I.C.U. Chest Radiology E-Book

Harold Moskowitz

• Herausgeber: John Wiley & Sons
• Kategorie: Fachliteratur
• Sprache: Englisch

Seitenzahl: 162

Veröffentlichungsjahr: 2011

Beschreibung

A practical, highly useful guide to the principles of I.C.U. chest radiology, complete with case studies and radiographs on website For critically ill patients in a hospital's I.C.U., a portable chest radiograph is the most helpful, and most commonly used, x-ray examination. Cardiopulmonary complications and the malposition of lines, tubes, and catheters are often initially detected on a portable chest film. It is essential for hospital personnel to know how to approach and read these films, and yet little attention has been paid to teaching the accurate evaluation of this crucial diagnostic tool. The first book in more than a decade to specifically address this topic, I.C.U. Chest Radiology is an authoritative and concise guide to interpreting portable chest film; identifying and correcting any abnormal positions in the various devices inserted into the vascular and respiratory systems; and diagnosing abnormalities of the cardiopulmonary system. Radiology expert Dr. Harold Moskowitz outlines his approach and philosophy toward x-ray interpretation of the I.C.U. patient--one that can be used daily and in any I.C.U. setting. Divided into ten straightforward chapters, the book begins with a discussion of the physics necessary to obtain a proper film and moves on to the more clinical problems encountered each day in the I.C.U.--such as airspace disease, barotrauma, pneumonia, congestive failure, and malalignment of tubes and lines. Throughout, Moskowitz points out specific findings that can often make a difference in a patient's management. Supporting these detailed chapters is a website featuring real-life case studies and radiographic images that simulate common problems in the I.C.U. This is a unique way for readers to prepare to handle the all-too-common scenario: the 2:00 a.m. call from an I.C.U. nurse that a patient has "crashed" and needs attention. Using knowledge gleaned from the chapters, the reader is encouraged to study the radiograph in each case, identify the various problems, determine the clinical condition that caused deterioration in the patient, and plan a course of action. Readers can test themselves with the cases and then listen as Moskowitz discusses the pertinent findings on the film. I.C.U. Chest Radiology is essential reading for those who work in or are associated with I.C.U.s--radiologists, intensivists, hospitalists, emergency room physicians, residents, medical students, physician assistants, respiratory therapists, and nurses. It will also be a valuable guide for personnel who work in step down units and emergency rooms.

Leseprobe

CONTENTS

FOREWORD

PREFACE

SECTION I: PRINCIPLES

CHAPTER 1: INTRODUCTION

CHAPTER 2: PORTABLE CHEST TECHNIQUE IN THE ICU

CHAPTER 3: APPROACH TO READING A PORTABLE CHEST RADIOGRAPH

SYSTEMATIC REVIEW

CHAPTER 4: TUBES, LINES AND CATHETERS

ENDOTRACHEAL TUBE

TRACHEOSTOMY TUBES

CENTRAL VENOUS CATHETERS

THORACOTOMY TUBES (CHEST TUBES)

