Clinical Chest Radiography Interpretation Part II Anthony M. Angelow, PhD(c), MSN, ACNPC, AGACNP-BC, CEN Associate Lecturer, Fitzgerald Health Education Associates Clinical practice Division of Trauma Surgery and Surgical Critical Care Cooper University Hospital, Camden, NJ Assistant Clinical Professor, College of Nursing and Health Professions Drexel University, Philadelphia, PA Disclosure No real or potential conflict of interest to disclose. No off-label, experimental or investigational use of drugs or devices will be presented. Fitzgerald Health Education Associates 84 Objectives Part II At the end of this presentation, the participant will be able to: Apply a systematic approach to the interpretation of clinical chest radiography. Identify common abnormalities of the chest radiograph based on patient case studies. Describe normal and abnormal findings of the chest radiograph. Before We Begin. Some Reminders! Fitzgerald Health Education Associates 85 Fitzgerald Health Education Associates 86 Chest Radiograph Basics REMINDER! Standard rules of chest radiography Obtain a thorough history and physical examination Always evaluate the entire radiograph Before confirming a diagnosis re-examine the patient and the radiograph and be sure the diagnosis fits the clinical picture Always confirm the right patient Develop a systematic approach Do not get distracted Why is the plain radiograph appropriate? Why is a diagnostic study appropriate? Fitzgerald Health Education Associates 87 Chest Radiograph Interpretation A Systematic (A-I) Approach Adequacy and airway Bones and soft tissue Cardiac Diaphragm Edges (pleura) Fields (lungs) Gastric bubble Hila and mediastinum Impression Fitzgerald Health Education Associates 88
Fitzgerald Health Education Associates 89 MVC with Chest Pain A 35-year-old male presented to the trauma center with a chief complaint of chest pain after being involved in a motor vehicle accident. The patient describes left sided sharp chest pain and also complains of shortness of breath. Physical examination reveals hyperresonance on the right with absent breath sound in the lower right thorax. Fitzgerald Health Education Associates 90 MVC with Chest Pain Step 1 Adequacy and Airway Adequacy Inspiration? Penetration? Rotation? Fitzgerald Health Education Associates 91 Fitzgerald Health Education Associates 92 Step 1 Adequacy and Airway Airway Is the trachea midline? Step 2 Bones and Soft Tissue Bones Fractured ribs? Clavicles? Is the tracheal bifurcation at the level of T4 T5? Scapula, humerus? Fitzgerald Health Education Associates 93 Fitzgerald Health Education Associates 94
Step 2 Bones and Soft Tissue Soft Tissues Step 3 Cardiac Heart Is the soft tissue obscuring any structures? Is there any subcutaneous air? Is the heart positioned appropriately? Is the heart a normal size? Fitzgerald Health Education Associates 95 Fitzgerald Health Education Associates 96 Step 4 Diaphragm Diaphragm Are there sharp diaphragmatic margins? Step 5 Edges (Pleura) Pleura Are there any noticeable pleural lines? Is the contour normal? Any noticeable fluid or air accumulation? Fitzgerald Health Education Associates 97 Fitzgerald Health Education Associates 98 Step 6 Field (Lungs) Lungs Is there a normal vessel pattern? Step 7 Gastric Bubble Gastric Bubble Is the bubble round on the left side? Are the lungs air filled? Any lucencies or shadowing? Any suggestion of free air in the abdomen? Fitzgerald Health Education Associates 99 Fitzgerald Health Education Associates 100
Step 8 Hilum and Mediastinum Hilum Is the hilum clearly present? Any masses or lymphadenopathy? Step 8 Hilum and Mediastinum Mediastinum Size and position? Is the trachea to the right? Similar in size and density? Structures identifiable? Fitzgerald Health Education Associates 101 Fitzgerald Health Education Associates 102 Fitzgerald Health Education Associates 103 Abnormal Findings Trachea deviated to right Heart deviated to right Clear demarcation of pleural lines on the left with air in the pleural space Lung vasculature not extended to pleural wall on the left Mediastinum deviated to the right A 35-year-old male presented to the trauma center with a chief complaint of chest pain after being involved in a motor vehicle accident. The patient describes left sided sharp chest pain and also complains of shortness of breath. Physical examination reveals hyperresonance on the right with absent breath sound in the lower right thorax. Fitzgerald Health Education Associates 104 Fitzgerald Health Education Associates 105 Diagnosis? Does this make sense? A 35-year-old male presented to the trauma center with a chief complaint of chest pain after being involved in a motor vehicle accident. The patient describes left sided sharp chest pain and also complains of shortness of breath. Physical examination reveals hyperresonance on the right with absent breath sound in the lower right thorax. Fitzgerald Health Education Associates 106
