RADIOLOGY

3. Chest radiographs on the same patient few minutes apart showing the
effect of technique; the left image shows medistinal widening and basal
cloudning due to poor inspiratory effort

4. (posterioranterior) position.
Note that the x-ray tube is 72 inches away.
the supine AP (anteriorposterior) position
the x-ray tube is 40 inches from the patient.

6. 1-tubes
2-lines
3-air in chest
4-fluid in chest
5-vascular pedicles

8.  1.Pneumonia
 2.Lung collapse due to mucous
impaction
 3.Malposition of endotracheal tube.
 4.Fluid extravasation.

9. 1.Pneumonia
2.Lung collapse due to mucous
impaction
3.Malposition of endotracheal
tube.

10.  To check it is in the right position
 To check for complications of placement
of the tube/line

11. •Endotracheal tube
•Nasogastric tubes
•Intercostal chest drains

12.  Uses:
› Assisted ventilation
› To secure airway
The tip should lie between the clavicles,
at least 5cm above the carina

13. Dee method for approximating the position o f t he carina can be
used.
This involves defining the aortic arch and then drawing a line
Infer omedially through the middle of the arch at a45 degree

14. The Ideal position for endotracheal tubes is in the
mid trachea, 5cm from t he carina, when the head is
neither flexed nor extended. This allows for
movement of the tip with head movements. The
minimal safe distance from the carina is 2cm.

15.  Tube too far advanced
› Typically, within right main stem bronchus
 Placement within oesophagus
 Tracheal perforation

16. Tip of ET tube in right
main stem bronchus.
The patient is at risk of
left lung collapse

19.  Uses:
› Decompression of dilated stomach
› Administration of medication / nutritional support
The tip should lie below the diaphragm with at
least 10cm lying within the stomach

20. The tip should
lie below the
diaphragm
coiled within
the stomach

21. Tip of tube
Note that this patient also has
small bilateral pleural
effusions

22. Frontal(A) and lateral (B) radiographs of the neck
show An tube(arrow) coiled in the upper esophagus
with its tip in the oropharynx(arrowhead)

24. •Generally a chest x-ray is not necessary
following the placement of a nasogastric
tube.
•Feeding tubes are generally placed into the
proximal small bowel, as confirmed by an
abdominal film.
•A chest x-ray may be obtained following
the insertion of small-bore feeding tubes to
rule out placement within the lung, which
may have serious consequences

25.  Commonest (and most dangerous) is
placement within bronchial tree
› This can be FATAL if NG feeding occurs into the
lung
 Perforation of oesophagus is rare
Be suspicious of a misplaced NG tube if the patient is
extremely uncomfortable during tube insertion with
severe coughing

26. Frontal radiograph of the chest shows a NG tube forming
a loop in the left bronchus(arrow) before the
tip(arrowhead)reaches the right lower lobe bronchus

27.  These are used to remove fluid or air within the
pleural space
 Main indications for insertion
› Pneumothorax
 Tension
 Simple pneumothorax unresponsive to
aspiration
 Pnemothorax in a patient with chronic lung
disease
› Drainage of pleural fluid
 Pleural effusion
 Haemothorax

28.  This depends on why the drain is being
inserted:
› Pneumothorax
 Towards lung apex (superiorly)
› Pleural fluid drainage
 Towards cardiophrenic border (inferiorly)

29. This patient has bilateral
chest drains, inserted
following pneumothoraces
secondary to rib fractures.
Note surgical
emphysema. Both drains
lie towards the apex, but
the left drain is coiled and
should be withdrawn a
little.
The pneumothoraces are
not visible on this film.

30.  These mostly occur with drain placement
› Pain, damage to neurovascular bundle
› Trauma to liver, spleen, lung
› Drainage ports
 These must lie within the
chest or there is a risk of
surgical emphysema and
drain failure
Drainage hole correctly sited
within chest

31. Chest x-ray showing malpositioned intercostal
drainage tube in a case of pneumo-thorax
with collapse on right side

32. Chest x-ray showing malpositioned intercostal drainage tube in a case of
pleural effusion on left side

33. Chest X-ray showing malpositioned intercostal
drainage tube in a case of hydro-pneumothorax on the
left side

34. •Central venous catheters
• pulmonary artry catheter
•Cardiac Pacemaker

35.  Uses:
› Rapid fluid replacement
› Monitoring of central venous pressure
› Administration of some drugs
 May be inserted from either subclavian or
internal jugular vein
The tip should lie within the superior vena cava

