CLIN RESP Investigations & Devices - Week 3

Question 1

Process of CXR Interpretation

Answer 1

1. ID
   a. Patient’s name
   b. ID no.
   c. Gender
   d. Date XRT
2. View
   a. PA/AP/Lateral/Decubitus/Lordotic/Oblique/Supine/Erect
   b. Film markers (L/R/view)
3. Rotation
4. Inspiration
   a. Count no. posterior ribs above diaphragm
5. Penetration
   a. Adequate = if lung markings & thoracic spine are observable
   b. Over penetration = excess black – if cannot see lung markings
   c. Under penetration = excess white – if cannot see thoracic spine behind the heart
6. Artefacts
   a. Foreign bodies
   b. Hardware
7. Bones
   a. Deformities
   b. Fractures
   i. Clavicles
   ii. Scapula
   iii. Follow all ribs to ensure intact
8. Soft tissues
   a. Costophrenic angles
   b. Cardiophrenic angle
   c. Ensure white soft tissue outside lungs
9. Midline structures
   a. Trachea
   i. Central vs deviated
   b. Hilum
   i. Check for enlargement
   c. Lymph nodes
   d. Blood vessels
10. Heart
    a. Position
    b. Aortic arch/aortic knuckle position
    c. Size
    d. Silhouette
    e. Retrocardiac density
    f. Kerly-B/Septal lines
11. Diaphragms
    a. Air under diaphragm
    b. Gastric bubble position
12. Pleural
    a. Normal/thickened/plaque presence
13. Lungs
    a. Collapse
    b. Consolidation
    c. Opacity
    d. Air-fluid level in abscesses
    e. Lung markings
    f. Meniscus sign
14. Summarise

Question 2

When should you not comment on hypermegaly?

Answer 2

AP.

Question 3

How many ribs should be visible on CXR normally on full inspiration?

Answer 3

9-10 (post.).

Question 4

Darkness/shadowing in the space on either side of the lungs may indicate?

Answer 4

SC emphysema.

Question 5

What are Kerley-B/septal lines a strong indicator of?

Answer 5

Interstitial oedema (often caused by heart failure).

Question 6

What does the R middle lobe have contact w?

Answer 6

Heart.

Question 7

What may a meniscus sign indicate?

Answer 7

Pleural effusion.

Question 8

How to use a peak flow meter?

Answer 8

1. Move the marker to the bottom of the numbered scale.
2. Stand up straight.
3. Take a deep breath. Fill your lungs all the way.
4. Hold your breath while you place the mouthpiece in your mouth, between your teeth. Close your lips around it. Do not put your tongue inside the hole.
5. Blow out as hard and fast as you can in a single blow. Your first burst of air is the most important, so blowing for a longer time will not affect your result.
6. Write down the number you get. But, if you coughed or did not do the steps right, do not write down the number. Do it over again.
7. Move the marker back to the bottom and repeat these steps 2 more times. The highest of the 3 numbers is your peak flow number. Write it down in your log chart.

To ensure accuracy, manoeuvre must be performed with max effort, whilst standing (or if not possible, sitting erect) – no leaning forward/coughing during the test.

Question 9

How to use MDI inhaler?

Answer 9

1. Take the cap off
2. Shake the inhaler for 10 seconds
3. Breathe out
4. Tilt head slightly back
5. Place mouthpiece in mouth and close lips firmly around
6. Place your finger on top of the canister and press firmly. At the same time as you press the canister once, you must take a slow deep breath all the way in and hold for 10 seconds. Try to press the canister as soon as you start to breathe in- not before and not too long after starting.
7. Breathe out slowly away from mouthpiece
8. If you need to take another puff, wait 1 minute and then repeat steps 2 - 7
9. Replace cap and store in a cool place

Patients should be reminded to check the expiry date and the amount of medication left in the device. They should also be advised to rinse their mouths out after the use of steroid inhalers.

Question 10

How to use a spacer?

Answer 10

1. If required, assemble the spacer
2. Remove the cap from the puffer and shake the puffer well
3. Attach the puffer to the end of the spacer
4. Place the mouthpiece of the spacer in your mouth and close your lips around it. If using a spacer with a facemask, place the facemask over the mouth and nose to ensure a good seal. Breathe out into the spacer
5. Press down on the puffer canister once to fire the medication into the spacer
6. Breathe in and out normally for 4 breaths, or breathe in for 5 seconds, hold for 5-10 seconds and breathe out
7. To take more medication, shake the puffer and repeat steps 3-6.

Question 11

Instructions for cleaning a spacer.

Answer 11

Spacers should be cleaned before first use and then monthly by washing in warm water with kitchen detergent and allowing to air dry without rinsing. Drying with a cloth or paper towel can result in electrostatic charge (‘static’) on the inside of the spacer, which can reduce availability of dose. The mouthpiece should be wiped clean of detergent before use. Where spacers are for the use of more than one individual, infection control guidelines should be followed. Spacers should be reviewed every 6–12 months to check the structure is intact (e.g. no cracks) and the valve is functioning.