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Chest Xray - Technique and Pathology

PDY In-Service Presentation 2014
by

Katrina O'Keefe

on 12 August 2016

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Transcript of Chest Xray - Technique and Pathology

WHY
X-RAY??
Film Assessment
P -
A -
C -
M -
E -
N -
A -
B -
C -
D -
E -
F -
Positioning
Anatomy
Collimation
Marker
Exposure
'Nametag'
Airways
Bones
Cardiac silhouette
Diaphragms
Expanded lungs
Foreign bodies
A systomatic approach to assessing CXRs for Pathology
Good for Assessing the quality of a film
Common Pathologies In ICU
Adult Respiratory Distress Syndrome - ARDS
Nosocomial (hospital acquired) pneumonia
Atelectasis - sometimes a side effect from mechanical ventilation
Pulmonary Oedema - Cardiogenic and Non-Cardiogenic
Pneumothorax
Radiographic Signs
Differing Lung Opacities
Fissure Location and Opacity
Heart/Mediastinal Shadows
Visualisation of Costophrenic Angles
Signs of Pulmonary Oedema eg Kerley B lines
Differing Lung Opacities
Lung Fissures
Pulmonary Oedema
Cardiogenic Pulmonary Oedema
Fluid build up in lung Interstitium OR in alveolar spaces
Frequently seen, causes oxygen de-saturation in ICU patients.
Broadly divided into Cardiogenic and Non-Cardiogenic
Results from poor cardiac function.
Radiographic Signs include:
of large pulmonary vessels
Interlobar septal thickening
Bronchial wall thickening
Enlargement
Septal Lines
represent fluid in septae and lymphatics
Diffuse reticular pattern
Non-Cardiogenic Pulmonary Oedema
Topical Causes:
Acute Glomerulonephritis
Fluid Overload
Aspiration
Inhalation Injury
Adult Respiratory Distress Syndrome (ARDS)
Caused by:
Pulmonary vasoconstriction and increased vascular pressure microvascular injury and pulmonary capillary leak
Pulmonary Oedema
"Batwing" Sign
Septal Lines
Also known as Kerley B Lines
Caused by fluid between the secondary lobules of the lungs.
A difficult sign to notice, but once spotted, pulmonary oedema is almost always the cause, especially in patients with cardiac histories.
Air Space Consolidation vs Interstitial Consolidation
POP QUIZ!
Congestive Cardiac Failure
Pneumothorax - Signs on Supine Radiographs
Sign
Description
Etched Diaphragm
Diaphragm contrasted with air in pleural space.
Etched Mediastinum
Mediastinum contrasted with air in pleural space
Deep Sulcus Sign
Abnormally prominent/deep costophrenic angle.
Visible visceral pleura
Most often seen as 'double diaphragm' appearance.
Mediastinal Shift
May indicate pneumothorax under tension - same as erect imaging
Uneven Lung Density
Affected lung may appear more translucent - or more OPAQUE in hydro-pneumothorax
Absent Lung markings
Usually occurs in presence of other signs
Erect vs Supine
Radiographic Signs
Uneven Lung Opacity
Etched Diaphragm
Deep Sulcus Sign
Radiographic Signs
Etched Mediastinum
Etched Diaphragm
Radiographic Signs
Visible Visceral Pleura?
POP QUIZ!!
GRID CUT-OFF!!!
Our Responsibilities?
AIR Guidelines for Professional Conduct -
1. "The prime concern of radiographers shall be for the Welfare and Safety of Patients".
4. "Radiographers, recognising their responsibility to the patient, should alert medically significant findings to the medical personnel responsible for the patient's treatment and at the request of such personnel may provide an opinion that lies within their knowledge and expertise."
1.
2.
3.
4.
5.
6.
Differing Lung Opaticies
Mediastinal Shift
Lt Clavicle #
Lt Scapula #
Etched Mediastinum
Deep Sulcus Sign
Pulmonary Contusion
7.
Thank you!!
Relatively Inexpensive
Quick
Gives diagnostic information
Relieves pressure on emergency clinicians
or IMACREAP
Line and Drain placement
ARDS
PNEUMONIA/CONSOLIDATION
PULMONARY OEDEMA
PNEUMOTHORAX
Differing Lung Opaticies
Fissure Visibility/Displacement
Changed appearance of Mediastinal Shadow
Change to Costophrenic Angle
Consolidation (fluffy or reticular)
What's ARDS???
Acute Onset
Bilateral Infiltrates on CXR
Increased Pulmonary Arterial Wedge Pressure
Caused by DIRECT or INDIRECT lung injury
Pneumonia
Aspiration of gastric content
Inhalational Injury
Sepsis
Cardiopulmonary Byass
Overdose
Blood product Transfusion
Consolidation vs Collapse
Fluid into Alveola - no mechanism to remove it!
Tips for Mobile CXR
Need to be good quality to ensure diagnostic quality and avoid repeats.
Positioning
Erect
Positioning - FFD
Erect
Collimation
Exposure
Erect
Supine
Supine
Supine
Watch for lines and drains, avoid extubation
Take the same approach each time.
Be careful of machines (ECMO, VAD, balloon pumps etc).
Seek assistance from team - Communication
FULLY erect or do it Supine.
Lower pt, move up bed, then sit up again.
Angle to the sternum - be careful of grid.
Only when Erect not possible.
Sliders available - ward mobiles
Be careful of Grid.
No Angle to sternum.
180cm on CR
150 - 180cm on D'Art
Minimal Angle on D'Art (re-position patient).
At least 130cm
At < 150cm on D'Art you will get cut-off
Bed lowered to floor (ask for nurse assistance).
Use the Tape Measure!!
110kVp for Grid
Reduce to 85kVp for non-grid
? Patient size
CR Average 4mAs
CR Average 2.5mAs
Reduce Exposure for DR
Image Assessment
First check patient identification
Check position - Supine v Erect
Check lines, drains, artefacts
Check for Pathology
Inform Clinician
After checking for Image quality....
Lines/Drains
Endotracheal Tube (ETT)
Nasogastric Tube (NGT)
Orogastric Tube (OGT)
Tracheostomy Tube
Intercostal Catheter (ICC)
Central Venous Lines (CVL)
Swan Ganz Catheters
Pacemaker / Implantable Cardioverter-Defibrillator Leads
NGT/OGT
ICC
Antero-superior placement for Pneumothorax.
Postero-inferior placement for effusion.
No kinks at thoracic margin.
CVL
Tip should be in SVC/RA junction.
PICC, Portacath, Permacath etc.
Brachial/Cephalic, Subclavian, or internal jugular approach.
Swan-Ganz Catheter
Right atrium -> Right Ventricle -> to main Pulmonary Artery.
Measures 'wedge' pressure.
PM / ICD
Manage arrhythmias
Draw the following lines:
PICC line
Central Venous line (R internal jugular access)
Endo-tracheal tube
Naso-gastric tube
ETT
4cm above Carina
Can move up to 2cm with flexion/extension
Lightbox Radiology 2013

