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Data Interpretation Series: Chest X Rays Dr. Ozbil Ege Dumenci FY1Social MediasPresenting a Chest X Ray • Introduction • Technical qualities • (Most glaring/obvious abnormality) • ABCDE • SummaryIntroduction • This is the chest radiograph of XX, born on xx/xx/xxxx, taken on xx/xx/xxxx. • This was taken on the background of (insert indication here) • There is/isn’t a previous image to compare findings Case 1 Question In which ways is this film technically inadequate? A.Poor inspiration B.Rotated C.Underexposed D.Overexposed E.It is an AP filmTechnical Qualities of a Chest X Ray Rotation •The clavicles should be equidistant from the spinous processes Inspiration •5-6 anterior ribs OR 8 posterior ribs •Costophrenic angles should all be visible Projection RIPE •Is this a PA or an AP film? •If not noted, it is PA. Exposure •The left hemidiaphragm should be visible to the spine •The vertebrae should be visible behind the heart. NO ROTATION PA ADEQUATE INSPIRATION ADEQUATE EXPOSURE• This is the chest radiograph of XX, born on xx/xx/xxxx, taken on xx/xx/xxxx. • This was taken on the background of (insert indication here) • There is/isn’t a previous image to compare findings • This is a PA film, and it is technically adequate. • (or not, in which case explain why) • E.g. there is evidence of inadequate inspiration, the film is rotated, there is inadequate exposure • (Point out the most obvious abnormality if you catch it) • ABCDE!!! Case 1 Question In which ways is this film technically inadequate? A.Poor inspiration B.Rotated C.Underexposed D.Overexposed E.It is an AP film Case 1 Answer In which ways is this film technically inadequate? A.Poor inspiration B.Rotated C.Underexposed D.Overexposed E.It is an AP film - Only able to see 6 anterior ribs– inadequate inspiration - Left hemidiaphragm unclear, spine not visible behind heart – underexposed - While the radiograph is an AP film, this does not mean it is technically inadequate. Suboptimal but likely PA not an option! Airways Trachea Lung zones Breathing Lung edges (Pleura) Heart side Cardiac Aorta Cardiophrenic angles Flattening Diaphragm Paralysis Costophrenic angles Hilar structures Everything else Bones Gastric bubble Case 2 Question You are asked to see a 26-year-old female who has presented to the A&E following a road traffic accident. Following an A to E assessment, you note out a full examination, you order an urgent chest xry ray. What is the diagnosis? A. Primary spontaneous pneumothorax B. Lobar collapse C. Secondary spontaneous pneumothorax D. Acquired simple pneumothorax E. Tension pneumothorax Case 3 Question A 78 year old patient presents to the hospital with a 3 day history of cough, fevers and malaise. He has a past medical history of advanced Parkinson’s Disease. His Chest X Ray is as follows. What is the most likely diagnosis? A. Community acquired pneumonia B. Hospital acquired pneumonia C. Aspiration pneumonia D. R sided pleural effusion E. Metastatic disease 1. AIRWAYS 2. BREATHING • Assess for tracheal deviation • Lung edges • Thickening à ?mesothelioma • DDx? • In incorrect place à pneumothorax • Think tension vs simple • PUSH: pneumothorax • Tension pneumothorax • Large pleural effusion • Adjacent mass • Lung zones – these do not correspond to lobes • Upper • PULL: • Lobar collapse • Middle • Lower Pneumothorices Spontaneous Traumatic Primary Secondary Simple Underlying respiratory Tension pathologyConsolidation/Opacification • increased whiteness where lung tissue (black) should be • DDx? • Pneumonia • Neoplasm • Fibrosis • (Oedema) –a will cover laterLobar pneumonia - HAP vs CAP vs Aspiration - S&S- Cough +/- productive, SOB, fever, crackles on chest, percussion dullness, etc. - Bloods- FBC, U&Es, CRP, +/-blood cultures, - Imaging- CXR - Other- Sputum culture - Risk stratification- CURB-65 - Mx: Antibiotics based on organism, manage underlying risk factors (e.g. COPD)Bronchopneumonia • acute inflammation of the bronchi, accompanied by inflamed patches in the nearby lobules of the lungs • areas of the lung where there are patches of inflammation separated by normal lung parenchymaMaliganancyRisk factors • Smoking – in 90% of cases • Asbestos • Fibrosis – increases risk 10 foldTypes of lung malignancy • Small Cell Carinoma • Most common, associated with smoking • Centrally located • Adenocarcinoma • Less common Where does lung cancer metastisise to? • More commonly seen in non-smokers - Bone • Peripherally located - Brain - Liver • + Others – squamous, large cell • Mets – which ones? • Breast, colorectal, head and neck cancers Mesothelioma Note peripheral location– attached to the pleura ASBESTOS EXPOSURE!!!Cavitating lesions • Causes: • Abscess • On the background of infection • TB • Aspergilloma • Granulomatosis with polyangiitis • SarcoidosisLung Fibrosis • Increased shadowing • Ground glass opacity • Causes • Idiopathic • Hypersensitivity pneumonitis • Connective