Reported by Cristal Ann Laquindanum Chest Radiograph for Interns TMC Radiology Department

1. Chest Radiograph For Interns Reported by: Cristal Ann G. Laquindanum ASMPH Class of 2012

2. References Brant and Helm’s Paul and Juhls Learningradiology.com Clinical Radiology Made Ridiculously Simple School lectures

3. Outline Normal Chest Radiograph – adult and pediatric Requirement for chest xray film Anatomy Common pathologies – pleural effusion, pneumothorax, pneumonia, PTB

4. BACKTO*radiology*BASICS

5. More dense = More Xrays = WHITER / radioopaque Less dense = Less Xrays = BLACKER / radiolucent

6. Is it good enough? Recognizing a TECHNICALLY ADEQUATE chest radiograph

7. Penetration Inspiration Rotation Magnification Angulation Factors to Evaluate:

8. Penetration You should be able to see the thoracic spine through the heart

9. Underpenetration > Left hemidiaphragm may not be visible on the frontal film; left lung base may appear opaque > Pulmonary markings may appear more prominent Overpenetration > Lung markings may seem decreased or absent

10. Inspiration

11. Rotation If the spinous process of the vertebral body is equidistant from the medial ends of each clavicle, there is NO rotation

12. If the spinous process appears closer to the right clavicle (redarrow), the patient is rotated toward their own left side If the spinous process appears closer to the left clavicle (redarrow), the patient is rotated toward their own right side

13. Severe rotation may make the pulmonary arteries appear larger on the side farther from the film

14. Magnification vs PA AP

15. AP AP vs PA

16. PA AP vs PA

17. Angulation If the x-ray beam is angled toward the head (mostly because the patient is semi-recumbent), the film so obtained is called an “apical lordotic” view

18. Clavicles Unusually shaped heart

19. Penetration see spine through the heart Inspiration at least 8-9 posterior ribs Rotation spinous process between clavicles Magnification AP films will slightly magnify the heart Angulation clavicle over 3rd rib Factors to Evaluate:

20. How to read a Chest Xray:  Basics  Technically Adequate ☐ Anatomy

23. Trachea Upper Lobes Aortic knob Left Pulmonary Artery Right Atrium Left Ventricle Lower Lobes

25. Trachea Upper Lobes Aortic knob Carina Left Pulmonary Artery Right Atrium Left Ventricle Lower Lobes Costophrenic Angle Gastric bubble

26. Upper lobes Right middle lobe Lower lobes Lingula

27. RADIOLOGY

28. Airway (trachea) Bones (clavicles, ribs) Cardiomediastinalsilhoutte Diaphragms (and the costophrenic angles) Everything Else (lung fields, soft tissues, tubes, lines, wires, devices, etc)

29. Airway (trachea)

31. Bones (clavicles, ribs)

33. Cardiomediastinalsilhoutte

34. Cardiomediastinalsilhoutte

35. Diaphragms (and the costophrenic angles)

36. Diaphragms (and the costophrenic angles)

37. Everything Else (lung fields, soft tissues, tubes, lines, wires, devices, etc)

39. Lungs more radiolucent Thymus is often large, Widening of superior mediastinum Ribs angulate downward Heart is globular and large Left ventricle more prominent with age Diaphragm is higher Left > Right

40. Pathologies Pleural effusion Atelectasis Pneumothorax Pneumonia Pulmonary Tuberculosis

41. Pleural Effusion complete opacification of the right mid and lower zones is due to fluid in the pleural cavity meniscus sign - concavity of the fluid level due to surface tension with the pleura Blunting of costophrenic angle may be due to a small pleural effusion or focal pleural thickening. May coexist with pneumothorax or entrapped within fissures mimicking a tumor. Right pleural effusion in a patient with nephrotic syndrome The flattened and laterally displaced curvature of the right hemidiaphragm indicates presence of subpulmonic pleural fluid

42. Pleural Effusion Patient cannot stand? lateral decubitus Ultrasound or CT thorax as alternative modalities for early detection of small pleural effusion. Ultrasound advantage: no radiation; can be used to guide drainage CT advantage: evaluate the underlying lung and mediastinal structures to identify the cause of the effusion

43. Pneumothorax Pneumothorax represents abnormal air accumulation within pleural cavity. This may be due to trauma (accidental or iatrogenic), underlying pulmonary disease (e.g. asthma) or idiopathic in origin Erect chest radiograph in full expiration is diagnostic in majority of cases If the patient is unable to stand erect, lateral decubitus view may be helpful

44. Pneumothorax Radiologic Findings: Contralateral mediastinalshift Depression of ipsilateralhemi-diaphragm Compressive atelectasis of adjacent normal lung presence of significant increased intrathoracic pressure Role of imaging in patients with pneumothorax: 1. Confirm the clinical diagnosis 2. Assess extent of pneumothorax 3. Detect signs of tension 4. Follow-up examination to monitor resolution of pneumothorax after drainage

45. The right lung (white open arrows) has been pushed medially. The mediastinum is shifted to the left (black arrow). This appearance is typical of tension pneumothorax. Magnified view of a PA chest radiograph of a right pneumothorax. The visceral pleura (arrow heads) is seen as a thin white line.

