Falcon Reviews

Five Critical Diagnoses Not to Miss on a Chest X-ray

by : William Herring, MD, FACR

It’s 3:00 a.m. Mr. Smith is in Room 2, and is extremely short of breath, with a falling blood pressure. You are reviewing his chest x-ray. Here are five critical diagnoses you don’t want to miss:

Tension Pneumothorax

When air enters the pleural space, the lung and visceral pleura collapse toward the hilum. The visceral pleura then becomes visible as a thin, white line marking the lung’s outer border (visceral pleural line). If air loss into the pleural space occurs with a check-valve mechanism, the intrapleural pressure continues to rise, leading to a shift of the heart and trachea away from the side of the pneumothorax. This can lead to cardiopulmonary compromise, by impairing venous return to the heart (tension pneumothorax). Tension pneumothoraces require emergent decompression. (Fig. 1)

Aortic Dissection

Conventional radiographs are not sensitive enough to be diagnostically reliable, but they can suggest the diagnosis when several imaging findings occur together, especially in the proper clinical setting. Look for (1) a widening of the mediastinum — a subjective and often over-interpreted finding; (2) a left pleural effusion; (3) a left apical pleural cap of blood or fluid; (4) loss of the normal aortic knob shadow, and (5) deviation of the trachea or esophagus to the right. MRI and CT are more sensitive in making this diagnosis, by demonstrating the intimal flap separating the true (original) lumen from the false lumen created by the dissecting blood. (Fig. 2)

Ruptured Esophagus

Rupture of the distal esophagus can occur with increased intra-esophageal pressure in Boerhaave’s Syndrome. Think of Boerhaave’s Syndrome when the x-ray displays (1) a pneumomediastinum and/or (2) a left pleural effusion (3) in a patient with a history of retching or vomiting. Pneumomediastinum produces linear, streak-like lucencies associated with a thin white line paralleling the left heart border, spine or great vessels. Sometimes, pneumomediastinum outlines the central portion of the diaphragm beneath the heart, producing an unbroken diaphragmatic contour extending from one lateral chest wall to the other (continuous diaphragm sign). (Fig. 3)

Pulmonary edema

Unfortunately, congestive heart failure is frequently over-diagnosed on chest radiographs.  Stick to these four, key radiographic signs to recognize pulmonary interstitial edema: (1) thickening of the interlobular septa Kerley B lines ─ visible at the lung bases as 1-2 cm, thin, horizontally-oriented lines perpendicular to the pleural surface; (2) peribronchial cuffing – tiny “doughnuts” visible in the lung, due to fluid-thickened bronchial walls visualized en face; (3) fluid in the fissures ─ opacification and thickening of the major and minor fissures, and (4) pleural effusions ─ usually bilateral but, when unilateral, usually right-sided. As pulmonary venous pressure increases, fluid spills into the alveoli, producing pulmonary alveolar edema, which is characterized by perihilar, fluffy airspace densities frequently having an angel-wing or butterfly configuration and sparing the outer third of lungs. (Fig. 4)

Pneumoperitoneum

Free intraperitoneal air will frequently be first visualized on an upright chest x-ray. In the upright position, free air will usually reveal itself under the right hemidiaphragm as a crescentic lucency that parallels the undersurface of the diaphragm. The size of the crescent is roughly proportional to the amount of free air. Free air can be due to trauma, either accidental or iatrogenic, or rupture of a loop of bowel, mostly from gastric or duodenal ulcer disease. Remember that small amounts of free air will not be detectable in a supine view of the chest (or abdomen), and will require an upright view to be visible. (Fig. 5)

William Herring, MD, FACR, is the Radiology Residency Program Director at Albert Einstein Medical Center in Philadelphia, Pennsylvania, and the author of Learning Radiology: Recognizing the Basics, a fundamental radiology text.

 

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