Chest Pathologies 1 PDF

CHEST PATHOLOGIES Proper positioning and correct exposure factors are VERY IMPORTANT when taking radiographs of the respiratory system no rotation, tech factors ect. To have proper diagnosis the Radiologist must be able to detect subtle changes in pulmonary and vascular structuress...

CHEST PATHOLOGIES Proper positioning and correct exposure factors are VERY IMPORTANT when taking radiographs of the respiratory system no rotation, tech factors ect. To have proper diagnosis the Radiologist must be able to detect subtle changes in pulmonary and vascular structuressoemtimes f/u must be done on the same machine to reproduce same image resolution Ideally, follow-up studies should be performed with the same exposure factors  CHEST PATHOLOGIES Inspiration is SO CRUCIAL in a Chest radiograph that we ask the patient to take 2 full inspirations in order to if not held inspiration, lung markings are have the maximum inspiration possible not seen and looks white This also prevents the patient to avoid the Valsalva effect (forced expiration against the closed glottis that increases the intrapulmonary pressure) The Valsalva effect results in compression & large decrease in the size of the heart & blood vessels This can make it difficult to evaluate the heart size and pulmonary vascularity properly would not be acceptable if they cant take an inspiration properly if for caridac or repsiratory system  CHEST PATHOLOGIES Chest X-ray require a long scale of contrast to be able to visualize the entire spectrum of density in the thoracic cavity This is why we always choose a higher kVp (110-125) for all adult chest radiography It is also necessary to decrease the overall density, long scale of contrast and short time because heart can be stopped and this is done by reducing the mAs Decreasing the kVp will enhance the bony thorax (think when we image the ribs what kVp range do we use) & obscure vascular details & cause underpenetration of the mediastinal structures need to see vascular details to see mediastinal structures expore acceptable if we can see heart through the spine  CHEST PATHOLOGIES Short exposure time is essential when an X-ray of the chest is performed, because longer times may not eliminate the involuntary motion of the heart AEC is highly recommended in imaging the chest rather than manual technique to make sure that the image density remains the same if a follow up study is risking overexposing one area and undereposing the other with patients with masectomy or implant ect. if no AEC used done expiration = The exception is when doing an expiration chest X-ray always manual technique Recommend that a manual technique is used because AEC may cause excessive overexposure of the lungs & can obscure a pneumothorax if doing an expiration view, always do inspiration view, then decrease tech factors for expiration  DISORDERS OF THE PLEURA Pleural Effusion Pneumothorax Empyema  PLEURAL EFFUSION Excess accumulation of fluid in the pleural cavity can mean they have neoplastic disease, cancer May be caused by a variety of pathologies, the most common causes are: Congestive Heart Failure Pulmonary Emboli Infection (i.e TB) Pleurisy (Inflammation of the pleura) Neoplastic Disease Connective Tissue Disorder (disease that affects skin, jts or blood vessels) Trauma severe Abdominal disease (recent surgery, ascites, abscess, pancreatitis)  PLEURAL EFFUSION Radiographic Appearance: Early findings – Blunting of the normally sharp angle between the diaphragm & rib cage _______________ costophrenic angle Along with an upward concave (curving ________) inward border of the fluid level Small pleural effusions are best seen on a __________ lateral projection WHY? Because the costophrenic angles are deeper posteriorly than laterally Even with a large amount of fluid (500 ml), it will NOT show blunting on an AP/PA radiograph of the Chest need to do lateral always for pleural effusion to see any small amount of fluid Increase mAs by 35% when pleural effusion is suspected  PLEURAL EFFUSION Small pleural effusions can easily be mistaken for pleural thickening & fibrosis A horizontal x-ray beam with the patient in a lateral decubitus position is best to diagnose a small pleural effusion and wait 5 