describe common variants of normal, including aging changes. • Demonstrate a basic knowledge of radiographic interpretation of atelectasis, pulmonary infection, congestive heart failure, pleural effusion and common neoplastic diseases of the chest • Identify the common radiologic manifestation of thoracic trauma, including widened mediastinum, signs of aortic laceration, pulmonary contusion/laceration, esophageal and diaphragmatic rupture. • Know the expected postoperative appearance in patients s/p thoracic surgery and the expected location of the life support and monitoring devices on chest radiographs of critically ill patients (intensive care radiology); be able to recognize malpositioned devices. • Identify cardiac enlargement and know the radiographic appearance of the dilated right vs. left atria and right vs. left ventricles, and pulmonary vascular congestion • Recognize common life-threatening