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Cardio-Respiratory II-4 Physiotherapy Management Imaging the chest Review Functional Anatomy Can you name the Origin, Insertion, Function, Innervation? Palpate these structures Functional Anatomy of Lungs 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. Tracheal air column Carina First rib; count down from here for diaphragmatic level Peripheral 1-2 cm of lung fields have no markings except The minor fissure Top of the diaphragm is near the medial half of its length. The top of the right diaphragm is normally at a level between the anterior end of the anterior 6th rib and the anterior 7th rib. The level of the diaphragm can also be reported eith reference to the posterior ribs: on full inspiration, the domes of the diaphragm are seen overlying the posterior aspects fot he 10th and 11th ribs. Left diaphragm is lower in 90-95% of normals by roughly half an interspace (2% greater than 3 cm) Inferior margins of the posterior ribs are often ill-defined . Anterior mediastinal line (apposed visceral and parietal pleura of the two upper lobes Superior vena cava shadow blends imperceptibly into the shadows of the neck Region of the azygous vein (vein not visible). A caliber greater than 7 mm is suggestive of raised venous pressure, or enlargement of adjacent node. Normal may be up to 10 mm. Right descending pulmonary artery. Not greater than 16 mm in men, 15 mm in women Pulmonary arteries and veins. Hard to distinguish the two. Arteries are vertical and medial and emerge from the hilum. Veins are horizontal and lateral ad run toward the left atrium below the hilum. Border of the right atrium Inferior vena cava Aortic arch Left pulmonary artery Border of the left ventricle Descending aorta Fat density lines in the intermuscular fascial layers PA vs AP film PA film = posteroanterior AP film = anteroposteriorly •beam is directed from the back > optimum view of the lungs •Used for less mobile patients, unable to tale a deep breath •Patient is taking a deep breath in standing position, shoulders abducted > medial borders of scapula don’t obscure lungs •Heart is magnified by 15-20%, anterior ribs are less clear, lung fields are partly obscured by scapula & raise diaphragm •Erect position ensures gas passes upwards •Pleural effusion > non-specific homogenous density > DIFFICULT •Pneumothorax easy to detect, fluid passes downwards, so pleural effusion is easy to see Differentiation helps to avoid misunderstandings about the heart or diaphragm. PA film AP film Pleural effusion Left Preliminary checks • Check: Patient’s name, Date, PA or AP film, check exposure, check symmetry of spinous processes, placement of heart • Overexposed film > too block, low density lesions can be missed • Underexposed film > falsely white • Correct exposure > vertebral bodies are visible through the upper BUT not the lower heart shadow! • Spinous processes symmetry correct > appear as teardrop shapes down spine, midway between medial ends of clavicles • Heart > at front of the chest; patient rotated > heart shadow appears shifted towards the sight Systematic analysis • Observe first from distance & then close up. Previous films can be used as comparison. Abnormalities can be identified as: • Too black/white • Too big • In the wrong place • Dense structures absorb rays & are opaque • Air has a low density & appears black Structures Trachea Heart •Dark column of air, overlying upper vertebrae •Position: normally extended slightly left of midline •Size: transverse diameter < half of internal diameter of chest in PA film •Midline down to the clavicles •Big heart > result of ventricular, pulmonary hypertension or poor inspiratory effort •Narrow heart > caused by hyperinflation, when diaphragm pulls down the mediastinum or its normal in tall, THIN people •Slightly displaced to the right by the aortic