Diagnostic Testing and Imaging

Question 1

BRONCHOSCOPY gives direct visualization of what? 3

Can be used to sample and treat lesions or abnormalities such as ?
3

Answer 1

Direct visualization of the

1. trachea,
2. bronchi, and
3. segmental airways out to the third generation of branching
4. foreign bodies,
5. bleeding, tumors, or
6. inflammation in those airways.

Question 2

What things may it cause (3) and who is it contraindicated in (2)?

Answer 2

May cause

1. tachycardia,
2. bronchospasm, or
3. hypoxemia.

Contra-indicated in patients with cardiac problems or severe hypoxemia

Question 3

Diagnostic Indications for Bronchoscopy

11

Answer 3

1. Cough
2. Hemoptysis
3. Wheeze
4. Atelectasis/Accumulated secretions
5. Unresolved Pneumonia
6. Positive cytology
7. Biopsy of suspicious tissue
8. Abnormal CXR
9. Bronchial obstruction
10. Diffuse lung disease
11. Pre/post intubation

Question 4

Therapeutic Considerations for bronchoscopy?

6

Answer 4

1. Foreign bodies
2. Accumulated Secretions
3. Atelectasis
4. Aspiration
5. Lung abscess
6. Control of bleeding

Question 5

DIRECT LARYNGOSCOPY AND RIGID BRONCHOSCOPY: advantages over flexible bronchoscopy? 2

Answer 5

1. Better control of the airway

2. Easier to deal with large lesions, foreign bodies

Question 6

Disadvantages of rigid bronchoscopy

2

Answer 6

1. Requires general anesthesia

2. Higher rate of tissue damage/complications

Question 7

Absolute contraindications for rigid bronchoscopy? 5

Answer 7

1. Absolute – inability to adequately oxygenate the patient during procedure
2. Coagulopathy or bleeding diathesis that cannot be corrected.
3. Aneurysm, marked kyphosis.
4. Recent MI or unstable angina.
5. Respiratory failure requiring mechanical ventilation.

Question 8

Complications of rigid bronchoscopy?

4

Answer 8

1. Injury to the teeth
2. Hemorrhage from the biopsy site
3. Hypoxia and cardiac arrest
4. Laryngeal edema

Question 9

What is a major benefits of flexible bronchospy?

Mainly used for what kind of purposes?

Answer 9

1. Does not require general anesthesia
2. Limited intervention (e.g. suctioning)
3. Can be used for intubation

Limited airway control

Mainly for diagnostic purposes

Can do biopsy, minor cautery
Very few complications in healthy patients

Question 10

What is beneficial about flexible fiber optic bronscospy?
5

What do we want to do along with this?

Answer 10

1. Provides magnification and better illumination.
2. Smaller size –permits examination of subsegmental bronchi
3. Easy to use in patients with neck or jaw abnormalities
4. Can be performed under topical anesthesia & useful for bedside examination of critically ill patients
5. Can be easily passed through endotracheal tube or in tracheostomy opening.

Suctioning of biopsy channel helps to remove secretions, inspissated mucus plug and small foreign bodies.

Question 11

Who do we not use flexible fieber optic bronscospy with and why?

Answer 11

Limited utility in children –problem of adequate ventilations

Question 12

What is a VIRTUAL BRONCHOSCOPY?

Benefits? 3

Downsides? 1

Answer 12

Computer generated pictures of the endobronchial tree, which are constructed from computed tomography (CT) images of the thorax

1. Non-invasive,
2. fine detail, and also
3. provides information about structures outside of the airways

Cannot use for biopsy or treatment

Question 13

Limitations of a chest x-ray

4

Answer 13

1. 2 dimensional image of a 3 dimensional structure
2. X-ray findings may lag behind other clinical features
3. Normal x-ray does not rule out pathology
4. Dependent on good quality image

Question 14

The images seen on a chest radiograph result from what?

Answer 14

the differences in densities of the materials in the body.

Question 15

The hierarchy of relative densities from least dense (dark on the radiograph) to most dense (light on the radiograph) include:
5

Answer 15

1. Gas (air in the lungs)
2. Fat (fat layer in soft tissue)
3. Water (same density as heart and blood vessels)
4. Bone (the most dense of the tissues)
5. Metal (foreign bodies)

Question 16

Three Main Factors Determine the Technical Quality of the Radiograph

Answer 16

Inspiration

Penetration

Rotation

Question 17

The chest radiograph should be obtained with the patient in ______ ________ to help assess intrapulmonary abnormalities.

Answer 17

full inspiration

Question 18

At full inspiration, the diaphragm should be observed at about the level of the_______ posteriorly, or the _______ anteriorly.

Answer 18

8th to 10th rib

5th to 6th rib

Question 19

On a properly exposed chest radiograph:

The lower thoracic vertebrae should be visible through the _____?

