Lung Disease Investigation: Chest X-ray Analysis

Lung Disease Investigation

• Presentation by Dr. Ramez M. Othman, Pulmonary Consultant, PMAH
• Topic focused on the interpretation of chest X-rays.

Technical Aspects of Chest X-rays

• Identification: Includes name, file number, date, and time.
• Projection: Either PA (Posterior-Anterior) or AP (Anterior-Posterior).
• Position: Upright or Supine.
• Inspiratory Effort: Assessment for adequate inspiration. Potentially "poor inspiration" noted.
• Exposure: Evaluation for overexposure or underexposure.
• Positioning/Rotation: Clavicle heads equidistant from the spinous process.
• Thoracic intervertebral disc space should be visible.

Chest X-Ray Approach

• Inside-Out Approach: Systematic review starting with the heart, mediastinum, hilum, lungs, thoracic wall, and abdomen.
• Systematic Approach: Following a structured format for interpretation and evaluating abnormalities.
• Abnormality Detection: Identifies and assesses abnormalities in the chest X-ray.
• Pattern Recognition: Assessing the pattern of the abnormality found.
• Differential Diagnosis: Considering various potential diagnoses based on observations.

Expiratory View

• Air Obstructions: Useful in identifying unilateral obstructive emphysema (caused by a blocked bronchus).
• Pneumothorax: Small pneumothoraces can sometimes only be seen during expiration.

Normal Standards (PA View Only)

• Heart Size: Evaluated for normal size standards.
• Mediastinal Width: Evaluated for normal standards.
• Diaphragm Position: Evaluated for normal position.
• Pleural Effusion Meniscus: Evaluated for presence/absence.
• Vascular Shadows: Checked for normal appearance.

Film Centering

• Crucial for accurate interpretation and avoiding misdiagnosis.

Mediastinum Outline

• Located between the right and left pleural cavities.
• Superior: Thoracic inlet
• Inferior: Thoracic outlet (diaphragm)
• Antero-lateral: Sternum and ribs
• Posterior: Thoracic vertebrae

Lung Lobes and Segments

• Right Lung: 3 lobes (upper, middle, lower) and 10 segments. Two fissures (oblique and horizontal).
• Left Lung: 2 lobes (upper, lower) and 8 segments. One fissure (oblique).

Right and Left Lung Regions and Divisions

• RUL, RML, RLL: Right Upper, Middle, Lower lobes
• LUL, LLL: Left Upper, Lower Lobes

Pulmonary Pathology

• Consolidation: A complete filling of the lung tissue.
• Interstitial: Abnormal tissue between the alveoli (air sacs) in the lungs.
• Atelectasis: Collapsed lung tissue (which appears as a dark area on the X-ray).
• Nodule: Small, round opacity (a potential indication of disease).
• Mass: A more sizable opacity, which may represent a tumor or another abnormality.

Pleural Effusion

• Buildup of fluid between the lungs and the chest wall.
• Quantifiable: Assessed using volumetric estimations. (200-300ml, 2 liters, 5 liters)

Other Pulmonary Conditions (Images)

• Bronchiectasis
• Pulmonary Edema

Pulmonary Function Tests (PFTs)

• Indications: Diagnosis, disease severity, therapeutic response, disease progression, pre/post-surgical assessment, disability assessment, insurance, legal, and public health research.

PFT Types

• Spirometry: Measures airflow.
• Flow Volume Loop: Shows airflow during breathing.
• Bronchodilator Response: Assesses lung function improvement after a bronchodilator treatment.
• Lung Volumes: Total volume of air the lungs can hold.
• Diffusion Capacity (DLCO): Measures gas transfer ability of the lungs.
• Maximum Respiratory Pressures (NIF, PEF, MVV): Estimates inspiratory and expiratory pressures and volume of airflow.
• 6 Minute Walk Testing: Evaluates patient's ability to walk for 6 minutes.
• Cardiopulmonary Exercise Testing: Examines response to exertion.

Spirometry Details

• FVC (Forced Vital Capacity): Maximum amount of air exhaled forcefully.
• FEV1 (Forced Expiratory Volume in 1 Second): Volume of air exhaled in the first second of forced exhalation.
• FEV1/FVC Ratio: Proportion of air exhaled in the first second to the total forced exhaled volume.
• FEF25-75 (Forced Expiratory Flow 25%-75%): Measures airflow during the middle portion of the exhalation (important for airflow).

Lung Volumes and Capacities

• Diagram illustrating lung volumes and capacities.

Diffusing Capacity

• Measures lungs' ability to transfer inhaled gas between the alveoli and capillaries.
• Dependent on alveolar-capillary membrane, hemoglobin concentration, and cardiac output.

PFT Interpretation: Obstruction, Restriction, Mixed

• Table showing the pattern of changes in each PFT when determining obstruction, restriction, or mixed disease.

CT Pulmonary Angiography (CTPA)

• Indication: Pulmonary embolism (a blocked blood vessel in the lung).

High-Resolution Chest CT (HRCT)

• Indication: Various forms of idiopathic interstitial lung disease (pneumonia), particularly idiopathic pulmonary fibrosis.

Thoracentesis and Chest Symptoms

• Thoracentesis Procedure: A technique for extracting fluid from the pleural space.
• Chest Pain: Sharp pain from catheter, may be ipsilateral shoulder pain.
• Other Symptoms: Cough from lung re-expansion or vague anterior chest discomfort.

Pleural Biopsy

• Purpose: Differentiate between pleural TB and malignancies (e.g., Adenocarcinoma, mesothelioma).

This quiz focuses on the interpretation of chest X-rays, including guidelines for identifying key elements and evaluating technical aspects. Participants will learn systematic approaches to assess abnormalities and enhance their understanding of lung disease diagnostics.