Examine the Patient and then Look at the Chest Xray

1
Examine the Patient and thenLook at the Chest
Xray

• Vincent X Grbach COL, MC
• Pulmonary Disease/CCM
• Tripler Army Medical Center

2
Examine the Patient and thenLook at the Chest
Xray

• Part I Evaluation of the Patient
• History
• Physical examination
• Laboratory testing
• Part II Evaluation of the Chest Xray
• General guidelines
• Systematic approach
• Xray anatomy of the chest
• Recognition of common chest xray patterns

3
Evaluation of the Patient

• History
• Dyspnea
• Cough
• Chest pain
• Other symptoms
• Consider the nature and duration of complaints,
  the recent antecedent history, and the pertinent
  past medical history

4
Evaluation of the Patient

• History
• Dyspnea
• An abnormally uncomfortable sensation of
  awareness of breathing which is disproportionate
  to physical activity
  
• cant breathe, shortness of breath,
  breathlessness
  
• tightness, pressure
• increased work of breathing
• choking, suffocation
• inability to inhale/exhale
• The Language of Breathlessness Elliott, et al.
  ARRD 1991 144826-832.

5
Evaluation of the Patient

• Dyspnea
• Special types of dyspnea
• Paroxysmal nocturnal dyspnea--awakens patients
  from a sound sleep--chronic LV CHF, chronic
  bronchitis, asthma, obesity/sleep apnea
  
• Orthopnea--worse in supine position--CHF, COPD
• Instant orthopnea--inability to assume the
  supine position due to immediate respiratory
  fatigue--paralysis of both hemidiaphragms
  
• Platypnea--worse in upright position--PE, PFO

6
Evaluation of the Patient

• History
• Cough
• A coordinated neuromuscular function of the
  respiratory system consisting of three phases
  (inspiratory, compressive, expulsive) which
  serves as an essential defense mechanism
  protecting the airways from the adverse effects
  of inhaled particulate matter and removing
  excessive secretions and foreign substances,
  above and beyond mucociliary clearance

7
Evaluation of the Patient

• Cough
• Acute cough--hours to days
• The common cold/viral URI
• pneumonia, acute CHF, AECB (acute exacerbation of
  chronic bronchitis,) aspiration, PE
  
• Chronic cough--weeks to months
• Post nasal drip syndrome, asthma, GERD
• Chronic bronchitis, bronchiectasis, ACE inhibitor
  cough, MTB and other chronic infections,
  bronchogenic carcinoma, metastatic carcinoma,
  chronic CHF, interstitial lung disease

8
Evaluation of the Patient

• Cough
• Nonproductive
• URI, post nasal drip, asthma, GERD, ACE
• CHF, carcinoma, ILD, some pneumonias
• Productive
• Purulent--pneumonia, bronchiectasis, acute
  exacerbation of COPD
  
• Pink foamy--CHF
• Frothy saliva, copious--bronchoalveolar
  carcinoma
  
• Foul smelling--anaerobic abcess, necrotizing
  pneumonia

9
Evaluation of the Patient

• Cough
• Hemoptysis--expectoration of any blood
  whatsoever
  
• acute bronchitis
• bronchiectasis, chronic bronchitis, lung cancer,
  MTB
  
• CHF (especially from mitral stenosis)
• other chronic necrotizing pneumonia/lung abcess,
  bronchovascular fistula, bleeding
  diathesis/anticoagulation, PE
  
• Massive hemoptysis--greater than 200-600cc
  blood/24h
  
• MTB, bronchiectasis, necrotizing
  pneumonia/abcess, lung cancer, bronchovascular
  fistula
  
• Not hemoptysis--blood from pharyngeal or GI
  sources

10
Evaluation of the Patient

• History
• Chest pain
• An abnormal sensation of pain involving the chest

11
Evaluation of the Patient

• Chest Pain
• Pleurisy
• acute inflammation of the pleural surfaces
• restricted in distribution usually along
  intercostal nerve zones usually unilateral
  
• exacerbated by deep inspiration and cough and
  changes in body position
  
• can be reproduced by palpation
• sharp, burning, a catch
• acute--PE, bacterial pneumonia (classically
  pneumococcal), trauma, spontaneous pneumothorax,
  SLE
  