Fitzgerald Health Education Associates 107 Cough, Chills, and Fever A 65-year-old female presents with complaints of cough, chills, and fever for the last three days. She describes her cough as productive with yellow mucus and a fever ranging from 101.5 102.4 F (38.6 39.1 C). She describes a feeling of overall fatigue and shortness of breath with activity. Lung sounds produce crackles in the right base. Fitzgerald Health Education Associates 108 Cough, Chills, and Fever Step 1 Adequacy and Airway Inspiration? Adequacy Penetration? Rotation? Fitzgerald Health Education Associates 109 Fitzgerald Health Education Associates 110 Step 1 Adequacy and Airway Airway Is the trachea midline? Step 2 Bones and Soft Tissue Bones Fractured ribs? Is the tracheal bifurcation at the level of T4 T5? Clavicles? Scapula, humerus? Fitzgerald Health Education Associates 111 Fitzgerald Health Education Associates 112
Step 2 Bones and Soft Tissue Soft Tissues Is the soft tissue obscuring any structures? Step 3 Cardiac Heart Is the heart positioned appropriately? Is there any subcutaneous air? Is the heart a normal size? Fitzgerald Health Education Associates 113 Fitzgerald Health Education Associates 114 Step 4 Diaphragm Diaphragm Are there sharp diaphragmatic margins? Step 5 Edges (Pleura) Pleura Are there any noticeable pleural lines? Is the contour normal? Any noticeable fluid or air accumulation? Fitzgerald Health Education Associates 115 Fitzgerald Health Education Associates 116 Step 6 Field (Lungs) Lungs Is there a normal vessel pattern? Step 7 Gastric Bubble Gastric Bubble Is the bubble round on the left side? Are the lungs air filled? Any lucencies or shadowing? Any suggestion of free air in the abdomen? Fitzgerald Health Education Associates 117 Fitzgerald Health Education Associates 118
Step 8 Hilum and Mediastinum Hilum Is the hilum clearly present? Step 8 Hilum and Mediastinum Mediastinum Size and position? Any masses or lymphadenopathy? Similar in size and density? Is the trachea to the right? Structures identifiable? Fitzgerald Health Education Associates 119 Fitzgerald Health Education Associates 120 Fitzgerald Health Education Associates 121 Abnormal Findings Slight underpenetration of the radiograph Consolidation noted in the RLL A 65-year-old female presents with complaints of cough, chills, and fever for the last three days. She describes her cough as productive with yellow mucus and a fever ranging from 101.5 102.4 F (38.6 39.1 C). She describes a feeling of overall fatigue and shortness of breath with activity. Lung sounds produce crackles in the right base. Fitzgerald Health Education Associates 122 Fitzgerald Health Education Associates 123 Diagnosis? Does this make sense? A 65-year-old female presents with complaints of cough, chills, and fever for the last three days. She describes her cough as productive with yellow mucus and a fever ranging from 101.5 102.4 F (38.6 39.1 C). She describes a feeling of overall fatigue and shortness of breath with activity. Lung sounds produce crackles in the right base. Fitzgerald Health Education Associates 124
Fitzgerald Health Education Associates 125 Cough with Hemoptysis A 60-year-old male with a 40-pack-year smoking history presented with a complaint of cough with noted blood in his sputum and breathlessness. He states he has been short of breath for the last few months, but contributes that to his smoking. He also admits to a 10 lb (4.5 Kg) unprovoked weight loss over the last few weeks. Fitzgerald Health Education Associates 126 Cough, Chills, and Fever Step 1 Adequacy and Airway Inspiration? Adequacy Penetration? Rotation? Fitzgerald Health Education Associates 127 Fitzgerald Health Education Associates 128 Step 1 Adequacy and Airway Airway Is the trachea midline? Step 2 Bones and Soft Tissue Fractured ribs? Bones Is the tracheal bifurcation at the level of T4 T5? Clavicles? Scapula, humerus? Fitzgerald Health Education Associates 129 Fitzgerald Health Education Associates 130
