understanding the abnormal chest x-ray Flashcards
What are the first 5 things we check when analysis an x-ray?
geT PROPAREd
5 things we check when analysing an x-ray:
1) Correct patient (2 points of ID)
2) Correct date of radiograph (including correct historical dates)
3) PA vs AP; Oriented correctly (left/right)
4) Exposure/Penetration
5) Rotation
What are the 5 different x-ray densities?
5 different x-ray densities:
1) Air/gas: black,
* e.g. lungs, bowel and stomach
2) Fat: dark grey,
* e.g. subcutaneous tissue layer, retroperitoneal fat
3) Soft tissues/water: light grey,
* e.g. solid organs, heart, blood vessels, muscle and fluid-filled organs such as bladder
4) Bone: off-white
5) Contrast material/metal: bright white.
What are 7 examples of things that appear bright white on a chest x-ray?
7 examples of things that appear bright white on a chest x-ray (artefact/metallic):
1) Pacemaker
2) ETT
3) NG tube
4) Sternal wiring
5) Prosthetic heart valves
6) CVP line
7) Chest drain
What 4 things do we have to consider when analysing a CXR?
4 things we have to consider when analysing a CXR:
1) Pre-test question (reason for doing CXR)
* Is there pneumonia? Is there a cancer?
2) Consider history, signs, other factors
* Was there fever, cough and dirty phlegm? Weight loss & haemoptysis? (Coughing blood)
3) Consider the immediate answer to the pre-test question
* Multifocal cavitating lesions; large mass lesion
4) Review systematically the rest of the film
* Associated pleural effusion (empyema?); associated pleural effusion (malignant?)
What are the 8 parts of the systemic approach to searching a CXR?
8 parts of the systemic approach to searching a CXR:
1) Airway
2) Breathing
3) Cardiac (heart)
4) Diaphragm
5) External structures and equipment
6) Fat and soft tissue
7) Great vessels
8) Hidden areas
Why do we want to check an ET tube on an x-ray?
What is the difference between pneumothorax, collapsed lung, and atelectasis?
Why do certain pathologies pull/push the trachea away?
What are 2 pathologies where the trachea is deviated away from the pathology?
What are 4 pathologies where the trachea is deviated towards the pathology?
How do they each affect the colour of the x-ray?
We want to check an ET tube on an x-ray to make sure it is high up enough to ventilate both lungs
1- A pneumothorax means air in the pleural space (between visceral and parietal pleura), it doesn’t tell us anything about the state of aeration of the lung
2- Atelectasis is loss/reduction in inflation of the lung due to lobar/alveolar collapse
3- Collapsed lung is a term for complete atelectasis of the lung
These terms can be mutually exclusive
We can have a collapsed lung with or without pneumothorax
We can have a pneumothorax with or without a collapsed lung
Why do certain pathologies pull/push the trachea away?
What are 2 pathologies where the trachea is deviated away from the pathology?
What are 4 pathologies where the trachea is deviated towards the pathology?
How do they each affect the colour of the x-ray?
Pathology that decreases the pressure in one hemithorax will ‘pull’ the trachea towards it.
Pathology that increases the pressure of a hemithorax will ‘push’ the trachea away from it.
Pathologies where the trachea is deviated away from the pathology:
1) Pneumothorax (too black on x-ray) – air in pleural cavity
2) Pleural effusion (too white on x-ray) – fluid in pleural cavity
Pathologies where the trachea is deviated towards the pathology (all too white on x-ray)
1) Pneumonectomy - surgical removal of a lung
2) Lobectomy – removal of lobe of lung
3) Lobar collapse (atelectasis)
4) Fibrosis
What are clinical signs of pneumothorax/collapsed lung in:
* Inspection (6)
* Expansion (1)
* Percussion (2)
* Auscultation (1)
* Vocal fremitus (1)
Clinical signs of pneumothorax/collapsed lung in:
Inspection
1) Sharp, stabbing chest pain that worsens when trying to breath in.
2) Shortness of breath.
3) Bluish skin caused by a lack of oxygen.
4) Fatigue.
5) Rapid breathing and heartbeat.
6) A dry, hacking cough.
Expansion
1) This build-up of air puts pressure on the lung, so it cannot expand as much as it normally does when you take a breath
Percussion
1) Dull percussion notes for collapse
2) Hyper-resonant percussion notes for pneumothora
Auscultation
1) In pneumothorax and lung collapse, breath sounds are diminished to absent
Vocal fremitus
1) Decreased vocal fremitus for pneumothorax and collapse
Hickman line?
tunneled catheter
What is B for in analysing X-rays?