mins Symptoms: SOB Sharp Chest Pain Cough Rapid breathing Asymptomatic Treatment: Thoracentesis is done to remove fluid from the pleural cavity  PLEURAL EFFUSION Blunting Costophrenic Angles Sharp Costophrenic Angles guided with ultrasound and syringe pulls fluid out  PLEURAL EFFUSION fluid versus diphrgham fluid shown on decub Decubitus demonstrates Loculated Fluid Collections  PLEURAL EFFUSION Loculated Pleural Effusion Pleural effusions may produce less common appearances, such as: Effusion can become fixed due to fibrosis and mimic a solid mass looks like a mass, goes in between fissures in chest Effusion may develop in interlobbar fissure and resemble a nodule in fissure of left lwoer lobe -loculated pleural effusion  PLEURAL EFFUSION proper lung density on top but not on bottom shows patient is supine AP Supine The appearance of a pleural effusion is dependent on the position of the patient. Fluid in the chest will accumulate in the dependent areas of chest. In a supine position – fluid appears as homogeneous graded increase in density. would cause repeat****  PLEURAL EFFUSION Thoracentesis Treatment may just require therapeutic aspiration (Thoracentesis) Larger pleural effusion’s may require intercostal draining (Chest Tubes) depends on critical care needed, more than 15000, chest tube needed small or moderate use tharacentesis  PLEURAL EFFUSION Thoracentesis bring fluid to accumulation and can tell if patient has cancer Needle aspiration procedure done to drain the fluid Effusion is measured & analyzed US or CT guidance US is faster and cheaper hard time breathing out wit pleural effusion will feel better after Performed to relieve pressure on the chest Can be done as an out patient or in patient basis Area of puncture will be sterilized & anesthetized patient is fully away just thst side is anesthetized Needle is inserted through two posterior ribs Drainage tube inserted via guidewire CXR to follow to check for residual effusion & to rule/out Pneumothorax the longer the tube is out, the more pneumothorax thoracocentesis will always have a pneumothorax, depends how big it is  PLEURAL EFFUSION Thoracentesis Once the needle reaches the pleural space, fluid will be withdrawn with a syringe or suction Drainage catheter & bag is installed Procedure takes about 15 mins Needle is removed & pressure is applied to stop the bleeding A post procedure X-ray will be required to detect complications such as Pneumothorax  PNEUMOTHORAX The presence of air in the pleural cavity, can result in partial or complete collapse of the lung May be caused by a variety of ways, the most common ones are: Rupture of a subpleural bulla Complication of emphysema Spontaneously in an otherwise healthy young adults Trauma (stabbing, gunshot or fractured rib) Iatrogenic (lung biopsy or thoracentesis) Complication of neonatal hyaline membrane disease May coexist with a hemothorax  PNEUMOTHORAX Medial Scapular line may look like L visceral pleural line Radiographic Appearance: no lung markings=pneumothorax Hyper lucent area where there is no visible line pulmonary markings Classic demonstration of pneumothorax is the demonstration of the visceral pleural line A large pneumothorax can cause can cause the hemidiaphragms to collapse of an entire lung population superimpose in the lateral or 10% of with equal hemidiaphrams Depression of diaphragm of affected side due to increase pressure  PNEUMOTHORAX Should be taken in an upright no lung markings position Routine PA or AP full- inspiration and expiration images visceral pleura This maneuver causes the lung to decrease in volume & become dense The volume of air in the pleural lung markings space remains constant & is easier to detect  PNEUMOTHORAX ****it is lateral decubitis that detects pneumothorax Very small pneumothorax are detected on a lateral decubitus images Manual technique is preferred for the expiration view mAs should be increased 35% of what was used for the inspiration view kVp should be decreased by 8%  PNEUMOTHORAX Symptoms: Sudden & severe chest pain Dyspnea (_________________) difficulty breathing Shortness of breath Treatment: multiple pneumos Small pneumothoraxes usually reabsorb spontaneously Larger pneumothoraxes require chest tube drainage with suction