1. Chest Radiology in Intensive Care Medicine Dr. Andrew Ferguson MEd FRCA DIBICM FCCP Assistant Professor, Medicine (Critical Care) & Anesthesia Dalhousie University

3. Radiographic anatomy Or LA NOTE In spite of what you May have heard… The right heart border Is formed by left atrium in up to 38% of patients AV TV MV

6. Silhouette Sign Lobe Silhouetted structure Right middle lobe Right heart border Left lingula Left heart border Right lower lobe Right hemidiaphragm Left lower lobe Left hemidiaphragm Post apical segment left upper lobe Aortic knob Ant segment right upper lobe Ascending aorta

11. Pleural effusions

15. Pulmonary Oedema

17. Left atrial pressure & CXR signs

18. < 10% of cases of pulmonary oedema, usually in rapid onset oedema e.g. acute MR

19. Kerley B lines

20. Peribronchial Cuffing May be normal finding if right at hilum

22. Vascular Pedicle Width in Pulmonary Oedema

23. Martin, G. S. et al. Chest 2002;122:2087-2095 Landmarks for measurement of VPW and CTR on a routine CXR

24. Vascular pedicle width and fluid status in pulmonary oedema

25. Using Vascular Pedicle Width

26. VPW/CTR as predictor of PCWP > 18 Criteria Sensitivity Specificity PPV NPV Odds ratio VPW > 70 & CTR > 0.55 54% 83% 76% 65% 3.2 VPW > 70 69% 72% 70% 72% 2.5 CTR > 0.55 63% 50% 56% 57% 1.3

27. Lobar anatomy and collapse

28. Lobar anatomy & collapse

29. RUL collapse

30. RML collapse Indistinct right heart border

31. RLL collapse Fissure may be visible Sail-like line behind right heart plus indistinct diaphragm

32. LUL Collapse Lufsichel sign = Aerated superior segment of left lower lobe interposes between collapsed upper lobe and mediastinum producing lucency around aorta

33. LLL collapse Sail-like line behind heart – occasionally seen as extremely straight heart border

34. Total collapse

37. Pulmonary Interstitial Emphysema

40. Continuous diaphragm sign

41. Naclerio’s V sign Lucent band of gas extending along descending aorta and intersecting band of gas that extends along medial left hemi- diaphragm, together forming “V’

42. Double bronchial wall sign Air on both sides of bronchial wall makes full wall visible

43. “ Ring around the artery” sign Air around pulmonary artery

44. Tubular artery sign Air outlining left subclavian & left carotid

45. Thymic sail sign Thymus outlined by air Also air tracking up into neck

46. Extrapleural air e.g. pleura peeled off diaphragm

47. Mediastinal air

48. Mediastinal air running parallel to descending aorta

49. Pneumomediastinum vs pneumothorax

50. Pneumomediastinum vs pneumocardium

51. Pneumopericardium

52. Pitfalls – Mach band effect “ The Mach band effect is associated with convex surfaces, appearing as a region of lucency adjacent to structures with convex borders. The absence of an (associated) opaque line, which is typically seen in pneumomediastinum, can aid in differentiation ” Zylak C. Pneumomediastinum Revisited. Radiographics 2000; 20: 1043-1057.

54. “ Occult” pneumothorax Crisp cardiac silhouette with increased lucency

55. Occult pneumothorax II Cardiophrenic sulcus highly visible Crisp heart border

58. Double diaphragm sign

60. Posteromedial Pneumothorax

61. Subpulmonic pneumothorax Deep sulcus, lucent RUQ Rankine, J. J et al. Postgrad Med J 2000;76:399-404

62. Anteromedial pneumothorax Sharp outline of mediastinum and right heart border. Right hemithorax has concurrent consolidation and effusion Rankine, J. J et al. Postgrad Med J 2000;76:399-404

63. Mimics - Skin fold

64. Subcutaneous emphysema

65. Lines, tubes and drains

67. British Journal of Anaesthesia 2006 96(3):335-340

68. Catheter tips abutting SVC wall – risk of perforation

70. Malposition – subclavian line into jugular vein

71. Images to review

72. Asthma + diversion + peribronchial cuffing

73. Right Haemothorax with bullet

74. LUL collapse + LLL collapse

75. Linear (plate) atelectasis + small bowel obstruction

76. Bilateral hilar enlargement - lymphoma

77. Bilateral cavitating lesions with fluid levels - Staph abcess

78. Chilaiditi's syndrome – colon interspersed between liver/spleen and diaphragm

79. Deep sulcus sign – left pneumothorax

81. Diffuse alveolar haemorrhage

82. Node in aortopulmonary window

83. Fluid level behind heart – hiatus hernia

84. Silicone breast implants

85. Pneumothorax - blocked chest drain

86. Subcutaneous emphysema, LIJ CVC tip position poor

87. Residual haemothorax on left with chest tube and LLL collapse/consolidation + air bronchogram: haemothorax on right. Oesophagus displaced to left