how read chest xr 11
TRANSCRIPT
HOW READ CHEST XR -11
ANAS SAHLE ,MD
Brief review
PATCHY
INFILTIRATION
NODULE
MASS
CAVITARY
OPACITY
Consolidation
Infection causes
Pneumonia
Non-infection causes
Lymphoma
Broncho-
alveolar
carcinoma
COP
WEGNER disease
Sarcoi
d
Cardiac failu
re
Solitary Pulmonary Nodule(SPN)
Comparison with a previous x-ray toAssess growth over time.
Cavitary lesion
Air + tissue
Air-fluid level
StraightAbscess
Wavy ruptured
Hydatid cyst
Air only
ThickIrregular
inner wall
Cavitating
neoplasm
Regular
inner wall
Chronic
abscess
ThinPeriph
eral Emphesemato
us bulla
Centralpneu
matocele
Wall thickness
site1. Fungal ball.2. Rupture hydatid cyct3. Necrotic tumor4. Blood glot
LINEAR PATTERN
LINEAR PATTERNPerihilar and peripheral basal septal lines,changes acutely and resolves with diuretics
LEFT VENTRICULAR FAILURE
Coarsening of lung markings in lower zones, nochange on review of recent films
Normal ageing
Coarse nodular and linear thickening ofmarkings, known malignancy, often associatedwith pleural effusion, rapid clinicaldeterioration of patient
Lymphangitis
LINEAR PATTERNLINEAR PATTERN
Short thin lines, often basal, new on review ofprevious films
Atelectasis
Longer thicker bands, often perihilar or basal,suggest recent infection or infarction
Subsegmentalcollapse
Any length, persist over time unchanged
Volume loss is key, persists over time
Scarring
Fibrosis
Causes of fibrosisMid zone lung Lower zone lung Upper zone lung
tuberculosis Drug indused fibrosis(most common)
sarcoidosis
Chronic extrinsic allergic alveolitis
UIP
Radio-therapy Asbestose-related fibrosis
Ankylosing spondylitis
Progressive massive fibrosis
histoplasmosis
CASE-1• A 50-year-old male smoker is evaluated for chronic shortness of breath. • On physical examination his vital signs are:
– pulse 110 bpm; – Temperature normal; – respirations 30/min with use of accessory muscles and pursed-lip breathing; – blood pressure 110/78 mm Hg.
• Other pertinent findings are: – heart exam: apex beat (impulse) is medial to the mid-clavicular line– generalized decreased breath sounds on lung exam;
• ABGs (FiO2 0.21):– pH 7.38; PCO2 47 mm Hg; PO2 67 mm Hg.
• PFTs/spirometry: – FVC 2.80 L (67% of predicted); – FEV1 1.56 (50% of predicted); – FEV1/FVC% 56%;– TLC 134% of predicted; – RV 170% of predicted; – DLCO 43% of predicted.– There is no reversibility with bronchodilators.
CASE-1
POSITION •PA CXR
QUALITY •Good Technical Quality
LESION •Bilateral linar (vascular)infitration .•Laminar opacity from right hilum.•Hyper-lucency area at lower right zone.
MEDIASTINAL\Hilum
•Central trachea and mediasteinal.•Dangle heart.
ANGELS •Hazy left angle\irregular diaphragm(flat)
OTHER •No
CASE-1• 1. What is the most likely diagnosis?• a. Bronchial asthma with status asthmaticus• b. Emphysema• c. Chronic bronchitis• d. Tuberous sclerosis• 2. Associated with the above condition is• a. Obstructive sleep apnea• b. Increased IgE levels• c. Respiratory failure with increased A-aDO2
gradient• d. Clubbing
CASE-2• A 38-year-old man is admitted with progressive shortness of breath• and cough. • He denies any fever, chills, or purulent sputum production. • He wants to be evaluated to determine the reasons for his
symptoms. • On exam, he is afebrile and has decreased breath sounds with
hyper-resonant upper lung field more obvious on the right. • ABGs on RA: pH 7.35; PCO2 38mm Hg; PO2 78 mm Hg. • Spirometry:
– (FVC) 1.72 (70% of predicted); – (FEV1)1.34 L (60% of predicted); – FEV1/FVC% 76%; – TLC 4.1 L (100% of predicted);– TLC by helium dilution method 3.4 (71%); – DLCO 70% of predicted.– There is no bronchodilator response.
CASE-2
POSITION •PA CXR
QUALITY •Poor Technical Quality
LESION•Large bulla extend at right upper and middle zone.•Vascular marking crowded at lower zone.•Hyperlucensy area at left upper zone.
