(1) Lung Anatomy

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Lung Anatomy

Right Left

Anterior Posterior

(1)

1. Patient and clinical details2. Technical adequacy

1. Projection2. Inspiration3. Rotation

3. ABCDE1. Airway – position of trachea2. Breathing – lungs3. Circulation – cardiac and mediastinal contours4. Diaphragm – contours and below the diaphragm5. Everything else – lines and tubes

4. Review areas1. Lung apices2. Costophrenic angles3. Behind the heart4. Behind and below the diaphragm

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Approaching a CXR

HistoryA 35-year-old gentleman presents witha fever and cough. He has abackground of HIV and his mostrecent CD4 count was normal.

On examination, he has bronchialbreathing and dull percussion on theleft.

ObservationsHR 101, BP 130/86, RR 22, SpO2 93%,Temp 38.8

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Case-based discussion: 1

PLEASE INSERT IMAGE HERE (if appropriate)

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Question: 1

What radiographic feature is most suggestive of consolidation?

1) Loss of the left heart border2) Ill-defined opacification3) Air bronchograms4) Interstitial shadowing5) Bronchial wall thickening

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Question: 1

What radiographic feature is most suggestive of consolidation?

1) Loss of the left heart border2) Ill-defined opacification3) Air bronchograms4) Interstitial shadowing5) Bronchial wall thickening

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Lung Anatomy

Right Left

Anterior Posterior

(1)

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Lung Anatomy

Right Left

Anterior Posterior

Definition: loss of a normal thoracic contour (e.g. heart border or diaphragmatic border) as a result of pathology that is contiguous with that border.

Useful in lots of contexts!• Lobar collapse• Mediastinal masses• Consolidation

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Silhouette sign

HistoryA 35 year old gentleman presentswith a fever and cough. He has abackground of HIV and his mostrecent CD4 count was normal.

On examination, he has bronchialbreathing and dull percussion on theleft.

ObservationsHR 101, BP 130/86, RR 22, SpO2 93%,Temp 38.8

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Case-based discussion: 1

PLEASE INSERT IMAGE HERE (if appropriate)

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Question: 2

What is the most likely causative organism?

1) SARS-CoV-22) Streptococcus pneumoniae3) Mycobacterium tuberculosis4) Pneumocystis jirovecii5) Staphylococcus aureus

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Question: 2

What is the most likely causative organism?

1) SARS-CoV-22) Streptococcus pneumoniae3) Mycobacterium tuberculosis4) Pneumocystis jirovecii5) Staphylococcus aureus

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HistoryA 30-year-old man presents to theEmergency Department with pleuriticchest pain and shortness of breath.He is usually fit and well however is asmoker.

On examination, he appears dyspneicbut is not in respiratory distress.There is reduced air entry at the leftapex.

ObservationsHR 85, BP 110/80, RR 22, SpO2 95%,Temp 37.3

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Case-based discussion: 2

PLEASE INSERT IMAGE HERE (if appropriate)

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Question: 3

What is the most likely cause for the patient’s clinical presentation?

1) Pneumonia2) Pulmonary embolism3) Spontaneous pneumothorax4) Tension pneumothorax5) Costochondritis

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Question: 3

What is the most likely cause for the patient’s clinical presentation?

1) Pneumonia2) Pulmonary embolism3) Spontaneous pneumothorax4) Tension pneumothorax5) Costochondritis

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PneumothoraxDefinition• Presence of gas within the

pleural cavity

(2)

(3)

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HistoryA 30-year-old man presents to theEmergency Department with pleuriticchest pain and shortness of breath.He is usually fit and well however is asmoker.

On examination, he appears dyspneicbut is not in respiratory distress.There is reduced air entry at the leftapex.

ObservationsHR 85, BP 110/80, RR 22, SpO2 95%,Temp 37.3

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Case-based discussion: 2

PLEASE INSERT IMAGE HERE (if appropriate)

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Question: 4

How should you manage this patient? (Pneumothorax measures 1 cm at the hilum)

1) Pleurodesis2) Aspirate and repeat imaging3) Chest drain insertion4) Observe for 24 hours5) Discharge and review as outpatient

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Question: 4

How should you manage this patient? (Pneumothorax measures 1 cm at the hilum)

1) Pleurodesis2) Aspirate and repeat imaging3) Chest drain insertion4) Observe for 24 hours5) Discharge and review as outpatient

1. Patient and clinical details2. Technical adequacy

1. Projection2. Inspiration3. Rotation

3. ABCDE1. Airway – position of trachea2. Breathing – lungs3. Circulation – cardiac and mediastinal contours4. Diaphragm – contours and below the diaphragm5. Everything else – lines and tubes

4. Review areas1. Lung apices2. Costophrenic angles3. Behind the heart4. Behind and below the diaphragm

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Approaching a CXR

HistoryA 75-year-old man who was admittedearlier in the day with an ischaemicstroke has developed increasingshortness of breath and a cough.