Step 2 Bones and Soft Tissue Soft Tissues Is the soft tissue obscuring any structures? Step 3 Cardiac Heart Is the heart positioned appropriately? Is there any subcutaneous air? Is the heart a normal size? Fitzgerald Health Education Associates 131 Fitzgerald Health Education Associates 132 Step 4 Diaphragm Diaphragm Are there sharp diaphragmatic margins? Step 5 Edges (Pleura) Pleura Are there any noticeable pleural lines? Is the contour normal? Any noticeable fluid or air accumulation? Fitzgerald Health Education Associates 133 Fitzgerald Health Education Associates 134 Step 6 Field (Lungs) Lungs Is there a normal vessel pattern? Step 7 Gastric Bubble Gastric Bubble Is the bubble round on the left side? Are the lungs air filled? Any lucencies or shadowing? Any suggestion of free air in the abdomen? Fitzgerald Health Education Associates 135 Fitzgerald Health Education Associates 136
Step 8 Hilum and Mediastinum Hilum Is the hilum clearly present? Step 8 Hilum and Mediastinum Mediastinum Size and position? Any masses or lymphadenopathy? Is the trachea to the right? Similar in size and density? Structures identifiable? Fitzgerald Health Education Associates 137 Fitzgerald Health Education Associates 138 Fitzgerald Health Education Associates 139 Abnormal Findings Singular mass/lesion located in the left lung Left hilum is obstructed by the presence of a singular mass A 60-year-old male with a 40-pack-year smoking history presented with a complaint of cough with noted blood in his sputum and breathlessness. He states he has been short of breath for the last few months, but contributes that to his smoking. He also admits to a 10 lb (4.5 Kg) unprovoked weight loss over the last few weeks. Fitzgerald Health Education Associates 140 Fitzgerald Health Education Associates 141 Diagnosis? Does this make sense? A 60-year-old male with a 40-pack-year smoking history presented with a complaint of cough with noted blood in his sputum and breathlessness. He states he has been short of breath for the last few months, but contributes that to his smoking. He also admits to a 10 lb (4.5 Kg) unprovoked weight loss over the last few weeks. Fitzgerald Health Education Associates 142
Fitzgerald Health Education Associates 143 Chest Pain After Being Hit with a Bat An 11-year-old male with a chief complaint of left sided chest pain presented to the ED after sustaining a blow to the chest with a bat during a baseball game. He states the pain is sharp in nature and worsens with inspiration. On physical examination there is noted chest tenderness to palpation in the left upper chest. Fitzgerald Health Education Associates 144 Chest Pain After Being Hit with a Bat Step 1 Adequacy and Airway Adequacy Inspiration? Penetration? Rotation? Fitzgerald Health Education Associates 145 Fitzgerald Health Education Associates 146 Step 1 Adequacy and Airway Airway Is the trachea midline? Step 2 Bones and Soft Tissue Fractured ribs? Bones Is the tracheal bifurcation at the level of T4 T5? Clavicles? Scapula, humerus? Fitzgerald Health Education Associates 147 Fitzgerald Health Education Associates 148
Step 2 Bones and Soft Tissue Soft Tissues Is the soft tissue obscuring any structures? Step 3 Cardiac Heart Is the heart positioned appropriately? Is there any subcutaneous air? Is the heart a normal size? Fitzgerald Health Education Associates 149 Fitzgerald Health Education Associates 150 Step 4 Diaphragm Diaphragm Are there sharp diaphragmatic margins? Step 5 Edges (Pleura) Pleura Are there any noticeable pleural lines? Is the contour normal? Any noticeable fluid or air accumulation? Fitzgerald Health Education Associates 151 Fitzgerald Health Education Associates 152 Step 6 Field (Lungs) Lungs Is there a normal vessel pattern? Step 7 Gastric Bubble Gastric Bubble Is the bubble round on the left side? Are the lungs air filled? Any lucencies or shadowing? Any suggestion of free air in the abdomen? Fitzgerald Health Education Associates 153 Fitzgerald Health Education Associates 154
