12.10 elicker radiology - ucsf cmepneumothorax. 10/13/2016 15 checklist lines, tubes and foreign...

10/13/2016

1

Chest Radiology Checklist: Tips,

Tricks and Things You Should Never

Miss!

Case #1

Checklist

Lines, tubes and foreign bodies

Endotracheal tubes

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2

Airwaylandmarks

3-7 cm

What is the ideal location?

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3

Tip position with changes in head

Esophageal intubation Esophageal intubation

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4

Enteric tubes

When is the tube post-pyloric?

GE junction

2nd duodenum

3rd duodenum

4th duodenum

Ligament of Treitz1st duodenum

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5

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6

Tension PTX s/p feeding tube removal

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7

Central lines

AzV

SCV SCV

IJ IJ

RBCVLBCVSVC

Venous anatomy

The Elusive Cavoatrial Junction Venous landmarks

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8

Variation with expiration ? location

Right posterior oblique

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9

AzV

SCV SCV

IJ IJ

RBCVLBCVSVC

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Left SVC

Duplicated SVC Duplicated SVC

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11

Pacemaker in left SVC PICC in internal mammary vein

RIJ line in aorta PICC line in aorta

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12

Arterial line Venous line

Central line free in mediastinum

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13

Pulmonary artery catheters

Infarct from a PA line Pulmonary artery pseudoaneurysm

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14

Retained surgical sponge Retained catheter fragment

Checklist

Lines, tubes and foreign bodies

Pneumothorax

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15

Checklist

Lines, tubes and foreign bodies

Pneumothorax

Pneumothorax vs. skin fold

• Pleural line, NOT edge

• No vessels lateral to line

• Line doesn’t go outside chest wall or across

midline

Pleural Line

Air inpleura

Edge

Air inlung

Pleural Line

Air inpleura

Edge

Air inlung

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16

Skin fold

Where is the PTX?

Not a PTX!

Pre‐IJ line removal Post‐IJ line removal

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17

Deep Sulcus Sign ARDS with pneumothorax

Pneumothorax (subpulmonic) ? PTX

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18

Tension pneumothorax

Checklist

Lines, tubes and foreign bodies

Pneumothorax

Case #3

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19

Checklist

Lines, tubes and foreign bodies

Pneumothorax

Mediastinal abnormalities

Normal mediastinal interfaces

Rightparatracheal

stripe

Aorta

Leftpulmonary

artery

Aorticopulmonary window

Azygoesophagealrecess

Tuberculosis

Metastatic disease (unknown primary)

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20

Lung Cancer Esophageal cancer

Checklist

Lines, tubes and foreign bodies

Pneumothorax

Mediastinal abnormalities

Case #4

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21

Checklist

Lines, tubes and foreign bodies

Pneumothorax

Mediastinal abnormalities

Tough spots in the lungs

Subtle cancer #1

Subtle cancer #2 Subtle cancer #3

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22

? pneumonia ? pneumonia

Normal LLL Pneumonia Normal Pleural effusion

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23

Normal Nodule Normal Pott’s disease

Checklist

Lines, tubes and foreign bodies

Pneumothorax

Mediastinal abnormalities

Tough spots in the lungs

Don’t forget about the bones

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24

Checklist

Lines, tubes and foreign bodies

Pneumothorax

Mediastinal lymphadenopathy

Lung nodules

Bones

A simple approach to lung opacities…

Alveolar Interstitial

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25

Airways Not applicable

Alveolar

• Features of alveolar disease

– 1. Confluent opacities

– 2. Air bronchograms

– 3. Fluffy at the periphery

What producesalveolar opacities?

• Fluid

• Blood

• Pus

• Cells

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26

ARDS

Pulmonary edema

PCP Pneumonia

Hemorrhage

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Which compartment of lung is affected Interstitial

Interstitial Alveolar Miliary TB

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What diseases cause small nodules?

• Infections (fungus and tuberculosis)

• Malignancy

• Sarcoidosis

Miliary TB

Miliary fungal

Sarcoidosis

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Metastatses: lung cancer

Interstitial

What diseases cause lines?

• Pulmonary edema

• Malignancy

• Interstitial lung disease (e.g. IPF)

Pulmonary edema

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30

Edema Idiopathic pulmonary fibrosis

Which compartment of lung is affected?

Airways disease

• Circular

• Tubular

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31

Cystic fibrosis