Interpreting thoracic x-ray of the supine immobile patient: Syllabus

Transcription

1 Interpreting thoracic x-ray of the supine immobile patient: Syllabus Johannes Godt Dep. of Radiology and Nuclear Medicine Oslo University Hospital Ullevål NORDTER 2017, Helsinki

2 Content - Why bedside chest x-ray? - Image interpretation and clinical findings - Take-home-message All images from OUH-Ullevål

3 Why bedside Chest X-ray? - Much information from just one x-ray image, supplement to clinical exam - X-ray image often available bedside - Can be useful when patient is isolated (infectious diseases) - Low cost - No patient transport necessary

4 Bedside x-ray or transport to CT? Gain of additional diagnostic information must be weighed against increased risk of transporting the patient, radiation dose and (if necessary) iv.contrast Bedside chest x-rays: Often difficult imaging conditions, often foreign materials in field of view Most patients unable to cooperate

5 Normal chest x-ray: - Usually 2 images, PA and lateral - Fixed distance (film-focus distance) and patient position Bedside chest x-ray at the ICU: - Patient in bed - Just one AP- anteriorposterior picture - FF-Distance and patient position different between exams -Typical effective dose : 0,06 msv

6 Saturday morning at OUH-Ullevål Emergency room ICU (surgical/medical) Pediatric ICU Cardiac surgery-postoperative Nevrosurgery-postoperative Cardiac ICU

7 Indications Positioning of monitor devices Cardiopulmonary disorders Mechanically ventilated patients Lancet 374/ Radiology 255, 2010

8 Technical considerations Check patient and date, prior exams Lung parenchyma completely covered? Rotated patient? Check positions of clavicula Good or poor inspiration? Lordotic view? (anterior part of first rib should be below clavicle).

9 Position of monitoring devices Important in ICU patients Malposition can cause serious problems One main reason for frequently control x- ray

10 Nasogastric tube Optimal position: 10cm below gastroøsofageal junction

11 Central venous lines

12 Tracheal tubes Optimal position: 4-6 cm from carina,head in neutral position

13 Chest tubes Apex when pneumothorax Lower lung posterior when pleural effusjon Or: in fluid collections

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15 Tracheostomy tube Tip should not damage lateral tracheal wall Look for abnormal widening of upper mediastinum (hematoma?)

16 Intraaortic balloon pump Tip in the last part or just distally of aortic arch

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18 Pulmonary artery catheter (Swan-Ganz) Tip should be in right or left pulmonary artery trunk Image? Next slide! Test case.

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21 Pneumothorax- signs on bedside chest x-ray - Sharp outlining of mediastinal structures and diaphragm - Hyperlucency - Deep costophrenic sulcus (deep sulcus sign) - Not always: «classical» sign of pneumothorax

22 Pneumothorax

23 Atelectasis Often: left lower lobe (after cardiac surgery) Compressionor obstruction Male, 55 year old patient

24 Direct signs: Triangular or wedge-shaped opacity Displacment of fissures or vascular structures Indirect signs: Elevation of hemidiaphragm Mediastinal shift Compensatory hyperinflation on non-affected side

25 Pneumonia Alveolar / air space opacity (DD hemorrhage, edema ) Often patchy areas of consolidation, no volume loss, changes over days Often hospital-acquired (nosocomial) ----Look for other findings: pleural effusions or empyema/abscess

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28 Negative radiograph despite pneumonia Older patients Dehydration Neutropenia COPD or fibrosis Heart failure

29 ARDS Adult respiratory distress syndrome Def.: Hypoxia requiring mech.ventilation, diffuse infiltrates on x-ray and low pulm.artery wedge pressure (<18mmHg). Permeability edema, damage of endothelium

30 ARDS Exsudative phase (<24h): Loss of volume, later patchy consolidations (edema) Intermediate phase (2-7d): progress of consolidations, white lung, air bronchogram Late or proliferative phase (>1week): often reticular pattern, regional hyperinflation Remember: pleural effusions not common.

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32 Congestive heart failure Signs on plain x-ray bedside Apical redistribution Cardiomegaly Peribronchial cuffing Unsharp vascular structures («blurry») Widening of vascular pedicle «Bat wing»-alveolar edema (pleural effusions)

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34 Chest x-ray in patients after drug abuse Lunge edema (Heroin) Parenchymal damage with hemorrhage (Crack lung) - diffuse lung opacities Secondary problems (aspiration, infection)

35 When to call the clinician Pneumothorax Malposition of Catheters/Monitoring devices Severe parenchymal/cardiovascular changes everything that cannot wait until next days ICU X-ray round.

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37 How to look at a supine chest x- ray (after ATLS) Technical quality? Right patient and date? Prior studies! A: Airways. Trachea, bronchi, mediastinum. B: Breathing. Lung parenchyma? Pneumothorax? Emfysema? C: Cardiovascular status. Congestive heart disease? Pleural effusions? D: Diafragma E: Everything else. Skeleton? Catheters and other devices?

38 Literature Find a good book for chest x-ray imaging Critical Care Radiology Thieme Bedside Chest Radiography. Respiratory Care 2012 V 57 N 3, Thoracic imaging in the ICU. Critical Care Clinics 23 (2007)