to remove the air & prevent recurrence very urgent, extremely painful thoracentesis cannot be used for pneumothorax, only pleural effusion PNEUMOTHORAX life threatening pressure in lung and stays can cause mediastanum to move and blocks  CLOSED & OPEN PNEUMOTHORAX CLOSED OPEN Most common Large defect (from an open Defect between the pleura chest wound) & the atmosphere seals Sealing cannot occur itself & doesn’t reopen Causes massive collapse Air is re-absorbed & the Called a “sucking” lung re-expands pneumothorax stays inside would neeed chest tube to remove air  TENSION PNEUMOTHORAX Medical emergency in which air continues to enter the pleural space but cannot exit overinflating the patient Accumulation of air within the pleural space no lung markings, shifted all structures on left to the right causes a complete collapse of the ipsilateral (______________) same side lung & depression of the hemidiaphragm The heart & mediastinal structures shift towards the opposite side contralaterally This causes severe compromise of cardiac output The elevated intrathoracic pressure decreases the venous return to the heart If not treated immediately, the result can be fatal pressure on trchea from structures and shifting also TENSION PNEUMOTHORAX expiration is harder than inspiration  TENSION PNEUMOTHORAX shift = tension pneumothorax no shift = pneumothorax depressed right hemidiaphragm down  SPONTANEOUS PNEUMOTHORAX UPRIGHT R Sudden & unexpected Idiopathic – no known cause Usually occurs in otherwise healthy adult males aged 20-40 that are hyposthenic & asthenic types SPONTANEOUS PNEUMOTHORAX seen on lung window in CT  INSPIRATION VS EXPIRATION Pneumothorax R R shown best on expiration  PNEUMOTHORAX R Please analyze this image. What are your findings? tension pneumothorax: shifting of heart and mediastinal structures to the right lack of lung markings on left side: pneumothorax stent  CHEST TUBE INSERTION Inserted between the ribs & connected to a canister that contains sterile water Tube is stitched in place Chest tube remains in place until lung is Ensure that it is NEVER raised expanded above the chest wall Can easily be removed  CHEST TUBE INSERTION Possible Complications: Bleeding Subcutaneous Emphysema Pulmonary Edema Local Infection Recurrent Pneumothorax Tension Pneumothorax can cause larger pneumothorax Organ Perforation if lower, stomach PA/AP CXR Inspiration & Expiration view must be done soon after insertion  CASE STUDY What pathology is density demonstrated? Is this considered small or large? cant tell which hemidiphragm is higher, pathology sharp costophrenic angle blurred angles, smaller pleural effusion to see fluid in lateral, small amount we dont see the other hemidiphragm (left side not visualized) COMPARING SHARP EDGES  EMPYEMA Presence of infected liquid or pus in the pleural space. May be caused by: Following an infection (bacterial pneumonia, lung abscess & esophageal perforation) Thoracic surgery Trauma Symptoms: Chest pain, worse on inspiration (pleurisy) Dry cough Fever & chills SOB  EMPYEMA Radiographic Appearance: Treatment: Resembles a pleural effusion Needle aspiration done under As the empyema progresses, it fluoroscopy stays in one place becomes loculated & appears as If mass is adjacent to the chest a mass that vary from small to wall, needle aspiration under large size ultrasound guidance Empyema are rare since the development of antibiotics  EMPYEMA versus pleural effusion Pleural Empyema Loculated Pleural Effusion looks like a mass versus pleural effsuion in lateral image  EMPYEMA white homogeneous density, looks like a mass, not fluid level Radiographic Appearance: Fluid consolidation in the pleural space Area of increased attenuation found in the Right pleural space MISCELLANEOUS LUNG DISORDERS Emphysema Subcutaneous Emphysema Atelectasis Acute respiratory distress syndrome Intrabronchial foreign bodies  EMPHYSEMA Crippling & debilitating condition in which obstructive & destructive changes in small airways lead to a dramatic increase in the volume of air in the lungs (the small airways in the lungs become blocked or damaged causing air to get trapped in the lungs, making it difficult to breathe) popping noise spontaneous: after surgery versus normal emphysema May