36. Lateral to thoracic spine, inferior to medial end of
right clavicle
igures copyright Primal Pictures 1993

37. Lateral to
thoracic
spine,
inferior to
medial end
of right
clavicle

39. Ideally the catheter tip should lie between the
most proximal venous valves of the
subclavian or jugular veins and the right
atrium.
How far from the brachiocephalic vein are
these valves?
•1. 15 cm
•2. 10 cm
•3. 5 cm
•4. 2.5 cm

40. Ideally the catheter tip should lie
between the most proximal venous
valves of the subclavian or jugular
veins and the right atrium.
How far from the brachiocephalic vein
are these valves?
• 15 cm
• 10 cm
• 5 cm
•2.5 cm

41. The tip of the line should be distal
to the last venous valve,which is
located 2.5cm from the j unction of
the internal jugular and the
subclavian veins.
On the CXR, the position of the
valve correspond s to the inner
aspect of the first rib.

42. Many central venous lines have two or
three lumens,each with adifferent orifice.If
the tip of the line is positioned in the
superior vena cava all orifices will bedistal to
the lastvalve.
On the CXR,the first anterior
intercostal space corresponds to the
approximate site of the junction of the
brachiocephalic veins to form the
superior vena cava

43. On the CXR, the cavo atrial junction
correspond s to the lower border of
bronchus intermedius.
If the line tip reaches the right atrium,it can
caused bys arhythmia or result in injection of
undiluted toxic medications into the heart.

45. Right internal jugular venous
line in good position (red
arrow)
The tip of this left internal
jugular venous line lies at
the origin of the SVC (green
arrow)

46. A central venous line inserted into
the right subclavian vein has
passed up into the right internal
jugular vein

47. Left internal jugular venous line. The tip lies too inferiorly,
within the right atrium (white arrow) and should be withdrawn
to the SVC (green arrow)

48. Frontal chest radiograph following placement of a central
venous catheter shows right paratracheal soft tissue with
abulging contour(arrows),due to mediastinal hematoma.

49. Frontal chest radiograp h shows an abnormally
medial course of the catheter(arrows)in acase of
inadvertent carotid cannulation

50.  This may be performed following cardiac
surgery and in patients with severe
cardiac / pulmonary dysfunction
 The approach is usually via the right
internal jugular vein
 The catheter passes through the SVC, the
right atrium, the right ventricle and the tip
lies within a pulmonary artery

51. The tip of the pulmonary
artery wedge pressure
catheter lies within the
right pulmonary artery
This patient has had
recent cardiac
surgery (note
sternotomy wires)

52. What other lines can you
see?
Answer next slide…

53.  Used to treat conduction abnormalities
 Pacemakers may be single chamber (pacing
lead embedded in right ventricular wall) or dual
chamber (second lead embedded in right atrial
wall)
 They are usually inserted via subclavian veins

54. Pacemaker
Pacing leads in
left subclavian
vein
Leads in superior
vena cava
Right ventricular
lead
Right atrial lead
Note that there are no sharp bends in the leads

55.  At insertion:
› Pneumothorax
› Vascular trauma
› Cardiac wall puncture
 Delayed
› Lead migration
› Lead fracture

56. This patient had a
single chamber
pacemaker inserted
several years ago,
but the pacemaker
no longer works.
Can you tell why?

57. The ventricular lead has
become detached and
now lies coiled within the
right atrium. It should lie
in the region of the red
circle

58. 1-tubes
2-lines
3-air in chest
4-fluid in chest
5-vascular pedicles

59. In the supine patient, intr apleural air rises
anteriorly and medially, often making the diagnosis
of pneumothorax difficult.
The anteromedial and subpulmonary locations are
the initial areas of air collection in the supine
patient.
An apical pneumothorax in a supine patient is a
sign that a large volume of air is present.
Subpulmonic pneumothorax occurs when air
accumulates between the base of the lung and the
diaphragm.

60. Notice the increased lucency of the cardiophrenic sulci in this patient with l
inferior anteromedial pneumothoraces. A CT scan confirms the diagnosis

61.  a hyperlucent upper
quadrant with
visualization of the
superior surface of the
diaphragm and
visualization of the
inferiorvena cava.
 double-diaphragm sign

62.  Antero lateral air may
increase the
radiolucency at the
costo phrenicsulcus.
This is called the deep
sulcus sign.

63.  Apicolateral
pneumothorax
(arrows) with right
upper lobe collapse
(arrowheads)

64.  shifting of the heart border,
 the superior vena cava, and
the inferior vena cava.
 The shifting of these structures
 can lead to decreased venous return.

