Disclosure. Objectives NONE

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1 Susan Collazo MSN, APN-CNP Thoracic Surgery Northwestern Memorial Hospital Chicago, Illinois NONE Disclosure Objectives 1. The participant will be able to locate at least one pulmonary structure, as a costo-phrenic angle, on a chest x-ray. 2. The participant will be able to state one structure on a lateral cxr. 3. The participant will be able to define silhouette sign. 1

2 85y/o female Dementia, COPD, cervical stenosis s/p fusion obtains a dubhoff. Verify correct placement. Chest X-rays Indications Density/Structures Anatomy Lobes/Fissures AP vs PA views Reading a CXR Abnormal CXRs pneumothorax, ARDS vs CHF and Atelectasis vs Consolidation Indications for Radiographic Imaging The American College of Radiology Appropriateness Criteria (AC) are evidence-based guidelines to assist referring physicians and other providers in making the most appropriate imaging or treatment decision for a specific clinical condition. The appropriateness rating scale is an ordinal scale that uses integers from 1-9 grouped into three categories: 1, 2, or 3 are in the category usually not appropriate ; 4, 5, or 6 are in the category may be appropriate ; 7, 8, or 9 are in the category usually appropriate. 2

3 Density Variations and Subjective Image Interpretation Reported Radiologists error: 41% potential significant errors 56% indeterminant disagreements Of these 78% false (-) 22% false (+) Look at picture what do you see? Hermann, et al. Disagreements in Chest Roentgen Interpretation. Chest 68:3: :

4 Density Anatomy PA vs AP film Density is expressed in Houdsfield Units (HU) Air=1000HU Fat=50-100HU Blood=40-60HU Water=0 HU NONcalcified nodule = HU Calcified Nodule=>200HU 4

5 Identifying Ribs Lobes/segments 5

6 Fissures Fissures on CXR can be difficult to identify Best seen with an abnormality this is atelectasis w small amount of fluid in the fissure Fluid in the fissure = pseudotumor 6

7 Thoracic Landmarks Heart Structures 7

8 Putting it all together densities, anatomy CXR: Mediastinal Outline Lateral Landmarks 8

9 Lateral Chest X-ray 85y/o F presents w f/c, cough x 5 days also with increasing leftsided cp, dyspnea: A PA/Lat CXR was taken. Please read. Lordotic views / Kyphotic views : Behind clavicle; apical focus Notice clavicles are higher to see apex of lungs RUL lesion confirmed Decubitus Films : to assess ability of pleural fluid to layer 9

10 Posterior Anterior (AP) Anterior Posterior (PA) Right Right (Magnifies heart/mediastinum) PA film vs AP film Variations of images PA AP The AP shows magnification of the heart and widening of the mediastinum. Normal Heart Size on a CXR = ½ the width of the entire thorax 10

11 1. Check patient s name, date, time, gender. 2. Check quality of film overexposed vs underexposed 3. Check for patient effort: deep inspiration nml diaphragm should be 8 10th posteriorly and 5 6th anteriorly 4. Review Clinical Hx why was the CXR taken? Check the basics Sequential Method of Reading a CXR 1. A = Airway: are the trachea and mainstem bronchi patent; is the trachea midline? 2. B = Bones: are the clavicles, ribs, and sternum present and are there fractures? 3. C = Cardiac silhouette: is the diameter of the heart > ½ thoracic diameter (enlarged)? 4. D = Diaphragm: are the costophrenic and costocardiac margins sharp? is one hemidiaphragm enlarged over another? is free air present beneath the diaphragm? 5. E = Effusion/empty space: is either present? 6. F = Fields (lungs): are there infiltrates, increased interstitial markings, masses, air bronchograms, increased vascularity, or silhouette signs? 7. G = Gastric bubble: is it present and on the correct (left) side? 8. H = Hilar region: is there increased hilar lymphadenopathy? 9. I = Inspiration: did the patient inspire well enough for 10 ribs to be counted, or was the patient rotated? 11

12 Reading CXR systematically Practice reading a CXR COPD and blebs 12

13 Bullae 9 th rib Flattened diaphram Paraseptal Emphysema or Bullous Emphysema Review of COPD radiographic changes Hyperinflated lungs Flattened diaphrams Vertical heart Bullae Widened rib spaces Domed apices 13

14 Placement of right IJ large R px in intubated pt. Pneumothorax - No vascular markings on right - Shift of mediastinum to left - Deep sulcus - Atelectatic right lung - Increased haziness on left: - Diversion of entire cardiac output Other Etiologies of Pneumothorax Pneumo after placement on mechanical ventilation WHY? Pneumo from central line 16% risk Proximity of Subclavian Vein and Parietal Pleura is approx 0.5cm! 14

15 Atelectesis vs Pleural Effusion Whenever you see an area of increased density within the lung, it must be the result of one of these four patterns. Consolidation - any pathologic process that fills the alveoli with fluid, pus, blood Interstitial - involvement of the supporting tissue of the lung parenchyma resulting in fine or coarse reticular opacities Nodule or mass - any space occupying lesion either solitary or multiple Atelectasis - collapse of a part of the lung due to a decrease in the amount of air in the alveoli resulting in volume loss and increased density. ATELECTASIS Loss of lung volume Anatomy shifts towards atelectasis Linear, smooth, wedge-shaped Loss of pleural definition Plate-like or discoid Narrow rib spaces 15

16 Consolidation Normal lung volume No anatomical shift No rib crowding Fissure is not shifted Silhouette Sign = obliteration of mediastinal/lung margin Review structures at mediastinal/lung margin Can you identify the location of consolidation? Loss of cardiac border Lingula Superior/inferior segments of LUL 16

