Chest Radiographs Loyola University Stritch School of Medicine

Chest Radiographs Loyola University Stritch School of Medicine Drs. Pierce and Demos Loyola University Medical Center Department of Radiology

Radiographs • • Free Intraperitoneal Gas Pneumothorax Pleural Effusion Pulmonary Edema

Free Intraperitoneal Gas Free Air

Free Intraperitoneal Gas Upright chest Left lateral decubitus abdomen

Free Intraperitoneal Gas Patient Supine

Free Intraperitoneal Gas Neonate with distended abdomen Supine abdomen 58 -year-old man with acute abdominal pain Supine abdomen Free air under right hemidiaphragm Upright abdomen

Free Air in Supine Patient

Free Intraperitoneal Gas • When diagnosis is uncertain - If the patient can stand • Upright chest and abdomen - If the patient can not stand • Left lateral decubitus abdomen radiograph • Most sensitive - Computed tomography

Pneumothorax

Pneumothorax Displaced Visceral Pleura Skin Fold Pneumothorax Displaced pleura (arrows) Skin fold extends outside ribs Look for displaced Visceral Pleura

Tension Pneumothorax TENSION PNEUMOTHORAX ** Examine patient * Look for deviated heart and mediastinum, depressed hemidiaphragm * Compare to previous radiographs

Supine Patient Medial Pneumothorax

Supine Patient Deep Sulcus Sign Before…. No pneumothorax After…. Pneumothorax

Is there a pneumothorax or isn’t there? • Order a Lateral Decubitus chest radiograph - With the side of the chest in question as the upside • Possible left pneumothorax get right lateral decubitus chest > Look for displaced visceral pleura along upside lateral chest wall • Order Upright Expiratory chest radiograph - Look for pneumothorax at lung apex

Pleural Effusion

Pleural Effusion Upright…Meniscus Supine…Unilateral increased density Decubitus…Effusion layered on downside

Pleural Effusion Supine patient

Pleural Effusion Semiupright…. . Lung base opacity fades superiorly 63 -year-old man recovering from congestive heart failure…Effusion loculated in fissure

Massive Pleural Effusion or Total Lung Atelectasis Total Atelectasis Heart and mediastinum shifted toward whited out hemithorax Massive pleural effusion Heart and mediastinum shifted away from whited out hemithorax

Pleural Effusion • Most sensitive way to show pleural effusion - Decubitus chest radiograph • Least sensitive way to show pleural effusion - Supine chest radiograph

Pulmonary Edema

Normal Chest PA and Lateral Radiographs

Pulmonary Edema Normal pulmonary vessels Interstitial pulmonary edema Alveolar pulmonary edema Septal (Kerley B) lines due to interstitial pulmonary edema are thickened interlobular septae

Pulmonary Edema • Interstitial pulmonary edema • - Poorly defined pulmonary vessels - Visible lung fissures - Septal lines - Thick bronchial walls Alveolar pulmonary edema - Bilateral symmetric perihilar lung consolidation • Enlarged heart, Pleural effusion COMPARE TO PREVIOUS RADIOGRAPHS

Left Upper Lobe Pneumonia 27 -year-old man with productive cough, dyspnea, and fever

Monty Python Gumbies