The bronchovascular structures behind the heart should be seen. What are these?
3

Answer 19

heart

1. trachea,
2. aortic arch,
3. pulmonary arteries,

Question 20

What is the issue in an underexposed chest X-ray?
2

What pathology might it look like?

Answer 20

the cardiac shadow is opaque, with little or no visibility of the thoracic vertebrae.

The lungs may appear much denser and whiter, much as they might appear with infiltrates present.

Question 21

What is the issue in an overexposed chest X-ray?

What pathology might it look like?

Answer 21

With greater exposure of the chest radiograph,

1. the heart becomes more radiolucent and
2. the lungs become proportionately darker.

In an overexposed chest radiograph, the air-filled lung periphery becomes extremely radiolucent, and often gives the appearance of lacking lung tissue, as would be seen in a condition such as emphysema.

Question 22

Patient rotation can be assessed by observing what?

Answer 22

the clavicular heads and determining whether they are equal distance from the spinous processes of the thoracic vertebral bodies.

Question 23

Four major positions are utilized for producing a chest radiograph. What are they?

Answer 23

Posterior-anterior (PA)

Lateral

Anterior-posterior (AP)

Lateral Decubitus

Question 24

The standard position for obtaining a routine adult chest radiograph is what?

How are they positioned? 2

The pt is breathing how for the pic to be taken?

How should it be viewed?

Answer 24

PA

Patient

1. stands upright with the anterior chest placed against the front of the film
2. The shoulders are rotated forward enough to touch the film, ensuring that the scapulae do not obscure a portion of the lung fields

Usually taken with the patient in full inspiration

The PA film is viewed as if the patient is standing in front of you with his/her right side on your left

Question 25

What does the lateral view allow to be seen? How are they positioned? Usually ordered with what?

Answer 25

Allows the viewer to see behind the heart and diaphragmatic dome Patient stands upright with the left side of the chest against the film and the arms raised over the head usullay ordered with a PA

Question 26

When is AP used? How are they positioned? What do you have to remember about the film? Whats usually seen in the lung field?

Answer 26

Used when the patient is debilitated, immobilized, or unable to cooperate with the PA procedure The film is placed behind the patient’s back with the patient in a supine position Because the heart is a greater distance from the film, it will appear more magnified than in a PA The scapulae are usually visible in the lung fields because they are not rotated out of the view as they are in a PA

Question 27

When is the LD used? How are they positioned? How is the xray labeled?

Answer 27

Often useful in revealing a pleural effusion that cannot be easily observed in an upright view, since the effusion will collect in the dependent position The patient lies on either the right or left side rather than in the standing position as with a regular lateral radiograph The radiograph is labeled according to the side that is placed down (a left lateral decubitus radiograph would have the patient’s left side down against the film)

Question 28

Anatomical Structures in the Chest | 7

Answer 28

1. Mediastinum 2. Hilum 3. Lung Fields 4. Diaphragmatic Domes 5. Pleural Surfaces 6. Bones 7. Soft Tissue

Question 29

What should be centrally loctaed in the mediastinum? What is the first convexity on the left side of the mediatstim? What is the next convexity on the left? What lies above the right heart border?

Answer 29

The trachea should be centrally located or slightly to the right The aortic arch is the first convexity on the left side of the mediastinum The pulmonary artery is the next convexity on the left, and the branches should be traceable as it fans out through the lungs The lateral margin of the superior vena cava lies above the right heart border

Question 30

How much of the heart lies on the right and left side? The heart should take up how much of the thoracic cavity? What creates the left heart border? What creates the right heart border?

Answer 30

Two-thirds of the heart should lie on the left side of the chest, with one-third on the right The heart should take up less that half of the thoracic cavity (C/T ratio less than 50%) The left atrium and the left ventricle create the left heart border The right heart border is created entirely by the right atrium (the right ventricle lies anteriorly and, therefore, does not have a border on the PA)

Question 31

Both lungs should be scanned starting where and ending where?

Answer 31

Both lungs should be scanned, starting at the apices and working downward, comparing the left and right lung fields at the same level (as is done with auscultation)

Question 32

On a PA radiograph, the minor fissure can often be seen as a faint horizontal line dividing the what from the what? The major fissures are not usually seen on a PA view because they are being viewed ____?

Answer 32

RML from the RUL. obliquely

Question 33

The left dome is normally slightly lower than the right due to elevation by the _____ located under the right hemidiaphragm. The costophrenic recesses are formed by the _____ and _______.

Answer 33

liver hemidiaphragms and the chest wall

Question 34

The pleura and pleural spaces will only be visible when there is a what? Examples? 3

Answer 34

abnormailty present pleural thickening, or fluid or air in the pleural space.