Weird

and

Wonderful!
>10cm beyond gastro-oesophageal junction
Defibrillate dangerous rhythms
Opacity with NO Air bronchograms
Volume Loss (-ve Mass effect)
Displacement of Fissure/Hilum/Mediastinum
Elevation of Hemi-diaphragm
Airspace/Alveolar vs Interstitial
(coming up soon!)
Causes:
Pus = pneumonia
Blood = contusion
Fluid = oedema, ARDS
Cells = Alveolar cell Carcinoma
2 Slide sheets
Kids
PA/AP
Kids
Equipment
Factors to consider:
Location (upper vs lower)
Location (Anterior, posterior or axilliary)


Naming & orientation convention?
Departmental standard?
Rib Views
Rib Views
Rib Views
Sterno-clavicular Joints (SCJ)
CT
PA oblique (both sides)
Rockwood's (Serendipity view)
Sternum
PA CXR and Lateral Sternum
CXR assessment tools
Tips for good CXRs and Mobiles (paeds + adult)
Common ICU pathologies
Rib Views
Sternum/SC Joints
Lines/Drains
Practice Images
Positioning
Collimation
Movement
Exposure
Artefact
Inspiratory effort
Modified CXR
AP Erect and Supine
Mobile: is it clinically indicated?

Aim: comparable to department film

To grid or not to grid?

Up or down?

Infection control precautions

Radiation Hygeine
Can't sit or stand
On Oxygen
On monitoring/unstable
ICU/Ventilated
Unwell patient
Take your time
Full transcript