RADIOLOGY IMAGING

IN PULMONARY

EMERGENCY

Widiastuti

Radiology Department of Dr. Moewardi Public Hospital /

Medical Faculty of Universitas Sebelas Maret

September 12nd, 2019

Chest Imaging

Chest Imaging includes imaging and diagnosis of the lung parenchyma, pleura, mediastinum and the hila.

Cardiovascular Imaging

Cardiac CTA can be used to evaluate ventricular function - anatomy, aortic valve function - anatomy, aneurysms, pseudoaneurysms and myocardial infarcts.

North Broward Radiologist, 2012

• Pulmonary emergencies are life-threatening conditions that occur when a person has difficulty breathing normally.

• A broad range of different respiratory emergencies is covered, from pneumothorax, pulmonary embolism, right heart failure and haematothorax to acute exacerbations of diseases such as asthma and chronic obstructive pulmonary disease.

• Radiologic imaging:

conventional radiography, multidetector computed tomography (CT).

1. GUNSHOT WOUND 8. PNEUMOTHORAX

2. COPD 9. RIB/STERNAL FRACTURE

3. DIAPHRAGMATIC RUPTURE/HERNIA 10. PNEUMOMEDIASTINUM

4. FLAIL CHEST 11. PULMONAY CONTUSION

5. FOREIGN BODY – INGESTED FOREIGN BODIES 12. PNEUMOCARDIUM

6. OESOPHAGEAL PERFORATION/RUPTURE 13. CARDIAC TAMPONADE

7. PNEUMONIA 14. AORTIC RUPTURE

Radiology Case Reports | radiology.casereports.net, 2012

M, 24 Yo: A gunshot wound to the right mid-abdomen of hemodynamic instability with marked hypotension and tachycardia

Characteristic Radiological features

A spectrum of conditions including chronic bronchitis and emphysema

CXR : are only moderately sensitive (40–60%), but highly specific in appearance.

expiratory airflow, infection, mucosal oedema, bronchospasm and bronchoconstriction due to reduced lung elasticity

hyper-expanded lungs with associated flattening of both hemidiaphragms, pruning of pulmonary vasculature, barrel-shaped chest’ and lung bullae

Causative factors include smoking, chronic asthma, and chronic infection.

A to Z of Emergency Radiology. Cambridge,2004

The lucency of the lung fields, flattening of the hemidiaphragms, narrowed cardiac silhouette and reduced of peripheral vascular markings.

Med Clin North Am. Author manuscript; 2014 April 29

CXR: Left diafragmatica herniation MSCT Thorax: Herniation Of The

Stomach

DIAPHRAGMATIC RUPTURE/HERNIA

Radiographics 2002 Oct; 22 Spec No: S103-16

A Newborn with A Congenital Diapragmatic Hernia

Herniation of the stomach in the left hemithorax Pediatric surgery

Pediatric surgery

• Multiple rib fractures (black arrows) with some ribs fractured in two or more places

• Pulmonary contusion (red arrow) and subcutaneous emphysema (white arrow)

Learningradiology, 2015

RSDM, Feb 2017

RSDM, Feb 2017

(a,b) Typical chest radiograph findings of intrapleural oesophageal perforation.

Oesophageal emergencies, 2015

CT appearances of spontaneous oesophageal perforation. (a) Left pleural hydropneumothorax. (b) Left basal intercostal chest drain in.

Oesophageal emergencies, 2015

Contrast swallow demonstrating free extravasation of contrast media after oesophageal perforation during balloon dilatation of achalasia.

Oesophageal emergencies, 2015

M, 80 Yo

a nonsegmental consolidation

in the right middle lung field.

A

IMAGING FINDINGS OF CAP Streptococcus pneumoniae Mycoplasma pneumoniae

ill-defined consolidation in the right lower lung field

F, 30 Yo

B

Nambu A et al . Imaging of CAP, Oct 28, 2014,Vol.6

Streptococcus pneumoniae Mycoplasma pneumoniae

a nonsegmental consolidation with air bronchograms suggestive of

alveolar pneumonia

Non-segmental consolidation with air bronchograms at the dorsal aspect of the right lower lobe.

Nambu A et al . Imaging of CAP, Oct 28, 2014,Vol.6

• Iatrogenic tension pneumothorax.

• This is secondary to the high intrathoracic pressures generated during ventilation resulting in rupture of a pleural bleb.

• There is progressive mediastinal shift to the right.

A to Z of Emergency Radiology. Cambridge,2004

Extensive pulmonary fibrosis and left pneumothorax

• Axial CT shows that drain (arrow) has transversed lung parenchyma.