tissue diseases e.g. RhA, SLE, ank spond • Medication induced Case 2 Question You are asked to see26-year-old female whas accident. Following an A to E assessment, you note that the patient is short of breath. Before you carry out a full examination, you order an urgent chest x ray. What is the diagnosis? A. Primary spontaneous pneumothorax B. Lobar collapse C. Secondary spontaneous pneumothorax D. Acquired simple pneumothorax E. Tension pneumothorax Case 2 Answer What is the diagnosis? A. Primary spontaneous pneumothorax C. Secondary spontaneous pneumothorax D. Acquired simple pneumothorax E. Tension pneumothorax - Can follow the lung edges (orange) – massively displaced - Trachea deviated AWAY from the pneumothorax – being pushed by the air - NEVER X-ray someone with a ?tension pneumothorax – treat by inserting wide bore cannula in safe triangle! Case 3 Question A 78 year old patient presents to the hospital with a 3 day history of cough, fevers and malaise. He Parkinson’s Disease.l His Chest X Ray is as follows. What is the most likely diagnosis? A. Community acquired pneumonia B. Hospital acquired pneumonia C. Aspiration pneumonia D. R sided pleural effusion E. Metastatic disease Case 3 Answer What is the most likely diagnosis? A. Community acquired pneumonia B. Hospital acquired pneumonia C. Aspiration pneumonia D. R sided pleural effusion E. Metastatic disease - This radiograph shows right lower zone consolidation - This rules out D and E as likely causes. - As this patient has presented to the A&E, this cannot be a HAP - Although this could be a CAP, aspiration pneumonia is more likely as per the patient’s history of Parkinson’s, as well as the location of the consolidation 3. CARDIAC 4. DIAPHRAGM 5. EVERYTHING ELSE • Assess for size • Flattening • Hilar structures • Assess cardiophrenic angles • Costophrenic angles • Bones • Symmetry • Below the diaphragm Case 4 Question A 65 year old woman presents to the A&E with shortness of breath of pink sputum. Which of thetive following is a finding that cannot be confirmed using the CXR below? A. Alveolar oedema B. Kerley B lines C. Cardiomegaly D. Upper lobe diversion E. Pleural effusion Case 5 Question A 76 year old with a 80 pack year A&E with SOB, productive cough the and a fever. Given the CXR here, what is the most likely diagnosis?Heart Failure • Presentation: • SOBOE • Cough with pink sputum • SOB worse on lying down • Third heart sound • Peripheral oedemaHeart Failure • ABCDE A. Alveolar oedema (bat wing opacities)Heart Failure • ABCDE A. Alveolar oedema (bat wing opacities) B. Kerley B linesHeart Failure • ABCDE A. Alveolar oedema (bat wing opacities) B. Kerley B lines C. CardiomegalyHeart Failure • ABCDE A. Alveolar oedema (bat wing opacities) B. Kerley B lines C. Cardiomegaly D. Upper lobe diversionHeart Failure • ABCDE A. Alveolar oedema (bat wing opacities) B. Kerley B lines C. Cardiomegaly D. Upper lobe diversion E. Pleural effusionsPleural effusionHow do we categorise Pleural effusions? • If rich in proteinà exudate • Due to ↑ capillary permeability • Infection: pneumonia, TB • Neoplasm: bronchial, lymphoma, mesothelioma • Inflammation: RA, SLE • Infarction • If not rich in protein à transudate • Due to ↑ capillary hydrostatic or ↓ oncotic pressure • Heart failure • Liver failure • Renal failure Obstructive lung disease: Asthma/COPD Hyperexpanded lungs - Flattened hemidiaphragms - more than 6 anterior or 10 posterior ribs above the diagphragm visiblePneumoperitoneum • Presence of single gastric bubble is NORMAL!Pneumoperitoneum • Additional air under the diaphragm – PATHOLOGICAL – suggestive of perforation in GI tractHilar lymphadenopathy • CAUSES: • sarcoidosis • infection • tuberculosis • mycoplasma • histoplasmosis • coccidioidomycosis • malignancy • lymphoma: more common inHodgkin • Carinoma • Inorganic dust disease • Silicosis • BerylliosisBone stuff Case 4 Question A 65 year old woman presents to the A&E with shortness of breath of pink sputum. Which of thetive following is a finding that cannot be confirmed using the CXR below? A. Alveolar oedema B. Kerley B lines C. Cardiomegaly D. Upper lobe diversion E. Pleural effusion Case 4 Answer Which of the following is a finding that cannot be confirmed using the CXR below? A. Alveolar oedema B. Kerley B lines C. Cardiomegaly D. Upper lobe diversion E. Pleural effusion - All options are findings in a CXR of someone with heart failure - As this is an AP film, it is not possible to comment on heart size! Case 5 Question A 76 year old with a 80 pack year A&E with SOB, productive cough the and a fever. Given the CXR here, what is the most likely diagnosis? Case 5 Answer What is the most likely diagnosis? Infective exacerbationof COPD - Evidence of hyperexpansion – count ribs + flat diaphragm - RLZ opacity O O F Feedback & Instagram + 3C N O Please complete feedback to receive slides! Follow our In3tagram pa e for MCQs! NH O Cl CH 3 CH3 OH CH 3 CH OH 3 3HC CH3 3HC O