• chronic--MTB, lung cancer, mets

12
Evaluation of the Patient

• Chest pain
• Other unique chest pain
• Tracheobronchitis--raw or burning dull pain
  substernally exacerbated by deep breathing--viral
  or bacterial infection, malignancy, inhalation
  injury or burns
• Pulmonary hypertension--resembles angina may be
  caused by right heart/PA distention (right heart
  ischemia if acute)
  
• costochondritis and neuritis/radiculitis

13
Evaluation of the Patient

• History
• Other symptoms
• fever--any infection, PE, lymphoma, CTD
• headache--atypical pneumonia
• arthralgias/myalgias--atypical pneumonia,
  sarcoidosis, SLE, RA, other CTDs
  
• weight loss--MTB, cancer, cachexia associated
  with severe COPD or CHF or HIV infection

14
Evaluation of the Patient

• Physical examination
• General appearance
• WNWD versus toxic, ill-appearing
• Age
• Stigmata of comorbid conditions--advanced cardiac
  or pulmonary disease or malignancy, alcoholism,
  homelessness
  
• Vital signs
• Fever or hypothermia
• Tachypnea
• Tachycardia
• Hypotension

15
Evaluation of the Patient

• Chest examination
• Inspection
• cough, stridor, wheezing, hoarseness
• muscles of respiration
• inspiration--primary muscles are diaphragm,
  external intercostals, parasternal
  intercartilaginous accessory are SCM and
  scalenes
• expiration--passive expiration during quiet
  breathing results from elastic recoil of the
  lungs active breathing during exertion or in
  disease states (with decreased lung compliance)
  requires use of abdominal and internal
  intercostals

16
Evaluation of the Patient

• Inspection(continued)
• Chest wall lag
• underlying lung collapse or consolidation--pneumon
  ia, atelectasis, pneumothorax
  
• pleural effusion
• Palpation
• Palpate trachea in the suprasternal notch to
  detect mediastinal shifts
  
• Vocal fremitus
• increased over consolidated lung
• decreased over pleural effusion

17
Evaluation of the Patient

• Chest examination
• Percussion
• normal lung--resonant
• large consolidation or pleural effusion--dull or
  flat
  
• pneumothorax--hyper-resonant or tympanitic
• Auscultation
• Normal breath sounds
• vesicular--soft, low-pitched sigh or rustling
  inspiratory louder than expiratory with IE ratio
  of 13
  
• tracheal, bronchial, bronchovesicular sounds
  heard in specific locations

18
Evaluation of the Patient

• Auscultation (continued)
• Abnormal breath sounds
• wheezes and ronchi--continuous--indicate airway
  obstruction to the point of near closure
  (bronchospasm, secretions, or mucosal edema)
  --any OLD or sometimes CHF
• coarse crackle or fine crackle (also called
  rales)--discontinuous--indicate bubbling of gas
  through secretions in wet diseases (CHF,
  pneumonia) or popping open of small airways in
  dry diseases (ILD)
• egophony--increased transmission of spoken words
  through consolidated lung

19
Evaluation of the Patient

• Laboratory testing
• ABG
• WBC count
• Hemoglobin and Hematocrit
• Serum bicarbonate, BUN, and Creatinine
• LDH, protein, albumin
• Sputum and BAL fluid (the ultimate sputum)

20
Evaluation of the Chest xray

• General guidelines
• Evaluate the patient
• Since the radiologists did not have the
  opportunity to evaluate the patient, and they may
  have been given an inadequate clinical history,
  read their interpretations with prejudice
• Look at as many old films as possible
• When in doubt, discuss the case and look at the
  films with someone more experienced than you

21
Evaluation of the Chest xray

• Systematic approach
• Identification
• Technique
• Inorganic features
• Lung fields
• Pleura and fissures
• Hila and mediastinum including heart
• Diaphragm and below
• Bones and soft tissues

22
Evaluation of the Chest xray

• Identification--name and date
• Technique--PA and Lateral vs AP portable vs
  Other
  
• Inorganic features
• sutures, staples, sternal wires
• indwelling IV or pacemaker
• external tubes and lines
• prostheses and jewelry
• Lung fields
• Pleura and fissures

23
Evaluation of the Chest xray

• Hila and mediastinum including heart
• size and shape of heart
• angle of the carina
• size and distinctness of hilar structures
• width of the mediastinum
• Diaphragm and below
• contour of diaphragm
• abdominal gas pattern
• Bones and soft tissues
• obvious fractures or dislocations
• soft tissue abnormalities