Question 35

_______due to obesity may obscure some underlying structures such as lung markings?

Answer 35

thick soft tissue

Question 36

The bones visible in the chest radiograph include what? | 5

Answer 36

``` Ribs Clavicles Scapulae Vertebrae Proximal humeri ```

Question 37

What is a siloutte sign? Commonly seen with the borders of the what? 4

Answer 37

The loss of the lung/soft tissue interface due to the presence of fluid in the normally air-filled lung heart, aorta, chest wall, and diaphragm

Question 38

What is an Air Bronchogram? Conditions in which air bronchograms are seen? 6

Answer 38

A tubular outline of an airway made visible due to the filling of the surrounding alveoli by fluid or inflammatory exudates ``` Lung consolidation Pulmonary edema Non-obstructive pulmonary atelectasis Interstitial disease Neoplasm Normal expiration ```

Question 39

What is consolidation? This dense material may consist of what? 4

Answer 39

The lung is said to be consolidated when the alveoli and small airways are filled with dense material. This dense material may consist of: 1. Pus (pneumonia) 2. Fluid (pulmonary edema) 3. Blood (pulmonary hemorrhage) 4. Cells (cancer)

Question 40

What is atelectasis?

Answer 40

Almost always associated with a linear increased density due to volume loss

Question 41

Indirect indications for atelectasis of volume loss include?

Answer 41

1. vascular crowding or 2. mediastinal shift toward the collapse 3. Possible observance of hilar elevation with an upper lobe collapse, or 4. a hilar depression with a lower lobe collapse

Question 42

Typical findings on the chest radiograph for pneumonia include: 3

Answer 42

Airspace opacity Lobar consolidation Interstitial opacities

Question 43

What will a plueral effusion look like on an upright film?

Answer 43

On an upright film, an effusion will cause blunting on the lateral costophrenic sulcus and, if large enough, on the posterior costophrenic sulcus.

Question 44

How many ml are needed to detect an effusion on a PA film? In a lateral view? How will it appear on an AP film? A lateral decubitus film?

Answer 44

Approximately 200 ml of fluid are needed to detect an effusion in a PA film, while approximately 75 ml of fluid would be visible in the lateral view In the AP film, an effusion will appear as a graded haze that is denser at the base A lateral decubitus film is helpful in confirming an effusion as the fluid will collect on the dependent side

Question 45

A pneumthorax appears in a chest radiograph how? In a PA film it is usually seen where? The air is typically found peripheral to the ? When should we take the XRAy in breathing cycle?

Answer 45

Appears in the chest radiograph as air without lung markings In a PA film it is usually seen in the apices since the air rises to the least dependent part of the chest The air is typically found peripheral to the white line of the visceral pleura Best demonstrated by an expiration film

Question 46

There are two basic types of pulmonary edema. What are they and caused by?

Answer 46

Cardiogenic pulmonary edema caused by increased hydrostatic pulmonary capillary pressure Noncardiogenic pulmonary edema caused by either altered capillary membrane permeability or decreased plasma oncotic pressure

Question 47

Common features observed on the chest radiograph of a CHF patient include: 4

Answer 47

1. Cardiomegaly (cardiothoracic ratio > 50%) 2. Cephalization of the pulmonary veins 3. Appearance of Kerley B lines 4. Alveolar edema often present in a classis perihilar bat wing pattern of density

Question 48

Common features seen on the chest radiograph for emphysema include? 4

Answer 48

1. Hyperinflation with flattening of the diaphragms 2. Increased retrosternal space 3. Bullae 4. Enlargement of PA/RV (cor pulmonale)

Question 49

A lung mass will typically present as a what?

Answer 49

lesion with sharp margins and a homogenous appearance, in contrast to the diffuse appearance of an infiltrate.

Question 50

Measurements called Hounsfield Units are used to differentiate what in CT scans? 4 Bone is what value? Fat is what value? What can cause distortion of the image?

Answer 50

1. cysts, 2. lipomas, 3. hemochromatosis, 4. vascular and avascular lesions Bone is +1000, water is 0, fat is -1000 and other tissues fall within this scale Metal and barium can cause distortion of the image

Question 51

What are the benefits of a chest CT?

Answer 51

1. Depicts more nodules than plain CXR 2. Useful in differentiating hilar adenopathy from vascular structures seen on plain CXR, especially when contrast-enhanced images are obtained. 3. High resolution images are useful for characterizing interstitial lung disease

Question 52

``` Standard CT: Slice thickeness? Scans what kind of volume and at what speed? Covers what area? Contrast? ``` Indications? 5

Answer 52

Slice thickness: 3-10 mm scans a large volume, very quickly Covers the full lung +/- contrast Indications 1. CXR abnormality 2. Pleural and mediastinal abnormalities 3. Lung cancer staging 4. F/U metastases 5. Empyema vs abscess

Question 53

HIGH RESOLUTION (HRCT): Describe the xray beam calumniation. What kind of structures does it show? 4 Contrast? Indications? 9