CT: showing subcutaneous emphysema and pneumomediastinum

PNEUMOMEDIASTINUM

Annals of Nigerian Medicine / Jan-Jun 2015 / Vol 9 | Issue 1

M, 11 Yo: cough for 2 days, breathing difficulty, complained of swelling and pain over his neck, chest, abdomen, and upper limbs

F, 37 Yo: PULMONARY CONTUSION

Involved in a motor vehicle collision

a) Patchy air space disease representing pulmonary contusions b) Demonstrates a nonsegmental air space consolidation and a diffuse "ground

glass" appearance of the surrounding parenchyma due to blood filling the alveolar spaces. Note the associated left pneumothorax (star). European Society of Radiology, 2014

M, 39 Yo: After a motor vehicle accident

(a) Left sided pneumothorax and pneumopericardium (star) with a left dislocation of the heart b) Most likely air enter the pericardial space from the pleural space through

a tear in the pericardium ESR, 2014

RSNA, 2007

a) significant enlargement of the cardiac silhouette with the characteristic “water bottle” appearance/ shaped heart

b) a large pericardial effusion flattening the anterior cardiac contour

RSNA,2007

A. Cardiac tamponade in a newborn with respiratory distress syndrome who developed pneumopericardium associated with barotrauma from mechanical ventilation.

B. Pneumopericardium with cardiac tamponade in an adult patient with blunt thoracic trauma. The small heart sign suggests the presence of tension pneumopericardium.

A B

RSNA,2007

(a) Intrapericardial herniation of the colon (arrows), which produces

tamponade.

(b) The pericardial defect (white arrowheads) and the herniating bowel

loop with air (white arrow) compressing the anterior aspect of the

heart (black arrowheads). RSNA, 2007

F, 63 Yo: Pericardial tamponade with a delayed post traumatic diaphragmatic hernia.

Characteristic Chest radiograph CT Toraks

80-90 %t of patients die before reaching hospital

Widened mediastinum (8 cm on AP CXR) Vessel wall disruption or extra-luminal blood seen in contiguity with the aorta is indicative of rupture.

deceleration injuries, a fall from a height or in road traffic accidents > 40 mph

Blurred aortic outline with loss of aortic knuckle

The aorta usually ruptures 88–95%, just distal to the origin of the left subclavian artery

Left apical pleural cap

Left sided haemothorax

Depressed left/raised right main stem bronchus

Tracheal displacement to the right

Oesophageal NG tube displacement to the right

A to Z of Emergency Radiology. Cambridge,2004

Traumatic aortic rupture

http://torontonotes.ca/category/medical-imaging/chest/cardiovascular/2017

The markedly widened mediastinum in the AP , which is suggestive of aortic aneurysmal/dissection disease.

Show the “snowman” sign depicting the aneurysm, filling defects, and extravasation.

• Acute Type A ascending aortic dissection in an already aneurysmal aorta.

• The false lumen has partial thrombosis (the straight arrow) and there is a haemopericardium which compresses the left atrial appendage (curved arrow).

The British Journal of Radiology, 2011

• Pulmonary emergencies are life-threatening conditions that occur when a person has difficulty breathing normally.

• A broad range of different respiratory emergencies is covered, from pneumothorax, pulmonary embolism, right heart failure and haematothorax to acute exacerbations of diseases such as asthma and chronic obstructive pulmonary disease.

• Radiologic imaging: conventional radiography, multidetector computed tomography (CT).

Pulmonary Embolism Acute exacerbations of interstitial lung disease

Pneumothorax Haemoptysis

Right heart failure Foreign body aspiration and inhalation injury

Acute exacerbations of COPD Haematothorax

Acute exacerbations of asthma Severe community-acquired pneumonia

Pulmonary Embolism

• Acute PE is a common cause of acute onset chest pain presenting in the emergency room with as many as 1–2 per 1,000 patients potentially affected by VTE.

M, 55 Yo

A. CXR: shows a wedge-shaped opacity in the periphery of the right lateral lung (red arrows) concerning for infarction, dubbed a “Hampton hump”;

B. Coronal CTPA: shows a filling defect within an enlarged right lower lobe lateral segmental pulmonary artery consistent with occlusive thrombus (black arrow) and a wedge-shaped peripheral opacity consistent with infarct, correlating with abnormality on radiograph (red arrow).

Cardiovasc Diagn Ther 2018

A. a central filling defect surrounded by a ring of contrast exhibiting the “polo mint” sign of acute PE (black arrow).

B. a central filling defect surrounded by parallel lines of contrast consistent with the “railway sign” of acute PE (white arrows)

C. Extensive burden of large pulmonary emboli manifested by occlusive and mural filling defects whose edges form acute angles with the vessel walls (white arrows)

D. a large conglomeration of low density embolus is draped over the bifurcation of the pulmonary artery, exhibiting a “saddle embolus” configuration (black arrows).

