Title: Examine the Patient and then Look at the Chest Xray
1Examine the Patient and thenLook at the Chest
Xray
- Vincent X Grbach COL, MC
- Pulmonary Disease/CCM
- Tripler Army Medical Center
2Examine 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
3Evaluation 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
4Evaluation 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.
5Evaluation 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
6Evaluation 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
7Evaluation 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
8Evaluation 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
9Evaluation 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
10Evaluation of the Patient
- History
- Chest pain
- An abnormal sensation of pain involving the chest
11Evaluation 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
12Evaluation 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
13Evaluation 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
14Evaluation 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
15Evaluation 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
16Evaluation 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
17Evaluation 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
18Evaluation 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
19Evaluation 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)
20Evaluation 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
21Evaluation 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
22Evaluation 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
23Evaluation 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
24Da Lungs
25Evaluation 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
26Xray anatomy of the right lung
27Xray anatomy of the right lung
28Xray anatomy of the left lung
29Xray anatomy of the left lung
30Normal PA Chest xray
31Normal Lateral Chest xray
32Evaluation 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?
33Segmental-lobar opacification
34Segmental-lobar opacification(really, really bad)
35Evaluation 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
36Segmental-lobar opacification with pleural
effusion
37Segmental-lobar opacification with pleural
effusion (really bad)
38Evaluation 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
39Segmental-lobar opacification with cavitation
40Evaluation 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)
41Atelectasis/Lobar collapse
42Evaluation of the Chest xray
- Atelectasis/Lobar collapse
- mucous plug
- foreign body
- malignant tumor
- benign tumor
- bronchostenosis
- broncholithiasis
- iatrogenic
- extrinsic pressure
43Atelectasis with pleural effusion
44Collapse with pleural effusion
45Evaluation 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
46Solitary pulmonary nodule becomes a Large mass
lesion
47Evaluation of the Chest xray
- Solitary pulmonary nodule (
- bronchogenic carcinoma
- metastatic carcinoma
- granuloma
- bronchial adenoma
- hamartoma
- other benign tumors
- cyst
- pseudonodule
48Evaluation 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
49Multiple pulmonary nodules
50Multiple pulmonary nodules (really, really bad)
51Evaluation 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)
52Miliary nodules (multiple 2-6mm)
53Evaluation 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
54Cavitary and cystic lesions
55Evaluation 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
56Single non-circumscribed lesion
57Evaluation 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
58Multiple non-circumscribed lesions
59Multiple non-circumscribed lesions (really,
really bad)
60Evaluation 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
61Diffuse reticular (interstitial) patterns
62Diffuse reticular (interstitial) patterns (really
bad)
63Evaluation 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
64Pulmonary edema (diffuse alveolar infiltrates)
65Pulmonary edema (really, really bad)
66Evaluation 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
67Bilateral hilar enlargement
68Evaluation of the Chest xray
- Bilateral hilar enlargement
- sarcoidosis
- lymphoma
- metastatic malignancy
- infectious lymphadenopathy
- pneumoconioses
- multiple PE with PHTN
- other PHTN
- silicosis
69Unilateral hilar enlargement
70Unilateral hilar enlargement
71Evaluation 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)