Step 8 Hilum and Mediastinum Hilum Is the hilum clearly present? Step 8 Hilum and Mediastinum Mediastinum Size and position? Any masses or lymphadenopathy? Is the trachea to the right? Similar in size and density? Structures identifiable? Fitzgerald Health Education Associates 155 Fitzgerald Health Education Associates 156 Fitzgerald Health Education Associates 157 Abnormal Findings Slightly displaced fracture of the left 3 rd rib An 11-year-old male with a chief complaint of left sided chest pain presented to the ED after sustaining a blow to the chest with a bat during a baseball game. He states the pain is sharp in nature and worsens with inspiration. On physical examination there is noted chest tenderness to palpation in the left upper chest. Fitzgerald Health Education Associates 158 Fitzgerald Health Education Associates 159 Diagnosis? Does this make sense? An 11-year-old male with a chief complaint of left sided chest pain presented to the ED after sustaining a blow to the chest with a bat during a baseball game. He states the pain is sharp in nature and worsens with inspiration. On physical examination there is noted chest tenderness to palpation in the left upper chest. Fitzgerald Health Education Associates 160
Fitzgerald Health Education Associates 161 Hospitalized Patient Sudden Onset SOB An 47-year-old male who was admitted to the TICU after sustaining multiple traumatic injuries requiring numerous blood product transfusions complains this morning of severe onset of shortness of breath. He denies chest pain, cough, and no fever is documented. On physical examination his lung sounds are decreased with diffuse crackles. Fitzgerald Health Education Associates 162 Hospitalized Patient Sudden Onset SOB Step 1 Adequacy and Airway Adequacy Inspiration? Penetration? Rotation? Fitzgerald Health Education Associates 163 Fitzgerald Health Education Associates 164 Step 1 Adequacy and Airway Airway Is the trachea midline? Step 2 Bones and Soft Tissue Bones Fractured ribs? Is the tracheal bifurcation at the level of T4 T5? Clavicles? Scapula, humerus? Fitzgerald Health Education Associates 165 Fitzgerald Health Education Associates 166
Step 2 Bones and Soft Tissue Soft Tissues Step 3 Cardiac Heart Is the soft tissue obscuring any structures? Is the heart positioned appropriately? Is there any subcutaneous air? Is the heart a normal size? Fitzgerald Health Education Associates 167 Fitzgerald Health Education Associates 168 Step 4 Diaphragm Diaphragm Are there sharp diaphragmatic margins? Step 5 Edges (Pleura) Pleura Are there any noticeable pleural lines? Is the contour normal? Any noticeable fluid or air accumulation? Fitzgerald Health Education Associates 169 Fitzgerald Health Education Associates 170 Step 6 Field (Lungs) Lungs Is there a normal vessel pattern? Step 7 Gastric Bubble Gastric Bubble Is the bubble round on the left side? Are the lungs air filled? Any lucencies or shadowing? Any suggestion of free air in the abdomen? Fitzgerald Health Education Associates 171 Fitzgerald Health Education Associates 172
Step 8 Hilum and Mediastinum Hilum Is the hilum clearly present? Step 8 Hilum and Mediastinum Mediastinum Size and position? Any masses or lymphadenopathy? Is the trachea to the right? Similar in size and density? Structures identifiable? Fitzgerald Health Education Associates 173 Fitzgerald Health Education Associates 174 Abnormal Findings Costovertebral angles not clear Bilateral, diffuse patchy infiltrates An 47-year-old male who was admitted to the TICU after sustaining multiple traumatic injuries requiring numerous blood product transfusions complains this morning of severe onset of shortness of breath. He denies chest pain, cough, and no fever is documented. On physical examination his lung sounds are decreased with diffuse crackles. Fitzgerald Health Education Associates 175 Fitzgerald Health Education Associates 176 Diagnosis? Does this make sense? An 47-year-old male who was admitted to the TICU after sustaining multiple traumatic injuries requiring numerous blood product transfusions complains this morning of severe onset of shortness of breath. He denies chest pain, cough, and no fever is documented. On physical examination his lung sounds are decreased with diffuse crackles. Fitzgerald Health Education Associates 177 Fitzgerald Health Education Associates 178
