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Normal CXR PA
Anatomy of CXR PA
Lung Margins
Air Bronchogram
Causes: 1. Lung consolidation 2. Pulmonary Edema 3. Nonobstructive pulmonary atelectasis 4. Severe interstitial disease 5. Neoplasm 6. Normal expiration
An air bronchogram is a tubular outline of an airway made visible by filling of the surrounding alveoli by fluid or inflammatory exudates.
Silhouette sign
described by Dr. Ben Felson elimination of the silhouette or loss of lung/soft tissue interface (border) caused by a mass or fluid in the normally air filled lung commonly applied to the heart, aorta, chest wall, and diaphragm
ATELECTASIS
collapse or incomplete expansion of the lung or part of the lung Causes: 1. endobronchial lesion (most common) 2. mass 3. pleural effusion 4. cicatricial type secondary to scarring, TB, or status post radiation (unusual type) linear increased density on chest x-ray xthe density is associated with volume loss indirect signs of volume loss 1. vascular crowding or fissural 2. tracheal, or mediastinal shift, towards the collapse
CXR PA - Atelectasis
Bowing sign
Oblique fissure bows forward Forward movement of the oblique fissure
similar in appearance with RLL atelectasis silhouetting of the corresponding hemidiaphragm, crowding of vessels, and air bronchograms substantially collapsed lower lobe will usually show as a triangular opacity situated posteromedially against the mediastinum.
Atelectasis LLL
may cause minimal changes on the frontal chest film loss of definition of the right heart border more easily seen in the lateral view as a wedge of opacity pointing to the hilum.
PULMONARY EDEMA
Kerly B lines
Causes: 1. pulmonary edema 2. lymphangitis carcinomatosa 3. malignat lymphoma 4.viral & mycoplasmal PNM 5. interstitial pul fibrosis 6. sarcoidosis & pneumoconiosis horizontal lines less than 2cm long commonly found in the lower zone periphery these lines are the thickened, edematous interlobular septa
PNEUMONIA
Pneumonia
airspace disease and consolidation air spaces are filled with bacteria or other microorganisms and pus NOT associated with volume loss (space occupying lesion w/out volume loss) Causes 1. bacteria 2. viruses 3. mycoplasmae 4. fungi Other causes of airspace filling not distinguishable radiographically: 1. fluid (inflammatory) 2. cells (cancer) 3. protein (alveolar proteinosis) 4. blood (pulmonary hemorrhage)
X-ray findings
airspace opacity lobar consolidation interstitial opacities.
The characteristic chest x-ray appearance of some PNM: xLobar - entire lobe consolidated and air bronchograms common Lobular - multifocal, patchy, sometimes w/out air bronchograms Interstitial - starts perihilar and can become confluent and/or patchy as disease progresses, no air bronchograms Diffuse pulmonary infections - community acquired (Mycoplasma, resolves spontaneoulsy) nosocomial (Pseudomonas, debilitated, mechanical vent pts, high mortality rate, patchy opacities, cavitation, ill-defined nodular) immunocompromised illhost(bacterial, fungal, PCP
TUBERCULOSIS
Radiographica representation: consolidation adenopathy pleural effusion. Ghon focus - area of consolidation that most commonly occurs in the mid and lower lung zones. Ghon complex - addition of hilar adenopathy to a Ghon focus Radiographic features of post-primary TB: postfocal patchy airspace disease "cotton wool" shadows cavitation fibrosis nodal calcification flecks of caseous material occur most commonly in the posterior segments of the upper lobes, and superior segments of the lower lobes
CXR PA - PTB
Pulmonary Hemorhrrage
Causes 1. Trauma 2. Goodpastrue's syndrome 3. bleeding disorders 4. high altitude 5. mitral stenosis.
