Objectives CAPA 2011 Christy Wilson, PA C Georgia Lung Associates Identify the radiographic landmarks on a chest radiograph Recognize identifiers of poor quality on the chest radiograph Outline an approach to interpretation of frontal or lateral chest radiographs Recognize common identifiable infections including pneumonia, fungi and tuberculosis Recognize the spectrum of common cardiovascular disease processes Recognize patterns of primary or metastatic carcinoma of the lung Recognize normal and abnormal placement of chest tubes and lines CXR Workshop This workshop will provide a guided review of the anatomy of the thorax and demonstrate the radiographic image correlating to that anatomy. A sequential approach to chest radiographs will be demonstrated and practiced at the view box. Disease processes affecting the heart and lungs will be discussed, using visual correlations on radiographs. This didactic portion will be followed by hands on practice at view boxes, with the actual films, demonstrating a wide range of pathology and some normal films for comparison. What is a Chest X Ray? Definition (diagnostic tool/internal PE) Types Portable PA and Lat Decubitus Cost 1
Indications for Chest X rays Screening Tool Pulmonary complaints Pre op Clearance Trauma Line Placement Ten Rules for Reading a Chest X ray 1. The only way to learn to read CXRs is to read CXRs. Daily! 2. Always check the name and date on the film. 5% of the time it is wrong. 3. When confronted with an abnormal CXR, always compare with prior films. 4. Don t ignore the lateral film. It can often clarify the presence or absence of lower lobe dz. 10 Rules con t 5. Don t confuse technique with change on a CXR. 6. Consider everything on a CXR that might be useful, ie. FB, ET tubes, etc. 7. The presence of clear lung fields and normal heart size rules out CHF as a cause of patient s sx. 10 Rules con t 8. Lung fields can never be called clear on a PCXR until one has identified the left hemi diaphragm and lack of infiltrate behind the heart. 9. The Chest X ray never lies! 10. Ask for help, it is always available! ***The obvious is not always the most important finding! 2
Anatomy of the Lungs 3
Find these locations! Cardiac notch Lingula of Left Lung Oblique Fissure Anterior Border How to read a CXR? Step 1: Placement of CXR Verify the XR Name Date Position markers Type of CXR Patient History ex: surgical hx Step 1: Is it a Good CXR? A Good Chest X ray???? Film Quality Over vs.. under penetration Patient Placement rotation Body Habitus Maximize inspiration Nipple markers Adequate Inspiration 4
Normal Chest X ray ABC s of Reading a CXR A = Appliances and Airway B = Bones C = Circulation / Cardiac D = Diaphragm E = Everything Else Step 2: Airway and Appliances Airway Mediastinum Tracheal positioning Aortic calcifications Foreign Body Lines, cardiac monitor, ET tube, Chest tubes, prosthesis, FBs etc. Central Line Placement Appliances /Placement 5
Central Line Placement Central Line Placement Chest Tube Placement Step 3: Bones Examine the bones Count the ribs Clavicle alignment Spine alignment Alignment of Clavicles Lateral View vertebrae 6
Bones Look at the ribs Left Sided Chest Pain 7
Step 4: Circulation/Cardiac Cardiomegaly Pulmonary Edema Dextrocardia Pericardial effusion Pulmonary Edema Dextrocardia 8
Pericardial Effusion Step 5 = Diaphragm Diaphragm Compare elevation, gas patterns, hiatal hernia Pneumoperitoneum Elevated Right Hemidiaphragm 9
Step 6 = Everything Else Everything Else Soft Tissue Breast tissue Lung Parenchyma Description of Infiltrates ***Always compare to previous CXRs Pulmonary vasculature Pulmonary edema Costophrenic angles Pleural effusions Inflation Count the ribs emphysema Masses/nodule Consolidation Parenchyma Compare lung fields to each other Reading a Chest X ray Lines Bones Soft Tissue Trachea Air Mediastinum Aorta AP window Heart Diaphragm Hilum Lungs Describing a Chest X ray Unilateral vs. Bilateral Focal vs. Diffuse Location Peripheral vs. Central Interstitial vs. Alveolar Infiltrates 10