Cough An 25-year-old female presents with complaints of cough for two days and is demanding a chest x-ray for evaluation. The cough is non-productive, she denies SOB, and denies fever. There are no other symptoms reported by the patient, although she states she does have a history of wellcontrolled asthma. Her physical examination is unremarkable. Fitzgerald Health Education Associates 179 Fitzgerald Health Education Associates 180 Cough Step 1 Adequacy and Airway Inspiration? Adequacy Penetration? Rotation? Fitzgerald Health Education Associates 181 Fitzgerald Health Education Associates 182 Step 1 Adequacy and Airway Airway Is the trachea midline? Step 2 Bones and Soft Tissue Bones Fractured ribs? Is the tracheal bifurcation at the level of T4 T5? Clavicles? Scapula, humerus? Fitzgerald Health Education Associates 183 Fitzgerald Health Education Associates 184
Step 2 Bones and Soft Tissue Soft Tissues Step 3 Cardiac Heart Is the soft tissue obscuring any structures? Is the heart positioned appropriately? Is there any subcutaneous air? Is the heart a normal size? Fitzgerald Health Education Associates 185 Fitzgerald Health Education Associates 186 Step 4 Diaphragm Diaphragm Are there sharp diaphragmatic margins? Step 5 Edges (Pleura) Pleura Are there any noticeable pleural lines? Is the contour normal? Any noticeable fluid or air accumulation? Fitzgerald Health Education Associates 187 Fitzgerald Health Education Associates 188 Step 6 Field (Lungs) Lungs Is there a normal vessel pattern? Step 7 Gastric Bubble Gastric Bubble Is the bubble round on the left side? Are the lungs air filled? Any lucencies or shadowing? Any suggestion of free air in the abdomen? Fitzgerald Health Education Associates 189 Fitzgerald Health Education Associates 190
Step 8 Hilum and Mediastinum Hilum Is the hilum clearly present? Step 8 Hilum and Mediastinum Mediastinum Size and position? Any masses or lymphadenopathy? Is the trachea to the right? Similar in size and density? Structures identifiable? Fitzgerald Health Education Associates 191 Fitzgerald Health Education Associates 192 Abnormal Findings None identified An 25-year-old female presents with complaints of cough for two days and is demanding a chest x-ray for evaluation. The cough is non-productive, she denies SOB, and denies fever. There are no other symptoms reported by the patient, although she states she does have a history of wellcontrolled asthma. Her physical examination is unremarkable. Fitzgerald Health Education Associates 193 Fitzgerald Health Education Associates 194?? Diagnosis? Does this make sense? An 25-year-old female presents with complaints of cough for two days and is demanding a chest x-ray for evaluation. The cough is non-productive, she denies SOB, and denies fever. There are no other symptoms reported by the patient, although she states she does have a history of wellcontrolled asthma. Her physical examination is unremarkable. Fitzgerald Health Education Associates 195 Fitzgerald Health Education Associates 196
Reference Slides Other Common Abnormalities Fitzgerald Health Education Associates 197 Atelectasis Condition of volume loss in some portion of lung May involve sub-segment, segment, lobe or entire lung Increased density usually linear Collapse or incomplete expansion of the lung or part of the lung Segmental and sub-segmental collapse may show linear, curvilinear, wedge shaped opacities Fitzgerald Health Education Associates 198 Atelectasis Causes Obstructive Most common Bronchus obstructed by mucous plug, neoplasm, or foreign body Compressive Normal lung compressed by tumor, emphysematous bulla or heart enlargement Atelectasis Causes Cicatrization Organizing scar tissue Most often after healing granulomatous disease (i.e., TB), pulmonary infarct or trauma Adhesive Inactivation of surfactant (i.e., hyaline membrane disease) Fitzgerald Health Education Associates 199 Fitzgerald Health Education Associates 200 Atelectasis Causes Linear Atelectasis Passive Normal compliance of the lung with pneumothorax or pleural effusion Airway remains patent Source: https://commons.wikimedia.org/wiki/file:thorax_mit_bds_unterlappen- Atelektase_mit_Voraufnahme.jpg Fitzgerald Health Education Associates 201 Fitzgerald Health Education Associates 202
