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Reading chest radiographs in the critically ill (Part I): Normal chest radiographic appearance, instrumentation and complications from instrumentation.

Khan AN, Al-Jahdali H, Al-Ghanem S, Gouda A - Ann Thorac Med (2009)

View Article: PubMed Central - PubMed

Affiliation: Department of Medicine and Medical Imaging, King Saud University for Health Science, King Abdulaziz Medical City, King Fahad National Guard Hospital, Riyadh, Saudi Arabia. drkhan1966@msn.com

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Interpreting chest radiographs of the critically ill patients who are in intensive care units (ICUs) poses a challenge not only for the intensive care physicians but also for the radiologist... Instrumentation, mechanical ventilation, cardiac and other vital sign monitoring and feeding tubes, etc., detract from other findings on the ICU chest radiograph... Radiologists/Intensive care physicians are under pressure for rapid interpretation of chest x-rays when treating critically ill patients, often with inadequate clinical information, partly due to the fact that things can change rapidly in the critically ill... Current recommendations from the American College of Radiology suggest that daily chest radiographs be obtained on patients with acute cardiopulmonary problems and those receiving mechanical ventilation... Placing the tip at this level allows for flexion or extension of the head... The minimal safe distance from the carina is 2 cm... ICU patients with cardiac arrhythmias or a heart block may require temporary cardiac pacemakers... This is called the deep sulcus sign... Other features of a subpulmonic pneumothorax include visualization of the superior surface of the diaphragm and the superior part of the inferior vena cava... A posteromedial pneumomediastinum is usually the result of esophageal rupture, where air dissects into the paraspinal costophrenic angle and beneath the parietal pleura of the left diaphragm... The result is a V-shaped lucency called the V-sign of Naclerio... A pneumopericardium refers to an accumulation of gas/air between the myocardium and pericardium [Figures 32–34]... Pneumopericardium can be an occasional complication of pneumothorax but is more often found in the postoperative cardiac patient... The rapidity at which the pericardial effusion accumulates dictates hemodynamic consequences... Radiographically, a pericardial effusion appears as cardiomegaly with a change in cardiac silhouette, resulting in a featureless, globular or “water bottle” shape.

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Frontal radiograph showing vague opacification at the left lung base, suggestive of a pleural effusion that followed a difficult intravenous line placement. The ultrasound image (right) shows solid component within the posterior costophrenic angle, suggestive of a hemothorax. An ultrasound scan can easily differentiate a clear pleural effusion from a hemorrhagic pleural effusion
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Figure 0041: Frontal radiograph showing vague opacification at the left lung base, suggestive of a pleural effusion that followed a difficult intravenous line placement. The ultrasound image (right) shows solid component within the posterior costophrenic angle, suggestive of a hemothorax. An ultrasound scan can easily differentiate a clear pleural effusion from a hemorrhagic pleural effusion

Mentions: Pleural effusions are accumulations of fluid within the pleural space [Figures 35–41]. Pleural effusions occur frequently in the ICU patients, which may be secondary to heart failure, fluid overload, hypoproteinemia, infection, pulmonary embolism, thoracic and upper abdominal surgery, neoplastic disease, subphrenic inflammatory processes, trauma and ascites. The fluid could be blood, chyme, pus, transudates or exudates. The radiographic appearance of a pleural effusion is dependent on the position of the patient. Pleural fluid accumulates in the dependent areas of the chest. A pleural effusion is easier to identify in the erect patient as fluid collects at the base of the lung, causing costophrenic angle blunting and decreased visibility of the lower lobe vessels. In the supine position, identification of a pleural effusion is more challenging. In the supine position, pleural fluid accumulates in the posterior basilar space, which appears as homogenous density that increases in intensity towards the lung base. The normal bronchovascular markings are retained in this veil-like density. With increasing amount of pleural fluid, the diaphragm loses its contour and costophrenic angle may be obliterated. However, it should be remembered that the pleural space may accommodate up to a liter of fluid above the diaphragm without blunting of the costophrenic angle. With larger pleural effusions, the fluid may appear as pleural cap at the lung apex, making it easier to identify on a supine radiograph. The fluid may sometimes accumulate on the medial side of the lung, appearing as a widened mediastinum. Often, smaller pleural effusions are missed on supine chest radiographs despite meticulous technique. When effusions are not readily apparent on a supine chest radiograph but clinically suspected, a lateral decubitus film is indicated. The film should be taken with the side of the patient suspected to have an effusion in the dependent position. The lateral decubitus film would not only confirm smaller pleural effusions but can also differentiate between loculated and free effusions. The latter information is important when pleural drainage is planned, as loculated effusions may need more than one drain. A pleural effusion at the lung base is termed a subpulmonic effusion and is a common occurrence in the ICU patient. On the chest radiograph, a subpulmonic pleural effusion appears as a raised hemidiaphragm with flattening and lateral displacement of the dome. A lateral decubitus film can usually resolve this.


Reading chest radiographs in the critically ill (Part I): Normal chest radiographic appearance, instrumentation and complications from instrumentation.