be caused by: Very closely related to heavy cigarette smoking Chronic bronchitis Air pollution Long-term exposure to irritants of the respiratory tract With young adults who have hereditary disorders (osteogenesis imperfecta)  EMPHYSEMA Smokes, fumes & pollutants injure the cilia (fine hairs) of the respiratory mucosa and can no longer sweep away foreign particles This results in mucosal inflammation, excess secretion of mucus that clog up the air passages. The more exposure to toxic fumes the lungs get, the more bronchial narrowing & loss of elasticity happens As the walls between alveloli are destroyed, the tiny sacs transform to large air-filled spaces called bullae  EMPHYSEMA The surface for gas exchange decreases Limiting the transfer of oxygen into the carbon gets stuck and leads to emphysema bloodstream The lungs become less efficient, the heart tries to compensate This places excessive strain on the heart = enlargement The bullae can eventually rupture and allow air to enter into the pleural space causing spontaneous pneumothorax & atelectasis (collapse of the lung)  EMPHYSEMA Radiographic Appearance: Pulmonary overinflation (flattening of the domes of the diaphragm) Alterations in the pulmonary vasculature Bullae formation Increase in size and lucency of the retrosternal air space Do we remember where the retrosternal space is? (_____________________) space behind sternum and lungs, lateral projection AP diameter of the chest increases, chest becomes more barrel shaped as the disease progresses  EMPHYSEMA Radiographic Appearance continuation… Bullae can range in size from 1-2cm up to an entire hemithorax Found in the apices or at the bases of the lungs not in middle They can become so large that they can compress the normal lung Vascular lung markings are more prominent that normal They appear irregular, producing a “dirty chest” appearance Advanced stages of emphysema and a larger amounts of air is trapped in their lungs (radiolucent), we must decrease the technical factors – kVp decreased by 8%  EMPHYSEMA Symptoms: Coughing Wheezing Shortness of breath Chest tightness Treatment: There are no cure Treatment is used to relieve symptoms & prevent the disease from progressing  EMPHYSEMA bullae, circular Bullae seen at the base of the lungs More prominent lung markings no bullae, regular emhysema  SUBCUTANEOUS EMPHYSEMA Caused by penetrating or blunt injuries that disrupt the lung & parietal pleura and force air into the tissues of the chest wall When palpating the skin, you might hear or feel crepitation (crackling sound) Radiographic Appearance: Bizarre appearance with streaks of lucency outlining muscle bundles SUBCUTANEOUS EMPHYSEMA Subcutaneous Emphysema due to chest drain insertion  SUBCUTANEOUS EMPHYSEMA dark lucency outside lung: subcutaneous inside lung: regular Please analyze this image. What are your findings? What caused the disease? What level? broken on 5th and 6th ribs Analyze the positioning of the patient lung field shown with apices and costophrenic angle patien is in a RPO position as Rt stsernal end is further from spine, bring left side posteriorly to IR MCP was tilted anteriorly, manubrium at level of T5, >1" above clavicle shoudler blades out of field but one is lower than the other  ATELECTASIS Refers to a condition in which there is diminished air within the lung associated with reduced lung volume pneumothorax is collapse of the lung Regardless of the cause… May be caused by: Air cannot enter the part of the Bronchial obstruction lung supplied by the Neoplasm obstructed bronchus because the air is trapped in Foreign body (peanut, coin or tooth) the lung, it gets absorbed in Chronic Bronchitis the bloodstream causing the lung to collapse Complications of Abdominal surgery (mucus collects in the bronchi because of irritating effect of anesthesia) Complications of pneumothorax, pleural fluid, tumor, lung abscess or large emphysema Improper placement of the endotracheal tube  ATELECTASIS Radiographic Appearance: Local increase in density caused by the airless lung (can be thin streaks or lobar collapse) Displacement of interlobar fissures (shifts and become bowed, taking shape of the collapsed part) Elevated hemidiaphragm Displaced heart, mediastinum & hilum Treatment: Goal is to remove secretions & re-expand the affected lung tissue Incentive spirometry – increases lung volume by positive pressure (uses gravity to assist in expanding the affected lung tissue)  ATELECTASIS Improves lung performance Measures the inhaled air Helps dilate lung for people with chronic respiratory conditions lung expands ACUTE RESPIRATORY DISTRESS SYNDROME ARDS Severe, unexpected & life threatening acute respiratory distress that develops in patient’s who have a variety of medical & surgical disorders but no sign of major underlying disease generalizing lung disorders May be caused by: Nonthoracic trauma patient with hypotension Often called “shock lung” Severe pulmonary infection, aspiration or inhalation of toxins & irritants Drug overdose Structure of the lung completely breaks down Leads to massive leakage of cells Fluid into the interstitial & alveolar spaces Severe hypoxemia (______________________) decrease in oxygen ACUTE RESPIRATORY DISTRESS SYNDROME Radiographic Appearance: Patchy, ill defined areas of alveolar consolidation scattered throughout both lungs Heart remains normal in size (compare to pulmonary edema) Treatment: Hypoxemia in ARDS may be fatal, even with medical therapy Diuretics are used to decrease fluid load Oxygen therapy & ventilation may assist the patient in breathing to prevent more damage to the alveolar & capillaries Continuous positive-pressure ventilation may cause too much air to enter the lung ACUTE RESPIRATORY DISTRESS SYNDROME Bilateral Acute Respiratory Distress Syndrome happens in both versus emphysema happens in one  INTRABRONCHIAL FOREIGN BODIES Aspiration of solid foreign bodies into the tracheobronchial tree common in rt bronchus Occurs predominantly in young children Some foreign bodies are radiopaque & easily detected on a plain chest radiographs Others that are not opaque, obstruction will occur almost always involving the lower lobes (Right more than Left)  INTRABRONCHIAL FOREIGN BODIES Radiographic Appearance: Complete obstruction of a major bronchus leads to: Trapped air Alveolar collapse Atelectasis of the involved lobe obstruction, not enough air in lung Extensive volume loss causes: Shift of the heart & mediastinal structures towards the affected side Elevation of the ipsilateral hemidiaphragm Narrowing of the intercostal spaces  INTRABRONCHIAL FOREIGN BODIES A malpositioned endotracheal tube can be considered as an intrabronchial foreign bodies The tube will extend down the Right Mainstem Bronchus causing: - Hyperlucency of the Right Lung - Obstructive atelectasis of the Left Lung endotracheal tube is considered a foreign body and can cause injuries to lung if not placed properly Treatment: Expectoration – is the simplest method, requires the patient to cough hard enough to dislodge the foreign body & spit it out Bronchoscope – more invasive interventional procedure Surgery – most invasive  DIFFUSE LUNG DISEASE chronic obstructive pulmonary disease COPD can lead to... Chronic bronchitis Emphysema (discussed in earlier slides Asthma Bronchiestasis CHRONIC OBSTRUCTIVE PULMONARY DISEASE Several conditions in which chronic obstruction of the airways leads to an ineffective exchange of respiratory gases & makes breathing difficult Two disease causes the obstructive process: Chronic bronchitis Emphysema Factors that predispose to COPD: Cigarette smoking Infection Air pollution Occupational exposure to harmful substances (Asbestos)  CHRONIC BRONCHITIS Chronic inflammation of the bronchi leads to severe coughing with the production of sputum May be caused by : Respiratory infection Long-term exposure to air pollution Cigarette smoking 90% of cases are linked to smoking Severity of the disease & how quickly it can be resolved is directly related to the number of cigarettes smoked  CHRONIC BRONCHITIS Radiographic Appearance: Hyper inflated lungs (resembling emphysema) & a depressed diaphragm Half of the patients will demonstrate no changes on chest X-ray Most common sign – increase in bronchovascular markings aka “dirty chest” especially in the lower lungs Thickening of bronchial walls can cause parallel line shadows aka “tram lines” Overtime, the excessive production of mucus may lead to narrowing of the airways & excessive