What is consolidation?
What needs to happen when we see consolidation?
- B is for breathing in the analysis of X-rays
- Consolidation is a pathological diagnosis that means replacement of normal air-space (gas) with fluid or solid
- When we say we’ve seen consolidation, we need to have seen a radiographic representation of it, which would normally be an air bronchogram
- Air bronchogram refers to the phenomenon of air-filled bronchi (dark) being made visible by the opacification of surrounding alveoli (grey/white), as those seen in consolidation
- The large airways are spared so become visible (black) against the white background
- Lung volume does not change in consolidation
What is an air bronchogram?
What are 5 different causes of consolidation?
What is an example of when we might see each cause (in picture)?
How does lung volume change on consolidation?
- Air bronchogram refers to the phenomenon of air-filled bronchi (dark) being made visible by the opacification of surrounding alveoli (grey/white), as those seen in consolidation
- The large airways are spared so become visible (black) against the white background
- Lung volume does not change in consolidation
devoted trachea pathology:
towards pathology?
away from pathology?
towards pathology:
- pneumonectomy/ lobectomy
- lobar collapse (atelectasis)
away from pathology:
- tension pneumothorax
- (massive) pleural effusion, or any mass effect
How will consolidation present in terms of:
1) Percussion
2) Vocal resonance
3) Auscultation
How will consolidation present in terms of:
1) Percussion
* Dull to percuss
2) Vocal resonance
* Increased vocal resonance
3) Auscultation
* Increased auscultation/breath sounds = Bronchial breathing
what is consolidation?
replacement of normal air space (gas) with fluid or solid
What is atelectasis?
Atelectasis is Reduction in inflation of all or part of the lung due to lobar/alveolar collapse
What is a collapsed lung?
Atelectasis of the full lung is a collapsed lung
In what 6 situations would we suspect atelectasis?
6 situations would we suspect atelectasis:
1) Volume loss
2) Displacement of trachea
3) Displacement of diaphragm – pointy middle of diaphragm called tenting, which indicates loss of volume
4) Displacement of lung fissures
5) Compensatory overinflation of non-collapsed lung
6) Crowding of vessels & bronchi
What is the veil of left upper lobe collapse/atelectasis?
What causes this?
How is it characterised?
- A characteristic of left upper lobe collapse is the ‘veil’ of LUL collapse/atelectasis
- This is due to a lesion that has collapsed the left upper lobe and moved it forward, impairing the penetration of the x-rays, and leading to the veil of LUL collapse/atelectasis
- This is where there is elevated left hemi diaphragm and loss of cardio-mediastinal contour
- There also causes an even graininess over the left side
air bronchogram?
- consolidation
= large airways are spared so become visible (black) against the white background - there will be no volume loss
What can opacification be other than collapse/consolidation?
Opacification can also be pleural effusion (fluid in pleural cavity), not just collapse/consolidation
What are 3 characterizations of pleural effusion?
Pleural effusion can be characterized as having:
1) Trachea pushed away
2) Zone uniformly white (left lower zone on diagram)
3) Meniscus
What 2 things do we have to do after diagnosing pleural effusion?
2 things do we have to do after diagnosing pleural effusion? :
1) Look for the primary diagnosis, as pleural effusion is often a secondary diagnosis
* Review history/exam for clues
* Visible on both sides suggests systemic issue (eg.CCF – congestive heart failure)
* Large, unilateral, in elderly, think cancer until proven otherwise
2) Sample the effusion by carrying out a diagnostic tap
* Exudate (high protein) - consider infection, cancer, inflammatory eg. RhA
* Transudate (low protein) – consider systemic causes eg.CCF, liver, renal
What are characterisations of asbestos exposure?
Are pleural plaques dangerous?
What are we most concerned about with asbestos exposure?
- The main characterisations of asbestos exposure are calcified pleural plaques
- The straight lines seen from the plaques are so straight and defined that we can tell its pleural based (shown on the left x-ray)
- On the x-ray on the right, the pleural plaques are not calcified and may be confused them with metastases, so we have to do a CT to confirm
- Pleural plaques are not pathological, but are simply scars that indicate potential pathology
- Calcified pleural plaques don’t themselves require any intervention
- Most concerning thing is pleural cancer aka mesothelioma (pleural effusion, thickening)
how do you manage someone with a pleural effusion
START with a HISTORY and Examination!!!!
take a sample of the pleural effusion.
depending on high or low protein.
high proteins (high exudate) = usually cancer