Answer 53

``` narrow x-ray beam collimation: 1-1.3mm vs. conventional 3-10mm cross sections are further apart: 10 mm high definition images of lung parenchyma: 1. vessels, 2. airspaces, 3. airway and 4. interstitium No contrast ``` 1. Hemoptysis 2. Diffusely abnormal CXR 3. Normal CXR with abnormal PFTs 4. Baseline for patients with diffuse lung disease 5. Solitary pulmonary nodules 6. Reversible (active) vs. non-reversible (fibrotic) lung disease 7. Lung biopsy guide 8. F/U known lung disease 9. Assess treatment response

Question 54

Low dose CT: Why do we use it? Indications? 6

Answer 54

Premise: lower dose radiation will not reduce the diagnostic functionality of the scan (eg. 250 mAs 50 mAs) Detail is decreased Uses 1. Screening (example…smokers/former smokers) 2. ongoing trials 3. F/U 4. infections 5. post lung transplant 6. metastases

Question 55

Angiography (CTA) Where is the contrast injected? Indications? 3 Risks? 2

Answer 55

- -contrast injected into peripheral vein - - injection timing/rate controlled automatically 1. Pulmonary embolism 2. Aortic aneurysms 3. Aortic dissection Risks 1. Iodinated contrast: 2. Allergic/ nephrotoxic

Question 56

Benefits of a spiral CT? Useful in the diagnosis of what? 4

Answer 56

Minimizes motion artifact and allows capture of a bolus of contrast material at peak levels in the region being scanned Useful in dx of 1. PE, 2. evaluation of flank pain, 3. detection of kidney stones and 4. rapid evaluation of trauma

Question 57

COMMON PATHOLOGIC FEATURES ON CHEST CT 7

Answer 57

1. Air Bronchograms 2. Bronchiectasis 3. Septal Thickening 4. Ground Glass Opacity 5. Emphysema 6. Nodules 7. Filling Defect

Question 58

What is a V/Q (ventilation/perfusion) SCAN? What does each part evaluate? 2 Who is it a preferred test in?

Answer 58

A type of medical imaging using scintigraphy to evaluate the circulation of air and blood within a patient's lungs 1. The ventilation part of the test looks at the ability of air to reach all parts of the lungs 2. The perfusion part evaluates how well blood circulates within the lungs. pregnant women

Question 59

Indications for V/Q (ventilation/perfusion) SCAN? | 6

Answer 59

Most commonly done to diagnose or rule out 1. presence of a blood clot or 2. abnormal blood flow inside the lungs. 3. PE 4. COPD 5. Pneumonia 6. Post lobectomy

Question 60

What is the Virchow triad? | 3

Answer 60

Pulmonary Embolism Pathophysiology: 1. Hypercoagulability 2. Stasis to flow 3. Vessel injury

Question 61

Risk factors for PE: Hypercoagulability? 4 Venous Stasis? 3 Venous injury? 2

Answer 61

Hypercoagulability 1. Malignancy 2. Pregnancy 3. Postpartum status (less than 4wk) 4. Estrogen/ OCPs Venous Stasis 1. Recent cast or external fixator 2. Long-distance travel or prolong automobile travel 3. Bed rest > 24 hr Venous Injury 1. surgery 2. trauma (especially the lower extremities and pelvis)

Question 62

Presentation of PE? | 4

Answer 62

1. Dyspnea 2. Pleuritic chest pain 3. Low-grade fever 4. Tachycardia

Question 63

What is the Westermarck's sign? Whats is the Hampton’s Hump?

Answer 63

Westermarck's sign A dilation of the pulmonary vessels proximal to the embolism along with collapse of distal vessels, sometimes with a sharp cutoff. Hampton’s Hump A triangular or rounded pleural-based infiltrate or consolidation with the apex toward the hilum.

Question 64

Results for a normal perfusion scan? What about for a low probability V/Q scan? High probability V/Q scan: Intermediate probability V/Q scan:

Answer 64

means that the patient is very unlikely to have acute PE. means that the patient has less than 20% probability of having acute PE. means that the patient has greater than 80% probability of having acute PE. means that the patient has between 20 – 80% probabilities of having acute PE.

Question 65

Relative contraindications for VQ? | 2

Answer 65

1. Pulmonary Hypertension | 2. Right to Left shunts e.g. VSD.

Question 66

Spiral (Helical) Chest CT and PE: Advantages? 2 Disadvantages? 4

Answer 66

Advantages 1. Rapid 2. Alternative Diagnosis Disadvantages 1. Costly 2. Risk to patients with borderline renal function 3. Hard to detect subsegmental 4. pulmonary emboli

Question 67

Why dont we use a pulmoonary angiography for PEs often even though they are 100% effective in finding an obstruction?

Answer 67

Its super invasive