The CHEST Emergency Medical Conditions MI Zucker, MD.
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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
• Malignancy
• Infection
UIP DIP LIP BOOP LAM PEG sarcoid
Metastases, lymphoma
Viral, PCP, mycoplasma.Fungi, TB, MAC
Interstitial diseases
• Congenital
• Iatrogenic
• Pulmonary edema
NF TS CF
Drugs, radiation
Cardiogenic, renal,
noncardiogenic
Interstitial diseases
• Collagen-vascular
• Inhalational
RA, SLE, scleroderma,
AS
Allergic alveolitis, noxious gases, pneumoconiosis
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 alveolar-capillary 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 DiseaseCystic Fibrosis
Sickle Cell Disease
Cystic Fibrosis
Goodbye
• Copyright 2004
MI Zucker, MD
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