appearance is like that of other airspace filling processes (pneumonia, edema) has opacity often with air bronchograms blood fills the bronchi and eventually the alveoli may clear more quickly than other alveolar densities such as pneumonia
PULMONARY EMBOLISM
primary source is thrombus from the deep veins of the legs primary purpose of a chest film in suspected PE is to rule out other diagnoses as a cause of dyspnea or hypoxia most CXRs in patients with a PE are normal Signs in PE 1. Westermark's sign (oligemia in area of involvement) 2. increased size of a hilum (caused by thrombus impaction) 3. atelectasis with elevation of hemidiaphragm 4. linear or disk shaped densities 5. pleural effusion 6. consolidation 7. Hampton's hump (rounded opacity) pulmonary infarctions - multifocal consolidation at the pleural base in the lower lungs
Hamptons Hump Wedge shaped consolidation Lung periphery Pleural based Rounded convex apex towards hilum
PLEURAL EFFUSION
Common causes for a pleural effusion 1. CHF 2. infection (parapneumonic) 3. trauma 4. tumor (if malignant usually unilaterally large effusions) 5. autoimmune disease 6. renal failure Upright film 1. blunting on the lateral and if large enough, the posterior costophrenic sulci 2. large effusion can lead to a mediastinal shift away from the effusion and opacify the hemothorax 3. approximately 200 ml of fluid are needed to detect an effusion in the frontal 4. approximately 75ml for the lateral Supine film 1. graded haze that is denser at the base and the vascular shadows can usually be seen through the effusion 2. can veil the lung tissue and thicken fissure lines 3. may be no apparent blunting of the lateral costophrenic sulci Lateral Decubitis film 1. confirmation of effusion in a bedridden patient (fluid will layer out on the affected side [unless the fluid is loculated])
PNEUMOTHORAX
air inside the thoracic cavity but outside the lung spontaneous pneumothorax (PTX) - occurs without an obvious inciting incident Causes of spontaneous PTX 1. idiopathic, asthma 5. Marfans syndrome 2. COPD 6. cocaine 3. pulmonary infection 7. iatrogenic 4. neoplasm 8. trauma tension PTX - air enters the pleural cavity and is trapped during expiration CXR 1. air w/out lung markings in the least dependant part of the chest 2. air is found peripheral to the white line of the pleura 3. upright film air is most likely seen in the apices 4. best demonstrated by an expiration film Hydropneumothorax 1. both air and fluid in the pleural space 2. air-fluid level on an upright or decubitus film air3. Causes - trauma - rupture esophagus - thoracentesis - empyema - surgery
Pneumothorax
Tension PTX
EMPHYSEMA
CXR - diffuse hyperinflation with flattening of diaphragms - increased retrosternal space - bullae (lucent, air-containing spaces that have no vessels airthat are not perfused) - cor pulmonale - enlargement of PA/RV (secondary to chronic hypoxia) different types 1. panlobular 2. intralobular 3. paraseptal "Saber sheath" tracheal deformity is when the coronal diameter is less than 2/3 that of the sagittal. In smokers, upper lung zones are commonly more involved than the lower lobes. Chronic bronchitis commonly occurs in patients with emphysema and is associated with bronchial wall thickening
Anterior Mediastinal Mass 1. lymphadenopathy 3. Teratoma 5. aortic aneurysm 7. epicardial fat pad.
T-cell Lymphoma
Pneumomediastinum
streaky lucencies over the mediastinum that extend into the neck elevation of the parietal pleura along the mediastinal borders Causes - asthma - surgery (post-op complication) (post- traumatic tracheobronchial rupture - abrupt changes in intrathoracic pressure (vomiting, coughing, exercise, parturition) - ruptured esophagus - barotrauma - cocaine In pneumopericardium, air can be present underneath the heart, but does not enter the neck
CXR PA - Pneumomediastinum
Diaphragmatic Hernia
3 types 1. hiatal hernia - the stomach slips through the esophageal hiatus into the hest 2. Bochdalek hernia is through a weakness in the diaphragm, and usually occurs on the left side posteriorly 3. Morgagni hernias typically occur medially
Halo Sign
In a cavity with a fungus ball, there is a crescentic lucent space along the upper portion of the density giving the appearance of a halo
Honeycombing
Seen in end stage lung disease Indicative of diffuse interstitial fibrosis Due to bronchiolectasia Most of the time in bases Upper lobe distribution seen in eosinophilic granuloma
Diffrential Dx: Pleural fibrosis Extrathoracic density Bleb wall Lung fibrosis
Dissecting Aneurysm
S Curve of Golden
When there is a mass adjacent to a fissure, the fissure takes the shape of an "S".