Khan AN, Al-Jahdali H, Al-Ghanem S, Gouda A - Ann Thorac Med (2009)

Frontal radiograph showing vague opacification at the left lung base, suggestive of a pleural effusion that followed a difficult intravenous line placement. The ultrasound image (right) shows solid component within the posterior costophrenic angle, suggestive of a hemothorax. An ultrasound scan can easily differentiate a clear pleural effusion from a hemorrhagic pleural effusion
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC2700481&req=5

Figure 0041: Frontal radiograph showing vague opacification at the left lung base, suggestive of a pleural effusion that followed a difficult intravenous line placement. The ultrasound image (right) shows solid component within the posterior costophrenic angle, suggestive of a hemothorax. An ultrasound scan can easily differentiate a clear pleural effusion from a hemorrhagic pleural effusion
Mentions: Pleural effusions are accumulations of fluid within the pleural space [Figures 35–41]. Pleural effusions occur frequently in the ICU patients, which may be secondary to heart failure, fluid overload, hypoproteinemia, infection, pulmonary embolism, thoracic and upper abdominal surgery, neoplastic disease, subphrenic inflammatory processes, trauma and ascites. The fluid could be blood, chyme, pus, transudates or exudates. The radiographic appearance of a pleural effusion is dependent on the position of the patient. Pleural fluid accumulates in the dependent areas of the chest. A pleural effusion is easier to identify in the erect patient as fluid collects at the base of the lung, causing costophrenic angle blunting and decreased visibility of the lower lobe vessels. In the supine position, identification of a pleural effusion is more challenging. In the supine position, pleural fluid accumulates in the posterior basilar space, which appears as homogenous density that increases in intensity towards the lung base. The normal bronchovascular markings are retained in this veil-like density. With increasing amount of pleural fluid, the diaphragm loses its contour and costophrenic angle may be obliterated. However, it should be remembered that the pleural space may accommodate up to a liter of fluid above the diaphragm without blunting of the costophrenic angle. With larger pleural effusions, the fluid may appear as pleural cap at the lung apex, making it easier to identify on a supine radiograph. The fluid may sometimes accumulate on the medial side of the lung, appearing as a widened mediastinum. Often, smaller pleural effusions are missed on supine chest radiographs despite meticulous technique. When effusions are not readily apparent on a supine chest radiograph but clinically suspected, a lateral decubitus film is indicated. The film should be taken with the side of the patient suspected to have an effusion in the dependent position. The lateral decubitus film would not only confirm smaller pleural effusions but can also differentiate between loculated and free effusions. The latter information is important when pleural drainage is planned, as loculated effusions may need more than one drain. A pleural effusion at the lung base is termed a subpulmonic effusion and is a common occurrence in the ICU patient. On the chest radiograph, a subpulmonic pleural effusion appears as a raised hemidiaphragm with flattening and lateral displacement of the dome. A lateral decubitus film can usually resolve this.

View Article: PubMed Central - PubMed

Affiliation: Department of Medicine and Medical Imaging, King Saud University for Health Science, King Abdulaziz Medical City, King Fahad National Guard Hospital, Riyadh, Saudi Arabia. drkhan1966@msn.com

AUTOMATICALLY GENERATED EXCERPT
Please rate it.

Interpreting chest radiographs of the critically ill patients who are in intensive care units (ICUs) poses a challenge not only for the intensive care physicians but also for the radiologist... Instrumentation, mechanical ventilation, cardiac and other vital sign monitoring and feeding tubes, etc., detract from other findings on the ICU chest radiograph... Radiologists/Intensive care physicians are under pressure for rapid interpretation of chest x-rays when treating critically ill patients, often with inadequate clinical information, partly due to the fact that things can change rapidly in the critically ill... Current recommendations from the American College of Radiology suggest that daily chest radiographs be obtained on patients with acute cardiopulmonary problems and those receiving mechanical ventilation... Placing the tip at this level allows for flexion or extension of the head... The minimal safe distance from the carina is 2 cm... ICU patients with cardiac arrhythmias or a heart block may require temporary cardiac pacemakers... This is called the deep sulcus sign... Other features of a subpulmonic pneumothorax include visualization of the superior surface of the diaphragm and the superior part of the inferior vena cava... A posteromedial pneumomediastinum is usually the result of esophageal rupture, where air dissects into the paraspinal costophrenic angle and beneath the parietal pleura of the left diaphragm... The result is a V-shaped lucency called the V-sign of Naclerio... A pneumopericardium refers to an accumulation of gas/air between the myocardium and pericardium [Figures 32–34]... Pneumopericardium can be an occasional complication of pneumothorax but is more often found in the postoperative cardiac patient... The rapidity at which the pericardial effusion accumulates dictates hemodynamic consequences... Radiographically, a pericardial effusion appears as cardiomegaly with a change in cardiac silhouette, resulting in a featureless, globular or “water bottle” shape.

No MeSH data available.


Related in: MedlinePlus