65. •Mediastinal shifT is usually
seen in a tension
pneumothorax.
• The use of PEEP may
prevent this from occurring.
•The most reliable sign of
tension pneumothorax is
depression of a hemidiaphragm.

66. •A tension pneumothorax In the ICU patient is a
clinical diagnosis based on ventilatory and cardiac
compromise.
Radiographically, a tension pneumothorax
In an ICU patient can b e an extremely challenging
diagnosis.
Parenchymal disease such as ARDS may reduce
lung compliance such that to lung collapse in the
face of a tension pneumothorax may not occur

67.  In the intubated patient the most likely source of
air in the mediastinum is pulmonary interstitial
air dissecting centripetally.
 Air in the mediastinum may also originate from
tracheobronchial injury or air dissecting through
fascial planes from the retroperitoneum.
 A sudden increase in thoracic pressures (e.g.
blunt trauma) may also cause alveolar rupture
and consequently pneumomediastinum

69. The lucent stripe on the inferior border of the heart is
indicative of pneumopericardium

71. •Notice the lucencies around the great vessels and superior vena cava seen on
both AP chest film (left) and CT (right).
•Patients with posteromedial pneumomediastinum (usually due to esophageal
rupture) may have dissecting air at the paraspinal costophrenic angle and beneath
the parietal pleura of the left diaphragm. This is called the V-sign of Naclerio.

72. The ches t Xray is als o not always
Useful for the diagnosis of a
pneumothorax in a ventilated patient
in the ICU.
In such a patient the air in the pleura l
space tends to accumulate anterior to
the lung in the supine position,causing
it not to be seen on an AP view X-ray.

73. In addition, mechanically ventilated lungs do
not collapse even in the presence of a
pneumothorax.
For these reasons ,X-rays have a sensitivity
of only53% in detecting pneumothoraces
In such critically ill patients as compared to
the gold standar CT

74. Ultrasound compares favourably with CT
scan in the diagnostic ability for some
disease conditions ,most prominently
pneumothorax, where it has a sensitivity of
92%compared to CT.
For these reasons,ultrasound is fast
becoming an essential part of the chest
imagin garmamentarium in the ICU

75. Algorithm for the ultrasound diagnosis of
pneumothorax

76. Lung sliding

78. B lines

80. The granular pattern below the pleural line in the left half of the picture is lung
parenchyma, while the horizontall ines above it indicate the chest n

81. 1-tubes
2-lines
3-air in chest
4-fluid in chest

82. •The appearance of apleural effusion on a
chest film is largely Dependent on the
position of the patient.
Fluid in the chest cavity will accumulate in
the dependent areas of the chest.
This makes idenitifing small
collections extremely difficult ,especially in t
the supine patient.

83. Fluid in the posterior basilar space appears
as an homogenous graded increase in the
density of the lung base,maximal inferiorly.
The normal bronchovascular markings are
not lost.
As the amount of fluid increases ,the
diaphragmatic contour and lateral
costophrenic sulcus may be obliterated.

84. This patient has
large bilateral
effusions; notice
the density
gradient in each
lung field

85. Bilateral pleural effusions in a supine
patient. This film demonstrates fluid in
the posteriorbasilar space without loss of
normal bronchialmarkings.

86. A large pleural effusion may appear as a pleural
cap with fluid occasionally collecting on the
medialside ,appearing as a widened mediastinum.

87. How much fluid must accumulate before
you expect to see changes in the supine
patient's chestx-ray?
1.5 ml
2.50 ml
3.>500 ml

88. How much fluid must accumulate before
you expect to see changes in the supine
patient's chestx-ray?
1.5 ml
2.50 ml
3.>500 m

89. How much fuid must collect before costo
phrenic blunting is visible in the erect
patient?
1.20 ml
2.50-75 ml
3.100-200ml
4.>500ml

90. How much fuid must collect before costo
phrenic blunting is visible in the erect
patient?
1.20 ml
2.50-75 ml
3.100-200ml
4.>500ml

91. Howmuchfuidmustcollectbeforecostoph
renicbluntingisvisibleintheerectpatient?
1.20 ml
2.50-75 ml
3.100-200ml
4.>500ml
This Pa chest film of an erect patient shows a large
Pleural effusion on the right. Even an effusion this size may
be difficult to detect in a supine film.

92. Pleural fluid (arrows) layers out on this left
lateral decubitis film.

99. The most common cause of lung opacity in an ICU
patient.
There is an increased incidence after general
anesthesia and thoracic/upper abdominal surgery.
The incidence is also increased in patients with pre-
existing lung disease, smokers, obese patients,
and the elderly.
The left lower lobe is the most common location.

