Pulmonary Medicine Blog By Dr Deepu
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Lung
abnormalities mostly present as areas of increased density, which can be divided
into the following patterns:
Consolidation
Atelectasis
Nodule or
mass - solitary or multiple
Interstitial
Less
frequently areas of decreased density are seen as in emphysema or lungcysts.
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Chest X-Ray - Lung disease.
Consolidation
Atelectasis
Nodule
- Masses
Solitary
pulmonary node
Interstitial
pattern
Interstitial
lung diseases will be discussed in coming posts.
Pleura
Pleural
fluid
It
takes about 200-300 ml of fluid before it comes visible on an CXR (figure).
About 5
liters of pleural fluid are present when there is total opacification of the
hemithorax.
Total
opacification of the right hemithorax in a patient with pleuritis carcinomatosa
on both sides.
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On the
right there is only some air visible in the major bronchi creating an air
bronchogram within the compressed lung.
Pleural
fluid may become encysted.
Here we
see fluid entrapped within the fissure.
This
can sometimes give the impression of a mass and is called 'vanishing tumor'.
Pneumothorax
The
table lists the most common causes of a pneumothorax.
The
other cystic lungdisease which causes pneumothorax is Langerhans cell
histiocytosis (LCH) which is seen in smokers.
Study
the CXR.
There
are two important findings.
The
retracted visceral pleura is seen (blue arrow) which indicates that there is a
pneumothorax.
There
is a horizontal line visible (yellow arrow).
Normally
there are no straight lines in the human body unless when there is an air-fluid
level.
This
means that there is a hydro-pneumothorax.
When a
pneumothorax is small, this air-fluid level can be the only key to the
diagnosis of a pneumothorax.
Study
the CXR.
There
are 3 important findings.
Notice
that the mediastinum is slightly displaced to the left.
Does
this mean that there is a tension pneumothorax?
Do you
have an idea about the cause of the pneumothorax?
There
is a hydropneumothorax.
Notice
the air-fluid level (blue arrow).
The
upper lobe is still attached to the chest wall by adhesions.
Maybe
this patient was treated for a prior pneumothorax.
There
is a lung cyst in the upper lobe (red arrow).
So we
can assume that the pneumothorax has something to do with a cystic lung
disease.
Since
this patient is a woman, lymphangioleiomyomatosis (LAM) is a possible
diagnosis.
LAM is
a rare lung disease that results in a proliferation of smooth muscle throughout
the lungs resulting in the obstruction of small airways leading to pulmonary
cyst formation and pneumothorax.
LAM
also occurs in patients who have tuberous sclerosis.
Study
the CXR.
What is
your diagnosis?
This is
not a pneumothorax but a skin fold.
The
radiography was performed supine with a CR cassette inserted underneath the
patient, which resulted in a skinfold.
Notice
that there are lung markings beyond the apparent pneumothorax.
Here
two CXRs of another patient with obvious skinfolds.
Recognition
of a pneumothorax depends on the volume of air in the pleural space and the
position of the body.
On a
supine radiograph a pneumothorax can be subtle and approximately 30% of
pneumothoraces are undetected.
A sign
to look for is the 'deep sulcus sign'.
It
represents lucency of the lateral costophrenic angle extending toward the
hypochondrium (Figure).
The
image is of a patient in the ICU who is on mechanical ventilation. There was an
acute exacerbation of the dyspnea.
There
is a deep sulcus sign on the left
Notice
that the left hemidiaphragm is depressed.
This is
an important finding since it indicates a tension pneumothorax.
The
image on the below is after insertion of an intercostal drain.
Notice
that the diaphragm has regained its normal appearance.
Pleural
opacities
The
table lists the most common causes of pleural opacities.
Pleural
plaques
The CXR
shows multiple opacities.
They
have irregular shapes and do not look like a lung masses or consolidations.
Some of
these opacities are clearly bordering the chest wall (red arrows).
All
these findings indicate that we are dealing asbestos related pleural plaques.
Asbestos
related pleural plaques are usually:
bilateral
and extensive.
covering
the dome of the diaphragm.
Unilateral
pleural calcifications are usually due to:
infection
(TB)
empyema
hemorrhagic
Pleural
hematoma
These
images are of a patient, who had a pleural opacity after a chest trauma.
It was
believed to be a hematoma and resolved spontaneously.
Chest
wall
Ribfractures
The
most common identified chest wall abnormalities are old ribfractures.
The CXR
shows many rib deformities due to old fractures.
When a
rib fracture heals, the callus formation may create a mass-like appearance
(blue arrow).
Sometimes
a CT is necessary to differentiate a healing fracture from a lung mass.
Notice
the large lung volume and the enlarged pulmonary vessels.
Probably
we are dealing with pulmonary arterial hypertension in a patient with COPD.
The
second most common chest wall abnormalities that we see on a CXR are metastases
in vertebral bodies and ribs.
Notice
the expansile mass in the posterior rib on the right.
Abdomen
The
most obvious finding on this CXR is free air under the diaphragm.
This
finding indicates a bowel perforation, unless when the patient had recent
abdominal surgery and there is still some air left in the abdomen, which can
stay there for several days.
There
is another subtle finding in the left upper lobe.
A
subtle density projecting over the first rib - hidden area - proved to be a
lungcarcinoma.
Here
another patient with free abdominal air.
Notice
the very thin regular line which is the diaphragm (arrow).
At
first impression one might think that this is just some plate-like atelectasis
due to poor inspiration.
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