NASOGASTRIC TUBES

SWAN-GANZ CATHETERS

SENGTAKEN-BLAKEMORE TUBES

INTRA-AORTIC BALLOON PUMPS

PACERS AND DEFIBRILLATORS

CHAPTER 5: BAROTRAUMA

PNEUMOTHORAX

PNEUMOMEDIASTINUM

TENSION PNEUMOTHORAX

INTERSTITIAL EMPHYSEMA

SUBCUTANEOUS EMPHYSEMA

CHAPTER 6: PNEUMONIA

NODULAR IN FILTRATES

CHAPTER 7: PULMONARY EDEMA

CHAPTER 8: ACUTE RESPIRATORY DISTRESS SYNDROME

CHAPTER 9: PULMONARY EMBOLUS

PULMONARY HEMORRHAGE

CHAPTER 10: ATELECTASIS AND COLLAPSE

BIBLIOGRAPHY

SECTION II: CASE STUDIES

TUBES, LINES, AND CATHETERS

CASE 1

CASE 2

CASE 3

CASE 4

CASE 5

CASE 6

CASE 7

CASE 8

CASE 9

CASE 10

CASE 11

CASE 12

BAROTRAUMA

CASE 13

CASE 14

CASE 15

CASE 16

CASE 17

CASE 18

PNEUMONIA

CASE 19

CASE 20

CASE 21

CASE 22

CASE 23

CASE 24

CASE 25

CASE 26

CASE 27

NODULAR PNEUMONIA

CASE 28

PULMONARY EDEMA

CASE 29

CASE 30

CASE 31

CASE 32

CASE 33

CASE 34

ARDS

CASE 35

CASE 36

CASE 37

CASE 38

CASE 39

CASE 40

CASE 41

PULMONARY EMBOLUS

CASE 42

ATELECTASIS AND COLLAPSE

CASE 43

CASE 44

CASE 45

CASE 46

CASE 47

CASE 48

CASE 49

CASE 50

CASE 51

INDEX

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Library of Congress Cataloging-in-Publication Data

Moskowitz, Harold.

I.C.U. chest radiology: principles and case studies/Harold Moskowitz.

p.; cm.

ISBN 978-0-470-45034-5 (cloth)

1. Chest-Radiography-Case studies. 2. Chest-Diseases-Diagnosis-Case

studies. 3. Critical care medicine-Case studies. I. Title.

[DNLM: 1. Intensive Care Units-Case Reports. 2. Radiography, Thoracic-methods-

Case Reports. 3. Thoracic Diseases-diagnosis-Case Reports. WX 218 M911i 2010]

RC941.M67 2010

617.5′407572-dc22

2010001874

FOREWORD

Disclosure: The following story is true. And the author of this book is my father.

My first rotation during internship was hematology-oncology at Brigham and Women’s Hospital in Boston. I felt confident enough; after all, I had been studying and preparing for this moment for 4 years. I inherited quite a service, including four women under the age of 40 with advanced non-Hodgkin lymphoma. The outgoing intern smiled with relief as he signed out to me, adding that the sickest of these young women was the favorite patient of the chief of the division. As he left, he simply added, “I wouldn’t let her die on your watch if I were you.”

Needless to say, this young woman began to deteriorate with worsening respiratory failure my first night on call. I reviewed the differential diagnosis in my head: pneumonia because she was immunosupressed, pneumothorax or hemothorax from the internal jugular line that had been placed for access, transfusion-related acute lung injury from the platelets she had received earlier, congestive heart failure from fluid overload or chemotherapy-induced cardiomyopathy, or even pulmonary embolus given her sedentary status. A brief perusal of my Washington Manual bolstered these thoughts, and I ordered a stat chest x-ray.

That is when the panic really began to set in. I would have to interpret and act on that chest x-ray … was I really prepared for this? I had always been comfortable in the x-ray department, as I had spent significant time in my childhood following my father around while he read films, but I had had little formal training. Radiology wasn’t an individual requirement of my medical school curriculum; it was assumed you would be exposed to it during your clinical rotations. I had even taken the elective in radiology, but this actually consisted of simply sitting in an empty reading room reviewing chest films from case studies in the film library, on my own. Yet now I was on the front line caring for a sick woman and would have to implement the appropriate therapy based on my interpretation of the film.

So what were my resources? My resident was tied up with an admission in the emergency room. The radiology resident would give me a quick read when he had time, but he was busy with another procedure. The radiology attending wouldn’t over-read the film until the morning. The clinical scenario demanded an immediate decision on therapy, so I would have to try my best to interpret the film.

My experience that night led to the first of many conversations with my father regarding the status of radiology education in our medical training. Given the explosion of diagnostic imaging we use and rely on every day in the care of our patients, change would be imperative. Since that time, great strides have certainly been made. In many medical schools, imaging studies are now fully integrated into many courses such as anatomy; my father pioneered just such an initiative at UConn. Other schools have now added radiology requirements to their core curricula. Nevertheless, we still have a way to go. Standardization of basic curriculum requirements remains lacking. Many medical schools have shifted their training focus to outpatient settings, where direct interaction with diagnostic imaging is less likely—you will certainly review the report but not necessarily the imaging itself. And there is a growing component of care provided by physician extenders—PAs, NPs, and RNs—whose background training in reading even the most basic of radiology imaging is even less rigorous.