100. Radiographically, atelectasis may vary
from complete lung collapse to relatively
normal-appearing lungs
Mild atelectasis usually takes the form of
minimal basilar shadowing or linear streaks
(subsegmental or "discoid" atelectasis) and
may not be physiologically significant.
. lobe follows when collapsing.

101. •Atelectasis will often respond to increased ventilation, while
pneumonia, for example, will not.
•Crowding of vessels, shifting of structures such as interlobar
fissures towards areas of lung volume loss and elevation of
the hemidiaphragm suggests atelectasis.
• Another key for distinguishing between atelectasis and
consolidation is recognition of the typical patterns that each
pulmonary

102. Left lower lobe atelectasis with lost of the
hemidiaphragmatic shadow (arrows).

103. The arrows point to the horizantal fissure. Notice the normal
position of the pulmonary arteries in this patient.

104. Right middle lobe atelectasis is difficult to detect in the AP film (left). The lateral (right),
though, shows a marked decrease in the distance between the horizontal and oblique
fissures.

105. •The result is predominantly anterior shift of the upper lobe in
left upper lobe collapse,
• loss of the left upper cardiac border.
• The expanded lower lobe will migrate to a location both
superior and posterior to the upper lobe in order to occupy the
vacated space.
• The left mainstem bronchus also rotates to a nearly horizontal
position.

106. left upper lobe atelectasis following right upper lobectomy

107. In a supine patient who has aspirated, where are the
common locations of pneumonia?
1-Posterior segment of upper lobe
2-Superior segment of lower lobe
3-Basilar segment of lower lobe
4-Apex

108. pneumonia first appears as
• patchy opacifications or ill-defined nodules.
• multifocal and bilateral,
•often in the gravity dependent areas of the lung
.
 E-coli and pseudomonas species can rapidly
involve the entire lung. Their symmetric pattern often
simulates pulmonary edema.
The presence of patchy air space opacities, air
bronchograms, ill-defined segmental consolidation or
associated pleural effusion support the diagnosis of
pneumonia.

109. patchy infiltrate obscurring the right heart border is a common radiographic
presentation of right middle lobe pneumonia (left). Following treatment with
intervenous antibiotics the pneumonia resolved (right).

110. Aspiration is very common in ICU patients.
Aspiration and its consequences can be divided
into 3 forms:
1- Aspiration pneumonitis,
2- aspiration pneumonia,
3- obstruction of a central airway.
• The severity of aspiration is related to the
volume and type of the aspirate.

111. This patient suffered a witnessed aspiration during intubation. This film was
taken 24 hours later. Note the patchy infiltrates maximal at the left base.

112.  Aspiration of gastric acid is also known
as Mendelson's Syndrome, it is the most
common type of aspiration.
 The degree of irritation to the lung is directly
dependent on the acidity and volume of the
aspirated fluid.
 The lung responds to pH < 2.5 with severe
bronchospasm and the release of
inflammatory mediators. The initial result is a
chemical pulmonary edema.

113. These include
•discoid atelectasis,
•elevation of the hemidiaphragm,
•enlargement of the main pulmonary artery
"sausage" or a "knuckle" (Palla's sign),
•pulmonary oligemia beyond the point of
occlusion (Westermark's sign). Occasionally,
pulmonary embolisms will cause
• infarction causing a unique constellation of
radiographic signs.

114. The red arrow points to a consolidation, known as Hamptom's hump,which is associated
with pulmonary infarction.

116. Oligemia (Westermark's sign)
Increase in hilar vessel size with abrupt tapering(Knuckle
sign) Volume loss

118. •Features that are helpful in distinguishing
CHF from ARDS include the following:
•cardiogenic pulmonary edema typically
begins centrally in the bilateral perihilar areas,
• Pleural effusions are not typical of ARDS but
often present in CHF.
•Kerley B lines are common in CHF but not in
ARDS,

119. •cardiogenic edema may clear rapidly, ARDS typically
clears slowly.
• cardiogenic edema, which, once resolved, does not
leave behind permanent pulmonary changes.
• ARDS cases will result in some degree of permanent
pulmonary fibrosis,

120. ‫اله‬ ‫ال‬ ‫ان‬ ‫اشهد‬ ‫بحمدك‬ ‫و‬ ‫اللهم‬ ‫سبحانك‬‫اال‬‫اليك‬ ‫اتوب‬ ‫و‬ ‫استغفرك‬ ‫انت‬