Cardiogenic Increased hydrostatic pulmonary capillary pressure Non-cardiogenic Altered capillary membrane permeability or decreased plasma oncotic pressure Pulmonary Edema NOT CARDIAC (pneumonic) Near-drowning, Oxygen therapy, Transfusion or Trauma, CNS disorder, ARDS, Aspiration, or Altitude sickness, Renal disorder or Resuscitation, Drugs, Inhaled toxins, Allergic Alveolitis, Contrast or Contusion Fitzgerald Health Education Associates 203 Cardiogenic Pulmonary Edema Cephalization of the pulmonary vessels Kerley A lines Thin linear opacities in mid and upper zones radiating to hila Kerley B lines Linear opacities 1 2 cm long and 1 2 mm thick perpendicular to pleural surface caused by interstitial fluid (septal lines) Fitzgerald Health Education Associates 204 Cardiogenic Pulmonary Edema Peribronchial cuffing Bat wing" pattern Perihilar and medullary consolidation of both lungs Patchy shadowing with air bronchograms Heart enlargement Pleural effusions Fitzgerald Health Education Associates 205 Source: Anthony Angelow Pulmonary Edema Cephalization of Vessels Fitzgerald Health Education Associates 206 Bat Wing Pattern Pulmonary Edema Source: Anthony Angelow and Theresa Campo (used with permission) Source: Anthony Angelow Fitzgerald Health Education Associates 207 Fitzgerald Health Education Associates 208
Heart Failure Pleural Effusion Source: Anthony Angelow Causes CHF Infection (parapneumonic) Trauma PE Tumor Autoimmune disease Renal failure Fitzgerald Health Education Associates 209 Fitzgerald Health Education Associates 210 Pleural Effusion Pulmonary Nodules Source: Anthony Angelow Source: Anthony Angelow Fitzgerald Health Education Associates 211 Fitzgerald Health Education Associates 212 Pulmonary Nodules References Campo, T.M. (2017). Clinical Chest Radiography Podium Presentation at National Conference of Nurse Practitioners. Campo, T.M. (2016). Medical Imaging for Health Care Providers: Practical Radiograph Interpretation. Springer Publishing: New York, NY. Fitzgerald Health Education Associates 213 Fitzgerald Health Education Associates 214
References Collins and Stern. (2008). Chest Radiology: The Essentials. Wolters Kluwer/LWW: Philadelphia, PA. Daffner and Hartman (2014). Clinical Radiology: The Essentials 4th ed. Wolters Kluwer/LWW: Philadelphia, PA. Fitzgerald Health Education Associates 215 References Hermann et al. (2012). Best practices in digital radiography: White paper. American Society of Radiologic Technologies accessed from http://www.asrt.org/docs/whitepapers/ asrt12_bstpracdigradwhp_final.pdf Wallace, J.E. (2015). Radiographic exposure: Principles and practice. FA Davis: Philadelphia, PA. Fitzgerald Health Education Associates 216 Copyright Notice Images/Illustrations: Unless otherwise noted, all images/illustrations are from open sources, such as the CDC or Wikipedia or property of FHEA or author. All websites listed active at the time of publication. Copyright by Fitzgerald Health Education Associates All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopy, recording or any information storage and retrieval system, without permission from Fitzgerald Health Education Associates Requests for permission to make copies of any part of the work should be mailed to: Fitzgerald Health Education Associates 85 Flagship Drive North Andover, MA 01845-6184 Fitzgerald Health Education Associates 217 Fitzgerald Health Education Associates 218 Statement of Liability The information in this program has been thoroughly researched and checked for accuracy. However, clinical practice and techniques are a dynamic process and new information becomes available daily. Prudent practice dictates that the clinician consult further sources prior to applying information obtained from this program, whether in printed, visual or verbal form. Fitzgerald Health Education Associates disclaims any liability, loss, injury or damage incurred as a consequence, directly or indirectly, of the use and application of any of the contents of this presentation. Fitzgerald Health Education Associates 85 Flagship Drive North Andover, MA 01845-6154 978.794.8366 Fax-978.794.2455 Website: fhea.com Learning and Testing Center: fhea.com/npexpert www.facebook.com/fitzgeraldhealth @npcert Fitzgerald Health Education Associates 219 Fitzgerald Health Education Associates 220