Chest MEDICAL

The CHEST Emergency Medical Conditions MI Zucker, MD A dr Z Lecture The WHAT: • • • • • Normal chest films Abnormal patterns Atelectasis Infection Obstructive airway diseases • • • • • Heart failure Noncardiac edema Pulmonary embolism Aortic dissection …and a few others The WHY: • Give you a basic approach to acute medical diseases emphasizing CHEST Radiographs • Show you the most COMMON diseases • Show you commonly MISSED findings The NORMAL Chest PA/lateral Portable AP The PA (adult and kid) and Lateral • Check list • Commonly overlooked areas The PORTABLE AP • The “bottom feeder” of chest radiology Pitfalls in Chest Radiology • • • • Phase of respiration Position Comparison films Portables Poor Inspiration The PATTERNS Too dense Too lucent Location, Location, Location Lung? Chest wall? Mediastinum? Pleura? Lung: Too DENSE • Alveolar pattern • Interstitial pattern • Masses Lung: Alveolar Pattern • Something of unit/soft tissue/water density replaces the air in the alveolar ducts, alveolar sacs and the alveoli Alveolar Lung Pattern: causes • • • • • • PUS WATER BLOOD Lymphoma BAC Alveolar proteinosis Alveolar Lung Pattern: findings • • • • Increased density Confluence Ill defined margins Air bronchograms Lung: Interstitial Pattern Something thickens the interstitium of the lung parenchyma What? • • • • • Edema Inflammatory cells RBC’s Malignant cells Fibrosis How? All of them ADD tissue to the peripheral and axial interstitium of the secondary pulmonary lobule Secondary Pulmonary Lobules Who? • Many, many diseases present with the same interstitial patterns • You need history, lab, and frequently biopsy to make a specific diagnosis A Memory Aid “I Munch Ice Chips In Places Called Igloos” Interstitial diseases • Idiopathic UIP DIP LIP BOOP LAM PEG sarcoid • Malignancy Metastases, lymphoma • Infection Viral, PCP, mycoplasma. Fungi, TB, MAC Interstitial diseases • Congenital NF TS CF • Iatrogenic Drugs, radiation • Pulmonary edema Cardiogenic, renal, noncardiogenic Interstitial diseases • Collagen-vascular RA, SLE, scleroderma, AS Allergic alveolitis, noxious gases, pneumoconiosis • Inhalational The Interstitial Patterns • • • • Lines: fine, medium, or coarse Nodules: tiny to 3 cm Reticular: network of crossing lines Reticular-nodular: lines and nodules Lines Nodules Reticular pattern Lines and nodules What do they mean? • Coarse lines mean fibrosis, also called “honeycomb” pattern • The other patterns usually mean more active disease, but aren’t specific Kerley lines, A and B • Thickened secondary lobule septae • Often, but not always due to CHF • Basically, they are just a slightly specialized intertstitial linear pattern • A and B differ only by location INFECTION The pneumonias BACTERIAL PNEUMONIAS Pyogenic The Silhouette Sign • If two adjacent structures have the same density, the border between them is not visible. Replace air with an alveolar process and the border between the involved lung and the heart, or diaphragm, or aorta disappears The Spine Sign • On the lateral view the spine normally progressively looks darker caudally. If it looks whiter, there is an alveolar process in one of the lower lobes. Atypical Pneumonias • Mycoplasma • Chlamydia Patterns • Diffuse bilateral patchy opacities • Diffuse interstitial linear opacities Viral Pneumonias • Air-trapping • Mucus plugs and atelectasis • Diffuse interstitial linear and nodular opacities • Findings more pronounced in kids Pneumocystis carnii Pneumonia • Interstitial linear nodular pattern, usually bilateral • Followed by diffuse alveolar pattern • Early, 10% of CXR’s in PCP can be negative. Later, atypical patterns are fairly common. PCP Tuberculosis • Primary • Post-primary TB: primary TB: postprimary, early TB: postprimary, cavitary A few more Infections • Lung abscess • Empyema • Fungus Lung abscess Empyema: Hydro-pneumothorax Coccidioidomycosis ATELECTASIS Loss of Lung Volume Atelectasis: types • • • • • Obstructive Passive Compressive Cicatricial Adhesive Atelectasis: signs • • • • • • • Increased density Shift of fissure Elevation of diaphragm Shift of mediastinum Shift of heart Shift of hilum Compensatory hyperinflation Subsegmental Right upper lobe Lower lobes Right middle lobe Left upper lobe ATX: entire lung Edema Cardiogenic Renal Noncardiogenic Edema: pathogenesis • Cardiogenic: increased hydrostatic pressure • Noncardiogenic: increased alveolarcapillary membrane permeability • Renal: multiple factors Cardiogenic Congestive heart failure CHF • Cephalization 12 wedge pressure • Interstitial edema 20 • Alveolar edema 25 • Cardiomegaly, pleural effusions CHF: cephalization CHF: interstitial edema CHF: alveolar edema Renal related • Fluid overload • Increased permeability • CHF Edema: renal Noncardiogenic edema • • • • • • Near drowning High altitude Drugs Inhalation Hypoxia (ARDS) Noncardiogenic edema Obstructive lung disease Asthma COPD Asthma • • • • Hyperinflation Mucus plugs/atelectasis Interstitial inflammation Barotrauma Asthma: kid Asthma: adult COPD • • • • • Hyperinflation Flat diaphragm Increased retrosternum air space Pulmonary arterial hypertension Look for pneumonia as cause of exacerbation COPD Pulmonary embolism PE: diagnosis • • • • • • • Clinical: dyspnea, chest pain, increased RR & PR D-dimer Doppler ultrasound *CXR *CTPA Lung scan Pulmonary angiography Chest film • • • • • Subsegmental atelectasis Small pleural effusion Elevated diaphragm Westermark’s (rare) Hampton’s (rare) PE: CXR PE: CTPA Aortic Dissection Aortic Dissection • • • • HYPERTENSION Marfans Coarctation Turners, SLE, pregnancy Aortic Dissection • Type A: more common, ascending aorta, surgery • Type B: descending aorta, trial of medical management AD: imaging • • • • • CXR CTA MRI TEE Angiography AD: CXR • Mediastinum contour abnormality: abnormal shape or width • A change in contour from previous film AD: CXR Sensitivity: 80% AD: CXR AD: CXR AD: CTA axial AD: CTA reformat …and a few more Sickle Cell Disease Cystic Fibrosis Sickle Cell Disease Cystic Fibrosis Goodbye • Copyright 2004 MI Zucker, MD