24
Da Lungs
25
Evaluation of the Chest xray

• Da Lungs
• Right Lung-- 2 fissures3 lobes10 segments
• RUL--apical, posterior, and anterior
• RML--lateral and medial
• RLL--superior, medial basal, anterior basal,
  lateral basal, and posterior basal
  
• Left Lung--1 fissure2 lobes8 segments
• LUL--apicoposterior, anterior, inferior lingular,
  and superior lingular
  
• LLL--superior, anteromedial basal, lateral basal,
  posterior basal
  

26
Xray anatomy of the right lung
27
Xray anatomy of the right lung
28
Xray anatomy of the left lung
29
Xray anatomy of the left lung
30
Normal PA Chest xray
31
Normal Lateral Chest xray
32
Evaluation of the Chest xray

• Recognition of common chest xray patterns
• Does the lesion have discrete boundaries or is it
  diffuse?
  
• Is the lung volume generally preserved?
• Does the lesion occupy a whole lobe or segment?
• Is the lesion singular or multiple?
• How dense is the lesion?
• Air, Fat, Water (soft tissue), Bone, Metal
  (contrast)
  
• Are there associated pleural features?

33
Segmental-lobar opacification
34
Segmental-lobar opacification(really, really bad)
35
Evaluation of the Chest xray

• Segmental-lobar opacification
• bacterial pneumonia
• atypical pneumonia (Mycoplasma, Legionella,
  Chlamydia)
  
• aspiration pneumonitis
• MTB
• fungal infection (coccidioidomycosis,
  histoplasmosis)
  
• bronchiectasis, RML syndrome, or airway
  obstruction by a tumor (recurrent pneumonia in
  the same location)
  
• pulmonary infarction

36
Segmental-lobar opacification with pleural
effusion
37
Segmental-lobar opacification with pleural
effusion (really bad)
38
Evaluation of the Chest xray

• Segmental-lobar opacification with pleural
  effusion
  
• bacterial pneumonia
• bronchogenic carcinoma
• pulmonary infarction
• MTB or fungal infection
• atypical pneumonia (uncommon)
• atypical measles pneumonitis

39
Segmental-lobar opacification with cavitation
40
Evaluation of the Chest xray

• Segmental-lobar opacification with cavitation
• necrotizing pneumonia (Klebsiella, other GNRs,
  anaerobes, Staph)
  
• MTB/atypical mycobacteria
• Opportunistic fungal infections
• Obstructive pneumonitis
• Pulmonary infarction (rarely)
• Pneumococcal pneumonia (rarely)

41
Atelectasis/Lobar collapse
42
Evaluation of the Chest xray

• Atelectasis/Lobar collapse
• mucous plug
• foreign body
• malignant tumor
• benign tumor
• bronchostenosis
• broncholithiasis
• iatrogenic
• extrinsic pressure

43
Atelectasis with pleural effusion
44
Collapse with pleural effusion
45
Evaluation of the Chest xray

• Atelectasis/Lobar collapse with pleural effusion
• bronchogenic carcinoma
• pulmonary infarction
• lymphoma
• metastatic carcinoma
• infected mucous plugs
• obstructive pneumonitis
• chest trauma
• MTB
• fungal infections

46
Solitary pulmonary nodule becomes a Large mass
lesion
47
Evaluation of the Chest xray

• Solitary pulmonary nodule (
• bronchogenic carcinoma
• metastatic carcinoma
• granuloma
• bronchial adenoma
• hamartoma
• other benign tumors
• cyst
• pseudonodule

48
Evaluation of the Chest xray

• Large mass lesions (3cm)
• bronchogenic carcinoma
• metastatic carcinoma
• lung abcess (noncavitary)
• round pneumonia
• benign tumor
• granuloma
• pulmonary arteriovenous aneurysm
• pulmonary infarct
• round atelectasis
• fluid filled cyst
• pseudomass

49
Multiple pulmonary nodules
50
Multiple pulmonary nodules (really, really bad)
51
Evaluation of the Chest xray

• Multiple pulmonary nodules
• metastatic carcinoma
• bronchoalveolar cell carcinoma
• lymphoma
• MTB
• fungal granulomas
• septic emboli
• opportunistic infections
• noninfectious granulomas (rheumatoid nodules,
  Wegeners granulomatosis, sarcoidosis, others)

