Transcript Physiology II-4 - HvA Kennisbank

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
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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”
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ESP slide 19