TheCHEST

EmergencyMedicalConditions
MIZucker,MD

AdrZLecture

TheWHAT:

Normalchestfilms
Abnormalpatterns
Atelectasis
Infection
Obstructiveairway
diseases

Heartfailure
Noncardiacedema
Pulmonaryembolism
Aorticdissection
andafewothers

TheWHY:
Giveyouabasicapproachtoacutemedical
diseasesemphasizingCHESTRadiographs
ShowyouthemostCOMMONdiseases
ShowyoucommonlyMISSEDfindings

TheNORMALChest
PA/lateral
PortableAP

ThePA(adultandkid)and
Lateral
Checklist
Commonlyoverlookedareas

ThePORTABLEAP
Thebottomfeederofchestradiology

PitfallsinChestRadiology

Phaseofrespiration
Position
Comparisonfilms
Portables

PoorInspiration

ThePATTERNS
Toodense
Toolucent

Location,Location,Location
Lung?
Chestwall?
Mediastinum?
Pleura?

Lung:TooDENSE
Alveolarpattern
Interstitialpattern
Masses

Lung:AlveolarPattern
Somethingofunit/softtissue/waterdensity
replacestheairinthealveolarducts,
alveolarsacsandthealveoli

AlveolarLungPattern:causes

PUS
WATER
BLOOD
Lymphoma
BAC
Alveolarproteinosis

AlveolarLungPattern:findings

Increaseddensity
Confluence
Illdefinedmargins
Airbronchograms

Lung:InterstitialPattern
Somethingthickenstheinterstitium
ofthelungparenchyma

What?

Edema
Inflammatorycells
RBCs
Malignantcells
Fibrosis

How?
AllofthemADDtissuetothe
peripheralandaxialinterstitiumof
thesecondarypulmonarylobule

SecondaryPulmonaryLobules

Who?
Many,manydiseasespresentwiththesame
interstitialpatterns
Youneedhistory,lab,andfrequently
biopsytomakeaspecificdiagnosis

AMemoryAid
IMunchIceChipsInPlacesCalled
Igloos

Interstitialdiseases
Idiopathic

UIPDIPLIPBOOP
LAMPEGsarcoid

Malignancy

Metastases,lymphoma

Infection

Viral,PCP,mycoplasma.
Fungi,TB,MAC

Interstitialdiseases
Congenital

NFTSCF

Iatrogenic

Drugs,radiation

Pulmonaryedema

Cardiogenic,renal,
noncardiogenic

Interstitialdiseases
Collagenvascular

RA,SLE,scleroderma,
AS

Inhalational

Allergicalveolitis,
noxiousgases,
pneumoconiosis

TheInterstitialPatterns

Lines:fine,medium,orcoarse
Nodules:tinyto3cm
Reticular:networkofcrossinglines
Reticularnodular:linesandnodules

Lines

Nodules

Reticularpattern

Linesandnodules

Whatdotheymean?
Coarselinesmeanfibrosis,alsocalled
honeycombpattern
Theotherpatternsusuallymeanmoreactive
disease,butarentspecific

Kerleylines,AandB
Thickenedsecondarylobuleseptae
Often,butnotalwaysduetoCHF
Basically,theyarejustaslightlyspecialized
intertstitiallinearpattern
AandBdifferonlybylocation

INFECTION
Thepneumonias

BACTERIALPNEUMONIAS
Pyogenic

TheSilhouetteSign
Iftwoadjacentstructureshavethesame
density,theborderbetweenthemisnot
visible.Replaceairwithanalveolarprocess
andtheborderbetweentheinvolvedlung
andtheheart,ordiaphragm,oraorta
disappears

TheSpineSign
Onthelateralviewthespinenormally
progressivelylooksdarkercaudally.Ifit
lookswhiter,thereisanalveolarprocessin
oneofthelowerlobes.

AtypicalPneumonias
Mycoplasma
Chlamydia

Patterns
Diffusebilateralpatchyopacities
Diffuseinterstitiallinearopacities

ViralPneumonias
Airtrapping
Mucusplugsandatelectasis
Diffuseinterstitiallinearandnodular
opacities
Findingsmorepronouncedinkids

PneumocystiscarniiPneumonia
Interstitiallinearnodularpattern,usually
bilateral
Followedbydiffusealveolarpattern
Early,10%ofCXRsinPCPcanbe
negative.Later,atypicalpatternsarefairly
common.

PCP

Tuberculosis
Primary
Postprimary

TB:primary

TB:postprimary,early

TB:postprimary,cavitary

AfewmoreInfections
Lungabscess
Empyema
Fungus

Lungabscess

Empyema:Hydropneumothorax

Coccidioidomycosis

ATELECTASIS
LossofLungVolume

Atelectasis:types

Obstructive
Passive
Compressive
Cicatricial
Adhesive

Atelectasis:signs

Increaseddensity
Shiftoffissure
Elevationofdiaphragm
Shiftofmediastinum
Shiftofheart
Shiftofhilum
Compensatoryhyperinflation

Subsegmental

Rightupperlobe

Lowerlobes

Rightmiddlelobe

Leftupperlobe

ATX:entirelung

Edema
Cardiogenic
Renal
Noncardiogenic

Edema:pathogenesis
Cardiogenic:increasedhydrostaticpressure
Noncardiogenic:increasedalveolar
capillarymembranepermeability
Renal:multiplefactors

Cardiogenic
Congestiveheartfailure

CHF
Cephalization12wedgepressure
Interstitialedema20
Alveolaredema25
Cardiomegaly,pleuraleffusions

CHF:cephalization

CHF:interstitialedema

CHF:alveolaredema

Renalrelated
Fluidoverload
Increasedpermeability
CHF

Edema:renal

Noncardiogenicedema

Neardrowning
Highaltitude
Drugs
Inhalation
Hypoxia
(ARDS)

Noncardiogenicedema

Obstructivelungdisease
Asthma
COPD

Asthma

Hyperinflation
Mucusplugs/atelectasis
Interstitialinflammation
Barotrauma

Asthma:kid

Asthma:adult

COPD

Hyperinflation
Flatdiaphragm
Increasedretrosternumairspace
Pulmonaryarterialhypertension
Lookforpneumoniaascauseof
exacerbation

COPD

Pulmonaryembolism

PE:diagnosis

Clinical:dyspnea,chestpain,increasedRR&PR
Ddimer
Dopplerultrasound
*CXR
*CTPA
Lungscan
Pulmonaryangiography

Chestfilm

Subsegmentalatelectasis
Smallpleuraleffusion
Elevateddiaphragm
Westermarks(rare)
Hamptons(rare)

PE:CXR

PE:CTPA

AorticDissection

AorticDissection

HYPERTENSION
Marfans
Coarctation
Turners,SLE,pregnancy

AorticDissection
TypeA:morecommon,ascendingaorta,
surgery
TypeB:descendingaorta,trialofmedical
management

AD:imaging

CXR
CTA
MRI
TEE
Angiography

AD:CXR
Mediastinumcontourabnormality:
abnormalshapeorwidth
Achangeincontourfrompreviousfilm

AD:CXR
Sensitivity:80%

AD:CXR

AD:CXR

AD:CTAaxial

AD:CTAreformat

andafewmore

SickleCellDisease
CysticFibrosis

SickleCellDisease

CysticFibrosis

Goodbye

Copyright2004
MIZucker,MD