52
Miliary nodules (multiple 2-6mm)
53
Evaluation of the Chest xray

• Miliary nodules (multiple 2-6mm)
• miliary MTB
• primary coccidioidomycosis and histoplasmosis
• viral pneumonia
• other fungal pneumonia
• sarcoidosis
• silicosis/coal workers pneumoconiosis/berylliosis
  
  
• bronchoalveolar cell carcinoma
• lymphangitic/hematogenous metastasis
• lymphoma or leukemia
• hemosiderosis
• parasitic infections
• eosinophilic granuloma

54
Cavitary and cystic lesions
55
Evaluation of the Chest xray

• Cavitary and cystic lesions
• MTB/other mycobacterial infections
• bronchogenic carcinoma
• fungal infection
• postpneumonic lung abcess (esp GNR or Staph)
• obstructive lung abcess
• metastatic tumor
• cysts and bullae
• granulomatous diseases (esp Wegeners)
• parasitic cavities
• rheumatoid arthritis

56
Single non-circumscribed lesion
57
Evaluation of the Chest xray

• Single non-circumscribed lesion (infectious)
• CAP
• nosocomial pneumonia
• opportunistic pneumonia
• atypical pneumonia
• aspiration pneumonia
• mycobacterial infection
• fungal infection
• parasitic infection

• Single non-circumscribed lesion (non-infectious)
• pulmonary contusion
• pulmonary infarction
• bronchogenic carcinoma
• lymphoma
• necrotizing granuloma
• sequestration
• SLE

58
Multiple non-circumscribed lesions
59
Multiple non-circumscribed lesions (really,
really bad)
60
Evaluation of the Chest xray

• Multiple non-circumscribed lesions (infectious)
• CAP
• atypical pneumonia
• nosocomial pneumonia
• opportunistic pneumonia
• aspiration pneumonia

• Multiple non-circumscribed lesions
  (non-infectious)
  
• neoplastic diseases
• pulmonary infarction
• sarcoidosis
• eosinophilic pneumonia
• necrotizing granulomas
• alveolar hemorrhage
• VOD

61
Diffuse reticular (interstitial) patterns
62
Diffuse reticular (interstitial) patterns (really
bad)
63
Evaluation of the Chest xray

• Diffuse reticular (interstitial) patterns
• idiopathic pulmonary fibrosis
• pneumonia--infectious--viral, PCP, others
• sarcoidosis
• interstitial pulmonary edema
• pneumoconioses--asbestos, beryllium, silicates
• pneumonia--non-infectious--DIP, UIP, LIP, lipoid,
  others
  
• lymphangitic/hematogenous metastasis
• drug-induced pneumonitis
• lymphoma or leukemia
• hemosiderosis
• amyloidosis

64
Pulmonary edema (diffuse alveolar infiltrates)
65
Pulmonary edema (really, really bad)
66
Evaluation of the Chest xray

• Pulmonary edema (diffuse alveolar infiltrates)
• cardiogenic pulmonary edema
• ARDS
• fluid overload
• pneumonia--infectious--PCP, viral,
  histoplasmosis, bacterial (immunocompromised
  host)
  
• drug-induced pneumonitis
• alveolar cell carcinoma
• eosinophilic pneumonia
• alveolar hemorrhage
• pulmonary alveolar proteinosis
• fat embolism
• pregnancy complications--eclampsia, amniotic
  fluid embolism, hydatidiform mole

67
Bilateral hilar enlargement
68
Evaluation of the Chest xray

• Bilateral hilar enlargement
• sarcoidosis
• lymphoma
• metastatic malignancy
• infectious lymphadenopathy
• pneumoconioses
• multiple PE with PHTN
• other PHTN
• silicosis

69
Unilateral hilar enlargement
70
Unilateral hilar enlargement
71
Evaluation of the Chest xray

• Unilateral hilar enlargement
• peribronchial bronchogenic carcinoma
• metastatic adenopathy
• lymphoma or leukemia
• sarcoidosis
• vascular anomaly
• middle mediastinal mass (any cause)
• Castlemans disease (angiofollicular LN
  hyperplasia)