arch, before branching to the main bronchi •May move with mediastinum, if heart is displaced •Shape: boot shaped > right ventricular hypertrophy; rounded heart > indication pericardial effusion •Specific lobes are collapsed/consodilated if the following Borders are obscured: LLL (left lower lobe) > left hemidiaphragm RLL (right upper lobe) > right hemidiaphragm LUL > aortic arch RUL > right upper mediastinum Lingula > left heart border Middle lobe > right heart border ESP slide 11 LUL pneumonia with volume loss •Note the difference when there are only two lobes •Loss of heart borders/silhouetting •Note anterior displacement of fissure on lateral view Pulmonary Nodule Lateral film RUL collapse •Note differences: 3 vs. 2 lobes •Only fissures give straight lines Structures Hila Diaphragm •Hilar shadows > blood & lymph vessels Height: •full inspiration > diaphragm = level with 6th rib anteriorly, 8th rib laterally & 10th rib posteriorly > with the right side 2cm higher than the left > R pushed up by the liver •Low, flat diaphragm > hyperinflation •Elevated diaphragm > positional as on AP film, lack of full inspiration, pathological from pressure below i.e. abdominal distension •One side of diaphragm raised > lower lobe atelactasis, paralysed hemidiaphragm or on the L excess gas in the stomach •Hila are elevated by upper lobe fibrosis, atelactasis or lobectomy & depressed by lower lobe atelactasis •Bilateral enlargement of hilar shadows > pulmonary hypertension/lymph node enlargement •Unilateral enlargement > suspicion > malignancy Shape: •Diaphragm = dome-shaped & smooth •Flattening > hyperinflation Costophrenic angles (CA)> 200 ml of fluids needs to accumulate in pleura before blunting the CA Subphrenic abscess/perforated gut: •Air under right hemidiaphragm expected after abdominal surgery Lung fields Vascular markings Horizontal fissure Diffuse shadowing i.e. Localized opacities i.e. Unilateral white-out Ring shadows Air bronchogram •Fine White lines from hila = blood vessels •If visible, opposite to right hilum & meets 6th rib in axilla •>10° incline = abnormal •Ground glass appearance > alveolar pathology •Consodilatio n > patchy opacity & pneumonia, occupying segment /lobe •Dense opacities can be caused by collapse/ penumonect omy/ large pleural effusion •Bulla > hair line border, air filled > emphysem a/barotrau ma •Airways visible, if contrasted against opacity •If area of collapse has no bronchogram > obstructed airway •Pneumothor ax > black, non-vascular area demarcated medially by white line of visceral pleura •Coarser honeybomb pattern > progressive damage in interstitial disease •Bronchial tumors > located proximally; metastasis scattered •Cyst > wall thickness >1mm > bronchiect asis Bones • Check for cardiopulmonary resuscitation or other trauma, osteoporosis or malignant sec. deposit • Fresh rib fracture > discontinuation of border of rib • Old fractures > callous formation ESP slide 17 Empyhsema •Flattening of diaphragms/increased lung volumes •Enlarged left pulmonary artery •Attenuation of vessels •Diffuse hyperlucency References • • • Hough “Physiotherapy in Respiratory Care” http://images.google.com/imgres?imgurl=http://brighamrad.harvard.edu/education/online/clerk_2/g raphics/nml.gif&imgrefurl=http://brighamrad.harvard.edu/education/online/clerk_2/normal_cxr.html &usg=__AbgKaFE7YctJ2c8fFMZCeffXjQ=&h=326&w=353&sz=89&hl=de&start=2&tbnid=2Y1x2C2w4NHaM:&tbnh=112&tbnw=121&prev=/images%3Fq%3Dnormal%2BPA%2Bfilm%26gbv%3D2% 26hl%3Dde%26sa%3DG http://images.google.com/imgres?imgurl=http://www.colorado.edu/intphys/Class/IPHY3430200/image/17-1.jpg&imgrefurl=http://www.colorado.edu/intphys/Class/IPHY3430200/015breathing.htm&usg=__Yho6k9KeVbZIohDN2BrhXHGpDE=&h=490&w=919&sz=234&hl=de&start=1&tbnid=o5vDonmFufOhTM:&tbnh=78&tbnw=14 7&prev=/images%3Fq%3Dfunctional%2Banatomy%2Bof%2Blungs%26gbv%3D2%26hl%3Dde% 26sa%3DG ESP slide 19