MEDIASTINAL\Hilum
•Central trachea and mediasteinal.
ANGELS •Free
OTHER •No
CASE-2• 1. What is the most likely diagnosis?• a. Severe emphysema• b. Bulla• c. Pneumothorax• d. Bronchiectasis• 2. What is the next management option?• a. Place a chest tube urgently• b. Increase bronchodilator dosage and frequency• c. Start chest physical therapy• d. Perform CT scan of chest
CASE-3• A 39-year-old man, a smoker since age 16, is seen in
the clinic with complaints of fever, cough, and production of yellowish sputum.
• He has been chronically short of breath, but these symptoms have increased over the last week after he developed a flulike illness.
• On exam, he is febrile and looks ill. • Lung exam reveals diffuse wheezing with egophony
and whispering pectoriloquy on the right side. • ABGs show PO2 of 55 mm Hg on room air, • sputum is negative for TB.
CASE-3
POSITION •PA CXR
QUALITY •Poor Technical Quality
LESION •Multiple air-fluid level at right middle zone.•Area of hyperlucensy at right and left upper zone.
MEDIASTINAL\Hilum
•Central trachea and mediasteinal.
ANGELS •Free
OTHER •No
CASE-3• 1. The next step in the management of this patient
would be• a. Arrange with intervention radiology to do a needle aspiration• b. Consult thoracic surgery for lung reduction surgery• c. Start antibiotic and O2 therapy• d. Admit patient in an isolation room• 2. Appropriate measures at the first follow-up should
include• a. Pneumococcal and influenza vaccine• b. Allergy testing• c. Detailed occupational history• d. Genetic counseling
CASE-4• A 31-year-old African American man is admitted
with increasing cough, fever, and sputum production.
• He gives a history of repeated infections and “pneumonias” since childhood.
• Lung exam reveals:– diffuse rhonchi– bilateral crackles, more so in the left lung field.
• Routine labs are normal except for a poly-morphonuclear leuko-cytosis.
CASE-4
POSITION •PA CXR
QUALITY •Poor Technical Quality
LESION •Bilateral nodulo-reticular pattern crowded at lower,middle zone and cyct-like apperance.
MEDIASTINAL\Hilum
•Central trachea and mediasteinal.
ANGELS •Free
OTHER •No
CASE-4• 1. What is the most likely diagnosis?• a. Bronchiectasis• b. Cystic fibrosis• c. Sarcoidosis• d. Allergic bronchopulmonary aspergillosis• 2. What is the next management option?• a. Bronchoscopy• b. Steroid Rx• c. Antibiotics and postural drainage• d. Surgical consult
DISCUSSION• The history is suggestive of bronchiectasis, and
the bilateral cystic-appearing lesions on the CXR are consistent with that diagnosis.
• Cystic fibrosis is generally predominant in the upper zone.
• Sarcoidosis rarely presents with this history, and the fibrotic changes in sarcoidosis are usually in the upper lobes.
• Allergic bronchopulmonary aspergillosis is seen with an underlying asthmatic condition.
CASE-5• A 24-year-old male law student presents with
a 3-wk history of increasing dyspnea. • He has a history of chronic sputum production
of about 100 cc of purulent material each day for many years.
• In the past, he was hospitalized for a left pneumothorax.
• He is on inhaled bronchodilator as an outpatient.
CASE-5
POSITION •PA CXR
QUALITY •Good Technical Quality
LESION •Bilateral cyct-like opacity apperance.•At middle zone near hilum and extend to left upper zone (fibrosis).
MEDIASTINAL\Hilum
•Central trachea and mediasteinal.
ANGELS •Free\flated diaphragm.
OTHER •No
CASE-5• 1. Physical exam will most likely show• a. Clubbing• b. Koilonychia• c. Oncholysis• d. Pectus excavatum
• 2. Spirometry will most likely show• a. FVC 60%; FEV1 40%; ratio 66%• b. FVC 60%; FEV1 62%; ratio 90%• c. Normal• d. Normal except mild decrease in FEF25–75
• 3. The most helpful treatment option would be• a. Increase bronchodilator therapy• b. Start broad-spectrum antibiotic therapy• c. Initiate anti-pseudomonas antibiotic regimen• d. Start oral steroids
DISCUSSION
• The history and chest x-ray are consistent with cystic fibrosis with bilateral cystic upper zone predominance.
• Physical exam would reveal clubbing; spirometry would show a mixed obstructive with restrictive picture.
• The best option would be to initiate anti-pseudomonas antibiotics.