E. a dilated right lower lobe posterior basal sub-segmental pulmonary artery with an occlusive filling defect consistent with acute PE (black arrow)

A. a round opacity in the left lower lobe posterior segment that exhibits a ground glass center (red arrow) surrounded by a rim of consolidation (black arrows).

B. indicative of right heart strain. Extensive embolic burden in the dilated segmental and lobar pulmonary arteries (curved white arrows)

Axial T1-weighted fat saturated MR angiographic sequence with digital subtraction show low signal filling defects within the right pulmonary artery and left common basal pulmonary artery consistent with acute PE (white arrows). There is also a small right pleural effusion (black arrow) which is often seen with acute PE and a metastasis from colorectal cancer in the posterior left lung (red arrow)

Pneumothorax

• CXR shows unremarkable appearance ofintercostal drain (arrow)

• Axial CT shows drain (arrow) is located insubcutaneous tissues.

Right pneumothorax with a pigtail chest tube in place, diffuse reticular interstitial opacities.

Extensive centrilobular emphysema, moderate right pneumothorax with pigtail chest drain on the right, subpleural reticular opacities with peripheral and basilar preponderance suggesting interstitial fibrotic lung disease, and diffuse lung cysts

Southwest J Pulm Crit Care. 2017

Pneumothorax

Extensive pulmonary fibrosis and left pneumothorax

• Axial CT shows that drain (arrow) has traversed lungparenchyma.

Right heart failure classification

Class I No limitation is experienced in any activities; there are no symptoms from ordinary activities

Class II Slight, mild limitation of activity; the patient is comfortable at rest or with mild exertion

Class III Marked limitation of any activity; the patient is comfortable only at rest

Class IV Any physical activity brings on discomfort and symptoms occur at rest

Functional NYHA Classification

ACA/AHA Classification

Stage A Patients at high risk for developing HF in the future but no functional or structural heart disorder

Stage B A structural heart disorder but no symptoms at any stage

Stage C Previous or current symptoms of heart failure in the context of an underlying structural heart problem, but managed with medical treatment

Stage D Advanced disease requiring hospital-based support, a heart transplant or palliative care

a) Preoperative CT-scan shows the dissection membrane in the ascending aorta (arrow).

b) Preoperative angiography with proximal closure of the right coronary artery (double arrow).

• CT angiogram verifying the presence of a mass insidethe right atrium occupying almost the whole cavity.

Journal of Cardiothoracic Surgery,2011

Acute exacerbations of COPD

• COPD patient with extensiveareas of centrilobular emphysema predominantly in the superior lung fields.

CLINICS 2012;67(11):1335-1343

• Axial (A,B), Coronal (C): demonstrating varicose bronchiectasis (arrow), large bronchoceles and very little panlobular emphysema (circle).

Chronic Obstr Pulm Dis. 2016; 3(2): 601-604

Axial (A,B), Sagittal (C): reveal very mild bronchiectasis (arrow) and larger areas of panlobular emphysema (circles).

Chronic Obstr Pulm Dis. 2016; 3(2): 601-604

F, 44 Yo: Acute exacerbation of asthma and was diagnosed with allergic bronchopulmonary

aspergillosis

Dilated and mucus-filled bronchi in the right lung appearing as finger in glove (white arrow) producing the radiologic sign, finger-in-glove sign.

ResearchGate 2019

Right infiltrates and patchy ground-glass opacity with bronchial wall thickening

Respirology case reports 2017

Acute exacerbations of interstitial lung disease

Smoking-related interstitial lung diseases a) Pulmonary Langerhans cell histiocytosis b) Respiratory bronchiolitis-associated ILD c) Combined pulmonary fibrosisand emphysema d) Desquamative interstitial pneumonia

Eur Respir Rev 2015; 24: 428–435

66 Yo: patient with idiopathic pulmonary fibrosis. • Peripheral reticular abnormality with traction bronchiectasis and subpleural

honeycombing. • Extensive ground-glass abnormality superimposed on the background of

pulmonary fibrosis can also be seen.

Pulmonary medicine 2017

Hemoptysis

M, 52 Yo with cough and hemoptysis. The ill-defined mass in the right lower lobe was found to be squamous cell carcinoma

Cystic dilatation of the bronchi bilat-erally, consistent with cystic bronchiectasis.

• M, 44 yo with hemoptysis.

• The solid mass on the left is a mycetoma within a thin-walled cavity in the left upper lobe.