17 Mrs. EW is a 86 yo F s/p L neck mass dissection 9/28/11 for an enlarging neck mass secondary to malignant melanoma. Known to have lung mets who was noted by her daughter to be SOB for 2 days prior to presentation Bronchial mass causing occlusion of airway Post-procedure 06/14/

18 Pleural Effusion Homogenous density - Loss of cardiophrenic angle - Loss of diaphragmatic and right cardiac silhouette - Rib space widened - Structures shift AWAY affected site How do you distinguish from consolidation? Objective Evidence Radiographic: - effusions >150ml = blunting CPA - > 500ml = obscure diaphragmatic contour NORMAL Atelectesis vs Pleural Effusion 18

19 Decubitus films Layering out of: - 1.5cm or > = small effusion cm = moderate - >4.5cm = large effusion Mr. GD w HCV and recurrent right effusion. This is lateral decubitus film..is the fluid layering? What would be your next form of assessment? 89y/o w h/o breast cancer Review Patient hx 65y/o w compression fracture in bed x 7 days Decubitus Films vs Ultrasound vs CT chest Normal pleural space 65y/o F former smoker presents with dyspnea x 4 days; known h/o breast cancer. Parietal Pleura with malignancy 19

20 Mr. E is a 43y/o homeless male -h/o HTN, CHF, coke/etoh abuse -Crackles bi; JVD to ear; tachy;+3pitting edema BNP=2400; +NSTEMI; and hypoxemia; Echo notes severe LV functx w EF 17%; +mural thrombus After diuresis 80% of the etiology can be obtained via H&P Heart failure is the most common etiology of bilateral effusions Massive effusions are most likely related to a malignancy. Keuger, D. Evaluating the adult with new-onset pleural effusion. JAAPA 26:7; July Mr. F. C is a 53y/o nonsmoker asked to be re-evaluated by PCP due to persistent fevers after over one month. Originally presented to local ER on 4-22 w fever 103 after extensive w/u dx w viral URI. Sent home w no meds. 5-25, fever continued 102 cxr w effusion; pt sent home on Levaquin. He presents to NMH on 5-28 w above CXR. Pt had 2 of 4 SIRS criteria: WBC=16.4; temp; HR=85; RR=16. 20

21 Placed on Ceftriaxone/Zitromax; IR drained 150cc yellow pleural fluid w following finding: Fluid Serum Glucose T.Protein LDH What is it transudative vs exudative? Increased drainage of fluid into the pleural space Hydrostatic pressure (CHF) Colloid osmotic pressure (cirrhosis) Pleural Fluid Accumulation Increase production of fluid by cells in the space Decreased drainage from the space Increased capillary permeability infection, asbestosis Lymphatic Obstruction Empyema (thickened fluid) Imbalance between venous-arterial pressure and pressure within pleural space (hydrostatic O oncotic pressure) Factors altering production and/or absorption of pleural fluid Transudative effusion Exudative effusion Protein LDH Protein WBCs 21

22 Light s criteria to differentiate exudative vs transudative effusions 1. Pleural fluid protein/serum protein ratio > Pleural fluid LDH/serum LDH > Pleural fluid LDH > 2/3 the upper limits of nml for serum LDH (>200 IU/L at NMH) Exudate effusion = meet any one of the criteria No criteria are meet = Transudate effusion Ann Inter Med. 1972; 77: Etiology of Transudative and Exudative Effusions Exudative Transudative Pneumonia CHF Cancer Cirrhosis Pulmonary embolism Pulmonary Embolism MTB Atelectasis Collagen Vascular Disease Nephrotic Syndrome Asbestos-related Peritoneal Dialysis Trauma Constrictive Pericarditis Postcardiac injury syndrome Esophageal perforation Chylothorax 15% of pleural effusions, despite invasive procedures, have no diagnosis!! Placed on Ceftriaxone/Zitromax; IR drained 150cc yellow pleural fluid w following finding: Fluid Serum Glucose T.Protein LDH What is it transudative vs exudative? 22

23 Video-Assisted Thoracoscopic Surgery (VATS) Postoperative film: LVATS for evacuation of complex effusion. Intraop Findings: - Severe inflam of visceral/parietal pleuras -Adhesions at diaphram -Fibrin material adherant and trapping LLL requiring decortication. What is the indication for the CXR? Begin w basics review name, date, gender Review clinical history Go over CXR systematically interpret and assess applicability. Learn how to use the various options to interpret what you are seeing. Review 23

24 Thoracic Surgery Team Northwestern Memorial Hospital Chicago, IL Pneumothorax - No vascular markings on right - Shift of mediastinum to left - Deep sulcus - Atelectatic right lung - Increased haziness on left: - Diversion of entire cardiac output 27y/o F comes to ER c/o dyspnea after speaking a few sentences. This is her first occurrence. She began her menstruation on day of presentation. What is the name of this pneumothorax? 27y/o F comes to ER c/o dyspnea after speaking a few sentences. This is her first occurrence. She began her menstruation on day of presentation. 24

25 Lateral on day of presentation Female with a pneumothorax..d uring her menses..does anyone know the name of this pneumothorax? CATAMENIAL PNEUMOTHORAX Catamenial Pneumothorax - Pneumothorax occurring during menses; age or h/o endometriosis - Onset of px occurs within 72hours of menses - Endometrial tissues attaches within the thoracic cavity, forming chocolatelike cysts. Fenestrations in diaphragm 25