Lung Nodules What to do? 11
What is this? Loculated Effusion 12
Pneumoperitoneum Honeycombing Miliary TB What do you see? 13
The Lobes of the Lungs Left Lower Lobe Lt. Diaphragm border lost with LLL infiltrate/consolidation Left Upper Lobe Lt. Heart border is lost with a LUL infiltrate/consolidation Lingular portion Lt. Heart border lost but apex is clear Right Lower Lobe Rt. Diaphragm border lost Right Middle Lobe Rt. Heart border lost but able to see rt. Costophrenic angle Right Upper Lobe Rt. Apex shows consolidation Lateral View of CXR Lateral View of CXR Lateral Films 1.Rib 2.Sternum 3.Breast 4.Position of oblique fissure 5.Position of horizontal fissure 14
Pneumonia When to admit to the hospital and when to treat as an outpatient????? CURB 65 The CURB 65 score is based upon five easily measurable factors Confusion (based upon a specific mental test or new disorientation to person, place, or time) Urea (blood urea nitrogen in the United States) >7 mmol/l (20 mg/dl) Respiratory rate >30 breaths/minute Blood pressure [BP] (systolic <90 mmhg or diastolic <60 mmhg) Age >65 years Score of 2 or more: recommend admitting to the hospital PSI Pneumonia Severity Index 15
Which Pneumonia is this? What do you see? 45 yobw presents with fever and cough? What do you see? 16
Atelectasis vs. PNA Recent Surgery Pneumothorax with Chest Tube 17
Metz. Cavitating Squamous Cell Carcinoma Examples of TB Fungal Infection cavitary mass Bronchiectasis 18
Lung Nodule Case Study #1 WB 75 yo male presents with worsening SOB/dyspnea and LE edema Portable CXR Diagnosis Case Study #2 DL is a 70 yowm presents to ER via EMS after being involved in a head on collision. Pt states his chest hit the steering wheel. Portable CXR What do you see? 19
Case #3 YM is a 78 yo male with COPD was told he had an abnormal CXR. 20
Case Study #4 FC is a 67 yowm with PMHx of Head and Neck cancer, and chronic aspiration. He presented with worsening SOB and presumed aspiration PNA. Here is his initial CXR. Case Study #4 Patient s respiratory status worsens and here is a follow up chest x ray. 21
Case Study #4 Case Study #4 Bronch is done and large amount of sputum is collected. Here is the follow up Chest x ray. Case Study #5 Pt is a 47 yowm who presents with worsening SOB and approx. 20 lb. weight loss over 3 months. 22
Case Study #5 Case Study #5 CT Scan showed multiple pulmonary nodules What is the next step for diagnosis? Case Study #6 73 yobf complains of SOB and hypoxemia in the recovery room after just having a THR. What do you see? Case Study #7 44 yowf presents with fevers, cough and SOB for one week. She admits to a PMHx of Breast Cancer 5 years ago and was treated with bilateral mastectomies and chemo. Here is her initial Chest X Ray: 23
Case Study #7 Pt was started on antibiotics for pneumonia and underwent a L sided thorocentesis. The pleural fluid was sent to the lab cytology was pending, initial report showed an exudative effusion. One day after the procedure, a following chest x ray showed worsening L effusion. What did cytology show? Case Study #7 CT Scan what done to evaluate the recurrent pleural effusion. 24
Case Study #7 A PET Scan was obtained for staging work up. The Patient underwent Pleuradesis. Case Study #8 WD is a pleasant 62 yowm who presented with Right LE edema x 1 week and some L sided pleuritic chest discomfort. PMHx is unremarkable Labs: Unremarkable US of RLE: positive for DVT CT chest with PE protocol:?????? 25
Case Study #8 Case Study #8 What is the treatment? 26
updated 6/31/11 27