On examination, he appearsdistressed. There are bibasalcrepitations.

ObservationsHR 90, BP 110/80, RR 28, SpO2 95%,Temp 37.8

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Case-based discussion: 3

PLEASE INSERT IMAGE HERE (if appropriate)

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Question: 5

How would you manage this patient?

1) IV antibiotics2) IV diuretics3) Discuss radiograph with seniors/radiology4) Remove NG tube5) None of the above

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Question: 5

How would you manage this patient?

1) IV antibiotics2) IV diuretics3) Discuss radiograph with seniors/radiology4) Remove NG tube5) None of the above

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Question: 6

Which of the following is NOT correct when assessing the position of an NG tube?

1) It is safe to feed a patient through an NG tube with its tip in the duodenum2) The NG tube must bisect the carina3) The tip of the NG tube must be seen below the diaphragm4) It is safe to feed a patient through an NG tube with its tip in the oesophagus5) Measuring the pH of the aspirate is the first-line test

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Question: 6

Which of the following is NOT correct when assessing the position of an NG tube?

1) It is safe to feed a patient through an NG tube with its tip in the duodenum2) The NG tube must bisect the carina3) The tip of the NG tube must be seen below the diaphragm4) It is safe to feed a patient through an NG tube with its tip in the oesophagus5) Measuring the pH of the aspirate is the first-line test

An NG tube must:

1. Pass through the middle of the chest/mediastinum2. It must bisect the carina3. It must cross the diaphragm in the midline4. Its tip must be clearly visible below the diaphragm (10

cm below the GOJ)

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NG Tube Assessment

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HistoryA 57 year-old man presents with acough and weight loss. He is an ex-smoker and uses inhalers for COPD.He attends A&E with worseningshortness of breath.

On examination, he is dyspneic.

ObservationsHR 88, BP 101/78, RR 25, SpO2 87%,Temp 37.1

ABGShows a type 1 respiratory failure

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Case-based discussion: 4

PLEASE INSERT IMAGE HERE (if appropriate)

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Question: 7

What is the most likely cause for the patient’s type 1 respiratory failure?

1) Bronchogenic carcinoma2) Exacerbation of COPD3) Lobar collapse4) Pneumonia5) Heart failure

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Question: 7

What is the most likely cause for the patient’s type 1 respiratory failure?

1) Bronchogenic carcinoma2) Exacerbation of COPD3) Lobar collapse4) Pneumonia5) Heart failure

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Lung Anatomy

Right Left

Anterior Posterior

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1. Patient and clinical details2. Technical adequacy

1. Projection2. Inspiration3. Rotation

3. ABCDE1. Airway – position of trachea2. Breathing – lungs3. Circulation – cardiac and mediastinal contours4. Diaphragm – contours and below the diaphragm5. Everything else – lines and tubes

4. Review areas1. Lung apices2. Costophrenic angles3. Behind the heart4. Behind and below the diaphragm

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Approaching a CXR

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Question: 8

The loss of the left hemidiaphragm in this case is known as which sign?

1) Felson’s sign2) Mach effect3) Luftsichel sign4) Silhouette sign5) Sail sign

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Question: 8

The loss of the left hemidiaphragm in this case is known as which sign?

1) Felson’s sign2) Mach effect3) Luftsichel sign4) Silhouette sign5) Sail sign

Aetiology:• Endobronchial obstruction

• Mucus plug in young asthmatic• Endobronchial carcinoma until proven otherwise in older patient or smoker• Foreign body in children

Radiographic features:• Triangular retrocardiac opacity (sail sign) represents the collapsed left lower lobe• Loss of most of the left hemidiaphragm (silhouette sign) – due to loss of the air-tissue interface• Loss of the left hilum (pulled down due to volume loss)• Tracheal deviation towards the side of the collapsed lung (not seen in this case) which is also

due to volume loss• Increased lucency within the remaining left lung (hyperinflation of the left upper lobe)

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Summary of Left Lower Lobe Collapse

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HistoryA 40-year-old woman who wasadmitted with osteomyelitis in herfoot is due to be discharged with longterm outpatient antibiotic therapy.She has a past medical history of type2 Diabetes Mellitus.

