Chest Radiography: Support Lines & Devices-2

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Questions and Answers

A central venous catheter (CVC) is ideally positioned with its tip within which vessel?

  • Inferior vena cava (IVC)
  • Pulmonary artery
  • Superior vena cava (SVC) (correct)
  • Azygos vein

What is the recommended distance above the carina for the distal tip of a correctly positioned endotracheal tube (ET tube) on a chest radiograph?

  • 1-3 cm
  • 5-7 cm (correct)
  • 8-10 cm
  • 10-12 cm

A tracheostomy tube on a chest radiograph should be positioned at the level of which anatomical structure?

  • Carina
  • Thyroid cartilage
  • Suprasternal notch
  • Clavicles (correct)

When evaluating a nasogastric tube (NG tube) on a chest radiograph, what anatomical landmarks should be assessed to confirm correct placement?

<p>Midline descent, carina bisection, diaphragm crossing, and left hemidiaphragm (D)</p> Signup and view all the answers

In a patient with a right-sided pacemaker, through which vein is the lead typically advanced to reach the superior vena cava (SVC)?

<p>Right subclavian vein (C)</p> Signup and view all the answers

Following a median sternotomy, what radiographic finding is expected to be observed in the anterior chest?

<p>Sternotomy wires (C)</p> Signup and view all the answers

When assessing a chest radiograph for post-surgical changes following a CABG, what specific findings might indicate the use of surgical clips?

<p>Small, metallic densities along the mediastinum (A)</p> Signup and view all the answers

Which of the following findings on a chest radiograph is most indicative of a hair braid artifact?

<p>Linear densities projecting over the superior mediastinum (D)</p> Signup and view all the answers

What radiographic technique is considered the gold standard for both diagnosing and removing a foreign body in the airway?

<p>Bronchoscopy (D)</p> Signup and view all the answers

Which indirect radiographic sign is most suggestive of foreign body aspiration in a child?

<p>Mediastinal shift away from the affected side (D)</p> Signup and view all the answers

What is the normal range of retrosternal space as measured on a lateral chest radiograph?

<p>Less than 2.5 cm (B)</p> Signup and view all the answers

A premature neonate is diagnosed with respiratory distress syndrome (RDS) and a left-sided pneumothorax. Following treatment, a chest x-ray reveals a peripherally inserted central catheter (PICC) line that is malpositioned. Which of the following best describes the correct positioning of a PICC line?

<p>The tip of the PICC line should be located at the cavoatrial junction. (A)</p> Signup and view all the answers

A patient has a mass in the anterior mediastinum. The retrosternal clear space is effaced on the radiograph. This finding helps localize the mass in which mediastinal compartment?

<p>Anterior mediastinum (D)</p> Signup and view all the answers

A patient presents with suspected foreign body aspiration. The initial chest radiograph is inconclusive. Which additional radiographic view or technique is most useful for detecting air trapping?

<p>Inspiratory and expiratory films (D)</p> Signup and view all the answers

Which of the following findings on a chest radiograph would suggest malposition of a central venous catheter (CVC)?

<p>The tip of the catheter is located within the right atrium. (B)</p> Signup and view all the answers

A patient who underwent aortic valve replacement presents for a follow-up chest radiograph. Where would you typically expect to see the prosthetic valve?

<p>Somewhat medially over the spine (A)</p> Signup and view all the answers

A patient with a history of CABG has a chest radiograph. What radiographic finding would strongly suggest the use of sternotomy wires?

<p>Thin, curvilinear metallic densities running parallel to the sternum (D)</p> Signup and view all the answers

In the context of chest radiography, how would you differentiate between a foreign body and an artifact?

<p>Artifacts are external objects that create opacifications, while foreign bodies are internal. (D)</p> Signup and view all the answers

Assessing the position of medical support lines in chest radiographs is crucial. What is a potential consequence of a nasogastric tube (NG tube) not descending past the left hemidiaphragm?

<p>Risk of regurgitation and aspiration (D)</p> Signup and view all the answers

What could be the most severe outcome of placing an endotracheal tube too far down the mainstem bronchus?

<p>Atelectasis of the left lung (B)</p> Signup and view all the answers

How does hyperinflation manifest on a chest radiograph in the context of foreign body aspiration?

<p>Flattening of the diaphragm on the affected side. (D)</p> Signup and view all the answers

Distinguishing foreign body aspiration from other respiratory conditions on a chest radiograph can be challenging. Which indirect sign is most reliably associated with foreign body aspiration in children?

<p>Mediastinal shift away from the affected side during expiration (D)</p> Signup and view all the answers

In a trauma patient, rapid assessment of the proper placement of medical support lines is critical. What is the most concerning malposition of a chest tube?