expansion of the lungs (Emphysema)  CHRONIC BRONCHITIS Difficult to see anterior ribs b/c they are osteopenic (long-term steroid use) Dotted green lines indicates the diaphragm shape & position if we cant see anterior ribs flat diaphragm and narrow lungs  in normal CXR we dont CHRONIC BRONCHITIS see the inferior heart shadow Hyper Inflated lungs & flattened hemidiaphragms – the heart border appears to float above the diaphragm  IMAGE ANALYSIS What pathology do you see in this image? chronic bronchitis Name 2 reasons to have indicated the answer above? blunting of costophranic angles flat hemidiaphrams = hyperinflated lungs, we see the inferior border of the heart IMAGE ANALYSIS What pathology do you see in this image? pneumothorax of rt lung Name 2 reasons to have indicated the answer above? lack of lung markings is upper and middle lobe on rt side see the peural visceral line which indicates a collapsed lung IMAGE ANALYSIS What pathology do you see in this image? Name 2 reasons to have indicated the answer above? bronchiectisis, prominent lung markings and cystic honeycomb pattern  CHRONIC BRONCHITIS Treatment: There is no cure for chronic bronchitis Therapy reduce flare-ups & minimize progression of disease Prophylactic antibiotic therapy is used to reduce infections Bronchial dilators reduce spasm & open airways Expectorants assist in keeping the lungs clear All these treatments are designed to improve the symptoms  ASTHMA Common disease in which narrowing of the airways develops because of an increased responsiveness of the tracheobronchial tree to various stimuli (aka allergies) Common allergies are : House dust Pollen Molds Animal dander Fabrics Food (extrinsic asthma) Exercise, heat or cold exposure & emotional upset (intrinsic asthma)  ASTHMA Asthma causes: Swelling of the mucous membranes of the bronchi Severe narrowing Excess secretion of mucus of the airways Spasm of the smooth muscle in the bronchial walls Therefore leads to: Difficulty breathing especially on EXPIRATION Wheezing sound (caused by air passing through the narrowed bronchial tubes Untreated Asthma leads to permanently scarred bronchial structure which can lead to progressive disease  ASTHMA Radiographic Appearance: Early stage demonstrate no abnormalities Acute asthmatic attack - Increased volume of the hyperlucent lungs - Flattening the hemidiaphragms lateral projection - Increase in the retrosternal air space (seen on a _________ projection) early asthma not shown Pulmonary vascular markings remain normal Chronic Asthma with repeated episodes of attacks, can produce interstitial markings & the “dirty chest” appearance know which have dirty chest Most of the X-ray taken in ER are to determine if the asthma lead to a pneumonia  ASTHMA Treatment: Allergy induced Asthma use ꟕ2 stimulants bronchodilators Allergy shots help build natural antibodies Exercise induced Asthma take oral medication to decrease bronchiomuscular spasm Inhaled steroid drugs help to control the inflammatory process & decrease the chances of infections if no image on slide, image not on exam know definitions  BRONCHIECTASIS Permanent abnormal dilation of one or more large bronchi Results in the destruction & muscular component of the bronchial wall Common causes are : Bronchitis (always leads to bacterial infection) Severe necrotizing pneumonia Local or systemic abnormality that impairs the body’s defense mechanisms & promotes bacterial growth Antibiotic Therapy & vaccines have decreased the chances of people getting Bronchiectasis  BRONCHIECTASIS Common symptoms include: Chronic productive cough Acute pneumonia Hemoptysis (______________________) coughing up blood Involves the basal segments of the lower lobes More common to be seen bilaterally Treatment: Vaccines prevent many viral & bacterial infections that cause this disease Therapy to decrease the symptoms Antibiotics (specific to the bacterial cause)  BRONCHIECTASIS honeycomb pattern Radiographic Appearance: Coarseness & loss of definition on interstitial lung markings Advanced disease – cystic spaces/dilations can develop (up to 2cm in diameter) that contain air- fluid levels Severe cases will show areas of dilation resembling a honeycomb pattern similar to emphysema disruption of lung markings