The CHEST

Emergency Medical Conditions

MI Zucker, MD

A dr Z Lecture

The WHAT:

• Normal chest films• Abnormal patterns• Atelectasis• Infection• Obstructive airway

diseases

• Heart failure• Noncardiac edema• Pulmonary embolism• Aortic dissection• …and a few others

The WHY:

• Give you a basic approach to acute medical diseases emphasizing CHEST Radiographs

• Show you the most COMMON diseases

• Show you commonly MISSED findings

The NORMAL Chest

PA/lateral

Portable AP

The PA (adult and kid) and Lateral

• Check list

• Commonly overlooked areas

The PORTABLE AP

• The “bottom feeder” of chest radiology

Pitfalls in Chest Radiology

• Phase of respiration

• Position

• Comparison films

• Portables

Poor Inspiration

The PATTERNS

Too dense

Too lucent

Location, Location, Location

Lung?

Chest wall?

Mediastinum?

Pleura?

Lung: Too DENSE

• Alveolar pattern

• Interstitial pattern

• Masses

Lung: Alveolar Pattern

• Something of unit/soft tissue/water density replaces the air in the alveolar ducts, alveolar sacs and the alveoli

Alveolar Lung Pattern: causes

• PUS

• WATER

• BLOOD

• Lymphoma

• BAC

• Alveolar proteinosis

Alveolar Lung Pattern: findings

• Increased density

• Confluence

• Ill defined margins

• Air bronchograms

Lung: Interstitial Pattern

Something thickens the interstitium of the lung parenchyma

What?

• Edema

• Inflammatory cells

• RBC’s

• Malignant cells

• Fibrosis

How?

All of them ADD tissue to the peripheral and axial interstitium of

the secondary pulmonary lobule

Secondary Pulmonary Lobules

Who?

• Many, many diseases present with the same interstitial patterns

• You need history, lab, and frequently biopsy to make a specific diagnosis

A Memory Aid

“I Munch Ice Chips In Places Called Igloos”

Interstitial diseases

• Idiopathic

• Malignancy

• Infection

UIP DIP LIP BOOP LAM PEG sarcoid

Metastases, lymphoma

Viral, PCP, mycoplasma.Fungi, TB, MAC

Interstitial diseases

• Congenital

• Iatrogenic

• Pulmonary edema

NF TS CF

Drugs, radiation

Cardiogenic, renal,

noncardiogenic

Interstitial diseases

• Collagen-vascular

• Inhalational

RA, SLE, scleroderma,

AS

Allergic alveolitis, noxious gases, pneumoconiosis

The Interstitial Patterns

• Lines: fine, medium, or coarse

• Nodules: tiny to 3 cm

• Reticular: network of crossing lines

• Reticular-nodular: lines and nodules

Lines

Nodules

Reticular pattern

Lines and nodules

What do they mean?

• Coarse lines mean fibrosis, also called “honeycomb” pattern

• The other patterns usually mean more active disease, but aren’t specific

Kerley lines, A and B

• Thickened secondary lobule septae

• Often, but not always due to CHF

• Basically, they are just a slightly specialized intertstitial linear pattern

• A and B differ only by location

INFECTION

The pneumonias

BACTERIAL PNEUMONIAS

Pyogenic

The Silhouette Sign

• If two adjacent structures have the same density, the border between them is not visible. Replace air with an alveolar process and the border between the involved lung and the heart, or diaphragm, or aorta disappears

The Spine Sign

• On the lateral view the spine normally progressively looks darker caudally. If it looks whiter, there is an alveolar process in one of the lower lobes.

Atypical Pneumonias

• Mycoplasma

• Chlamydia

Patterns

• Diffuse bilateral patchy opacities

• Diffuse interstitial linear opacities

Viral Pneumonias

• Air-trapping

• Mucus plugs and atelectasis

• Diffuse interstitial linear and nodular opacities

• Findings more pronounced in kids

Pneumocystis carnii Pneumonia

• Interstitial linear nodular pattern, usually bilateral

• Followed by diffuse alveolar pattern

• Early, 10% of CXR’s in PCP can be negative. Later, atypical patterns are fairly common.

PCP

Tuberculosis

• Primary

• Post-primary

TB: primary

TB: postprimary, early

TB: postprimary, cavitary

A few more Infections

• Lung abscess

• Empyema

• Fungus

Lung abscess

Empyema: Hydro-pneumothorax

Coccidioidomycosis

ATELECTASIS

Loss of Lung Volume

Atelectasis: types

• Obstructive

• Passive

• Compressive

• Cicatricial

• Adhesive

Atelectasis: signs

• Increased density

• Shift of fissure

• Elevation of diaphragm

• Shift of mediastinum

• Shift of heart

• Shift of hilum

• Compensatory hyperinflation

Subsegmental

Right upper lobe

Lower lobes

Right middle lobe

Left upper lobe

ATX: entire lung

Edema

Cardiogenic

Renal

Noncardiogenic

Edema: pathogenesis

• Cardiogenic: increased hydrostatic pressure

• Noncardiogenic: increased alveolar-capillary membrane permeability

• Renal: multiple factors

Cardiogenic

Congestive heart failure

CHF

• Cephalization 12 wedge pressure

• Interstitial edema 20

• Alveolar edema 25

• Cardiomegaly, pleural effusions

CHF: cephalization

CHF: interstitial edema

CHF: alveolar edema

Renal related

• Fluid overload

• Increased permeability

• CHF

Edema: renal

Noncardiogenic edema

• Near drowning

• High altitude

• Drugs

• Inhalation

• Hypoxia

• (ARDS)

Noncardiogenic edema

Obstructive lung disease

Asthma

COPD

Asthma

• Hyperinflation

• Mucus plugs/atelectasis

• Interstitial inflammation

• Barotrauma

Asthma: kid

Asthma: adult

COPD

• Hyperinflation

• Flat diaphragm

• Increased retrosternum air space

• Pulmonary arterial hypertension

• Look for pneumonia as cause of exacerbation

COPD

Pulmonary embolism

PE: diagnosis

• Clinical: dyspnea, chest pain, increased RR & PR• D-dimer• Doppler ultrasound• *CXR• *CTPA• Lung scan• Pulmonary angiography

Chest film

• Subsegmental atelectasis

• Small pleural effusion

• Elevated diaphragm

• Westermark’s (rare)

• Hampton’s (rare)

PE: CXR

PE: CTPA

Aortic Dissection

Aortic Dissection

• HYPERTENSION

• Marfans

• Coarctation

• Turners, SLE, pregnancy

Aortic Dissection

• Type A: more common, ascending aorta, surgery

• Type B: descending aorta, trial of medical management

AD: imaging

• CXR

• CTA

• MRI

• TEE

• Angiography

AD: CXR

• Mediastinum contour abnormality: abnormal shape or width

• A change in contour from previous film

AD: CXR

Sensitivity: 80%

AD: CXR

AD: CXR

AD: CTA axial

AD: CTA reformat

…and a few more

Sickle Cell DiseaseCystic Fibrosis

Sickle Cell Disease

Cystic Fibrosis

Goodbye

• Copyright 2004

MI Zucker, MD