<p>The chest tube is abutting mediastinal structures (D)</p> Signup and view all the answers

When evaluating a lateral chest radiograph for cardiac size, what upper limit of normal measurement helps determine if the retrosternal clear space is being encroached upon by an enlarged heart?

<p>2.5 cm (A)</p> Signup and view all the answers

How does the radiographic appearance of interstitial lung disease differ from airspace disease on a chest x-ray?

<p>Airspace disease demonstrates patchy infiltrates, while interstitial disease shows reticular patterns. (A)</p> Signup and view all the answers

In neonatal chest radiography, what specific characteristic of the thymus gland’s appearance can help differentiate it from other mediastinal masses?

<p>Bilateral symmetry and the presence of the 'sail sign' (D)</p> Signup and view all the answers

Flashcards

Central Venous Catheters (CVC)

Tip of CVC within the SVC at or just above the level of the carina.

Endotracheal tube (ET tube)

Tube inserted into the trachea to provide oxygen.

Tracheostomy tube

Tube inserted into the trachea to provide an airway.

Nasogastric tube (NG tube)

Tube inserted through the nose into the stomach to provide nutrition or remove gastric contents.

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Pacemaker placement

Used to deliver electrical impulses to the heart to regulate the heart rate.

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Sternotomy wires

Wires used to close the sternum after open-heart surgery.

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Aortic valve replacement

Replacement of the aortic valve with a prosthetic valve.

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Surgical clips

Clips used to close blood vessels or other structures during surgery.

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Artifacts on chest imaging

Image artifacts caused by external objects, hair, skin folds, or motion.

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Foreign body aspiration (FBA) diagnosis

Inspiratory and expiratory films to visualize hyperinflation.

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Bronchoscopy

Gold standard to diagnose and remove foreign body.

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Radiolucent foreign body

Food: hyperinflation, mediastinal shift away from the affected lung, consolidation.

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Airspaces

Respiratory bronchioles, alveolar ducts, and alveoli.

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Retrosternal space

Between sternum and ascending aorta; should be <2.5cm.

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Interstitium

Tissue surrounding the airspaces, should be thin and faint.

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Study Notes

  • General Radiology PHA-649P covers Chest Radiograph - 2

Objectives

  • Evaluate the placement of support lines, cardiac support devices, post-surgical changes, and artifacts on chest imaging
  • Identify foreign body aspiration of the respiratory system
  • Explain the radiographic appearance of air space and interstitial

Common Support Lines

  • Central Venous Catheters (CVC) have their tip within the SVC at or just above the level of the carina

Endotracheal Tube (ET tube)

  • Should ideally be positioned 5-7 cm above the carina
  • If positioned too deep, pull it back so air goes to only one lung

Tracheostomy Tube

  • Tracheostomy tubes should be at the level of the clavicles

Nasogastric Tube (NG Tube)

  • Look for midline descent, carina bisection, diaphragm crossing, left hemidiaphragm

Cardiac Support Devices

  • Pacemakers have a pulse generator in the right pectoral region and a lead through the right subclavian vein into the superior vena cava
  • Pacemakers have two electrodes in the right ventricle

Post-Surgical Changes

  • Sternotomy wires are midline
  • Aortic valve replacements are somewhat medially over the spine
  • Surgical clips are typically placed post left surgery like CABG
  • A patient who had a CABG has their sternum cut and opened, then held back together with wires after the procedure

Artifact

  • Artifacts on chest radiographs can be caused by motion, external objects, hair, or skin folds
  • Hair braids can cause opacifications in the superior mediastinum

Foreign Body Aspiration (FBA)

  • Studies for FBA include Inspiratory and Expiratory Films to visualize hyperinflation
  • A CT Scan is used if there is high clinical suspicion but the CXR is inconclusive
  • Bronchoscopy is the gold standard for diagnosis and removal
  • A direct sign is a radiopaque foreign body such as metal objects
  • Indirect signs of radiolucent foreign body i.e., food include hyperinflation, mediastinal shift away from the affected lung, and atelectasis or lobar consolidation

Normal Air Space and Interstitium

  • Airspaces consist of respiratory bronchioles, alveolar ducts, and alveoli (dark areas)
  • Retrosternal space is the area between the sternum and ascending aorta, and should be <2.5cm (radiolucent)
  • Interstitium is the tissue surrounding the airspaces, appearing as thin, faint lines

Practice Questions

  • A peripherally inserted central catheter (PICC) line that is arching backwards and peripherally is malpositioned
  • The retrosternal clear space or retrosternal airspace is seen posterior to the sternum on lateral chest radiographs and should appear radiolucent
  • Increased soft tissue density posterior to the sternum may signify the presence of an anterior mediastinal mass

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