You are are reviewing her mostrecent chest XR with your consultantbefore discharging her.

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Case-based discussion: 5

PLEASE INSERT IMAGE HERE (if appropriate)

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Question: 9

How should you manage the patient?

1) Request a chest CT2) Insert a cannula and discharge patient home for OPAT3) Discharge patient for OPAT4) Insert a chest drain5) None of the above

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Question: 9

How should you manage the patient?

1) Request a chest CT2) Insert a cannula and discharge patient home for OPAT3) Discharge patient for OPAT4) Insert a chest drain5) None of the above

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(4)

HistoryA 31-year-old woman presents to theEmergency Department with acuteshortness of breath and wheeze. Shehas a past medical history of asthma.

On examination, she has awidespread wheeze. Dullness topercussion at the right apex

ObservationsHR 90, BP 110/80, RR 25, SpO2 100%,Temp 37.8

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Case-based discussion: 6

PLEASE INSERT IMAGE HERE (if appropriate)

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Question: 10

Based on the clinical findings and chest radiograph, what is the most likelydiagnosis?

1) Right upper lobe collapse secondary to mucus plugging2) Right upper zone primary lung carcinoma3) Right upper lobe collapse secondary to an endobronchial carcinoma4) Right upper zone pneumonia5) Acute exacerbation of asthma

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Question: 10

Based on the clinical findings and chest radiograph, what is the most likelydiagnosis?

1) Right upper lobe collapse secondary to mucus plugging2) Right upper zone primary lung carcinoma3) Right upper lobe collapse secondary to an endobronchial carcinoma4) Right upper zone pneumonia5) Acute exacerbation of asthma

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Question: 11

Which of the following is not a sign of loss of volume in right upper lobe collapse?

1) Elevation of the right hemidiaphragm2) Decreased spacing between the right ribs3) Right upper zone opacification4) Rightward tracheal deviation5) Elevation of the right hilum

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Question: 11

Which of the following is not a sign of loss of volume in right upper lobe collapse?

1) Elevation of the right hemidiaphragm2) Decreased spacing between the right ribs3) Right upper zone opacification4) Rightward tracheal deviation5) Elevation of the right hilum

1. Deviation of structures:1. Trachea2. Hila3. Mediastinum

2. Elevation of the diaphragm3. Decreased spacing between the ribs

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Signs of volume loss

HistoryA 45-year-old man presents to theEmergency Department with centralchest pain. He is normally fit and wellbut has been taking regular NSAIDsfollowing an injury a month ago.

On examination, the lungs are clear.

ObservationsHR 103, BP 98/62, RR 25, SpO2 94%,Temp 38.1

A blood gas reveals a lactate of 3.2

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Case-based discussion: 7

PLEASE INSERT IMAGE HERE (if appropriate)

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Question: 12

What finding is present on the chest radiograph?

1) Bilateral hilar enlargement2) Pneumoperitoneum3) Right apical pneumothorax4) Left apical pneumothorax5) Widened mediastinum

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Question: 12

What finding is present on the chest radiograph?

1) Bilateral hilar enlargement2) Pneumoperitoneum3) Right apical pneumothorax4) Left apical pneumothorax5) Widened mediastinum

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References

1) By David Richfield and Mikael Häggström, M.D.- Author info- Reusing images, CC BY-SA 4.0, https://commons.wikimedia.org/w/index.php?curid=76719949

2) By OpenStax College - Anatomy & Physiology, Connexions Web site. http://cnx.org/content/col11496/1.6/, Jun 19, 2013., CC BY 3.0, https://commons.wikimedia.org/w/index.php?curid=30148380

3) By BruceBlaus. When using this image in external sources it can be cited as:Blausen.com staff (2014). "Medical gallery of Blausen Medical 2014". WikiJournal of Medicine 1 (2). DOI:10.15347/wjm/2014.010. ISSN 2002-4436. - Own work, CC BY 3.0, https://commons.wikimedia.org/w/index.php?curid=27924395

4) By OpenStax College - Anatomy & Physiology, Connexions Web site. http://cnx.org/content/col11496/1.6/, Jun 19, 2013., CC BY 3.0, https://commons.wikimedia.org/w/index.php?curid=30148288

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