46. Pneumonia Role of imaging in patients with pneumonia 1. Confirm the clinical diagnosis 2. Detect possible complications such as pleural effusion / empyema or lung abscess if clinically not responsive to appropriate antibiotic treatment 3. Follow-up CXR to monitor response to treatment may take 4-6 weeks for consolidative changes to resolve Radiologic improvement usually lags behind clinical improvement If radiologic signs still present after adequate treatment, underlying predisposing factors have to be excluded (e.g. central obstructive carcinoma in elderly patients)

48. Visualization of air in the intrapulmonary bronchi

49. Abnormal

50. Denotes a pulmonary lesion/consolidation (excludes a pleural or mediastinal lesion)

51. Seen in pneumonia, pulmonary edema or pulmonary infarct Silhouette sign

52. Pneumonia Pneumonia caused by certain organisms may produce characteristic radiologic features Unilateral lobar involvement in streptococcus infection Bilateral patchy involvement sometimes with cavitation in staphylococcus pneumonia Upper lobe involvement with cavitation in pulmonary TB Bilateral symmetrical perihilar distribution which progresses rapidly over 3-5 days in PCP pneumonia in immunocompromised patients

53. Bilateral patchy involvement sometimes with cavitation in staphylococcus pneumonia

55. Upper lobe involvement with cavitation in pulmonary TB

56. Bilateral symmetrical perihilar distributionPCP pneumonia in immunocompromisedpatients

57. Pulmonary Tuberculosis Radiologic Findings in PTB Cavitation and air-fluid level- the opacity represents caseous necrosis in tuberculosis Enlarged hilum– representinggranulomatous inflammation of lymph nodes, usually in primary TB Fibrocalcificchanges in lung apex usually representing healing of previous TB infection Multi-focal air-space opacities representing bronchogenic spread of infection Tiny miliary nodules in both lungs representing miliary TB due to haematogenous spread of infection

60. CASE PRESENTATION

61. AM, 5year old female CC: fever and cough HPI: 6 days PTC – on and off fever (Tmax 39) + headache 3 days PTC – abdominal pain, consult done and was given Cefaclor and Ventolin expectorant Morning PTC – symptoms persisted, one episode of post-tussive vomiting, decreased appetite  admission HISTORY

62. PAST MEDICAL HISTORY TMC – Dengue and UTI – Oct 2010 VRMC – Pneumonia 2006 BIRTH HISTORY Born full term via NSD to a 30 year old G2P2 (2002) no fetomaternal complications VACCINATION HISTORY Only BCG, DPT, HepB, MMR x1, no HiB

63. NUTRITIONAL HISTORY Breastfed until 2 months, on milk formula until 15 months Weaning at months, food preference fish FAMILY HISTORY unremarkable

64. BP 90/60 , RR 30 , HR 118 , Temp 39.5 Harsh breath sounds, equal chest expansion, rales R>L, no wheezes, no alar flaring, no retractions Hyperactive bowel sounds, epigastric tenderness Tachycardic, normal rhythm PHYSICAL EXAMINATION

65. PCAP C IMPRESSION

66. CBC - normal Chest Xray (PA/Lat) DIAGNOSTICS

67. Patches of hazed densities are noted in the right middle lobe, bordered superiorly by the minor fissure. Hazy densities are likewise seen in the posterior segment of the right lower lobe. The pulmonary vascular pattern is within normal. Cardiac shadow is normal in size and configuration. The retrosternal and retrocardiac spaces are intact. The diaphragm, costophrenic sulci, and the bony thorax are unremarkable. Consider Pneumonia with beginning consolidation, right

68. Patches of hazed densities are noted in the right middle lobe, bordered superiorly by the minor fissure. Hazy densities are likewise seen in the posterior segment of the right lower lobe. The pulmonary vascular pattern is within normal. Cardiac shadow is normal in size and configuration. The retrosternal and retrocardiac spaces are intact. The diaphragm, costophrenic sulci, and the bony thorax are unremarkable. Consider Pneumonia with beginning consolidation, right

69. Admitted VS q4 DAT Monitor I&O D5Nm 1 L x 69-70 cc/hr (M+10) Paracetamol 250mg/5mL q4 Amoxicillin 250mg/5mL at 40mkd Currently on 3rd hospital stay MANAGEMENT

70. That’s all Folks!