Why wasn’t there a radiology equivalent to the Washington Manual that could help care providers get through a night like the one I had? It made perfect sense, but I could find no resource like this available. I jokingly referred to my idea as “Lines, Tubes, and Drains: Radiology for Dummies.” But once I discussed it with my father, it was no joke: A new project was born. It has grown and evolved over time, but he has worked tirelessly and diligently to bring a radiology reference manual aimed at providers on the front line of care to fruition. As we rely ever increasingly on imaging, I think this resource will prove invaluable to generations to come. I am extremely proud to introduce this new effort of my father, and I hope it fulfills its role for you.

January 21, 2009

ROBERT MOSKOWITZ, MD

PREFACE

During the past several years, there have been very few publications concerned with the field of ICU radiology. The portable chest x-ray has always been, and still is, one of the most important parts of the work up and treatment of a patient in the ICU. The film provides a reflection of the hemodynamics and an assessment of the etiology of the pathology of each patient. While the rest of radiology has enjoyed incredible change due to technological innovation and improvement, the ICU portable is still performed with equipment that has not changed over the past 30–40 years and is probably the least technologically advanced piece of equipment in the radiologic armamentarium. While the portable film can be augmented by other sophisticated studies, such as CT and MRI, moving the patient to obtain these studies is often extremely difficult and, at times, impossible. In effect, the portable film serves as a screening device as well as a diagnostic tool for the treatment of these very sick patients.

The material in this book stems from my experience as a radiologist at the University of Connecticut Health Center, where I reviewed all of the ICU films each day with the ICU team. At the urging of my students, ICU radiology became a mini-course that I taught during the 4th-year radiology elective.

This book is not intended to be a major reference source but is, in effect, an introduction to the way a student or a resident can approach and read an ICU film. It is a reflection of my own approach and philosophy toward x-ray interpretation of the ICU patient. The method proposed is one I use daily and one that can be used in any ICU setting. An attempt has been made to maintain a straightforward, orderly, and practical format and to emphasize specific points that I have found to be useful and that often can make a difference in a patient’s management. The most common problems are covered in detail and most rare ones are dealt with only superficially or not at all.

Interpreting a portable ICU film demands considerable art mixed with a limited amount of science, but understanding the underlying pathology and hemodynamics is extremely important and helpful and provides a sound foundation for the meaningful interpretation of the film. One must also look at many films because experience is a great teacher, and this takes time; thus this book can serve only as a starting point.

Section I of the book is divided into 10 chapters, starting with a short discussion of the physics necessary to obtain a proper film and proceeding to such topics as malalignment of tubes and lines, barotrauma, pneumonia and air-space diseases, congestive failure. Section II of the book consists of additional cases pertaining to each chapter. The cases are also included on the accompanying CD. After reading each chapter, students can test themselves with these cases, and then listen as I discuss the pertinent findings on the film. I hope this will enable readers to obtain considerable experience in recognizing common problems.

I would like to thank the many people who have had a hand in helping me with this book. First and foremost, I would like to acknowledge that the inspiration for this book sprang from my son Rob’s experience as a medical student and resident and his recognition of the need for students and residents to have a primer in how to approach the ICU portable in the middle of the night. Then I would like to thank the many 4th-year students and residents who have taken my radiology course and helped me shape and learn how to present this material, so that they could be successful in reading films. I am indebted to my colleagues on the front line, those in the ICU, who taught me and helped find the cases I use both in this textbook and in everyday teaching.

I am indebted to Martha Wilke for helping initiate the laborious typing of this manuscript and Jennifer Clark Evans who has typed, and retyped, the manuscript with grace and dedication. I salute my many friends and family who have lent encouragement and I would like to recognize my wife, Janet, who has diligently edited this book. Finally, I would like to acknowledge my debt to Andrew Warren who has worked tirelessly and long in digitizing the many images that appear within. My grateful appreciation to all.

HAROLD MOSKOWITZ, MD

SECTION I

PRINCIPLES

CHAPTER 1

INTRODUCTION

Patients in the ICU are the most critically ill patients in the hospital. They are usually supported by many different types of mechanical devices and generally have many monitoring lines, tubes, and catheters. Critical management of these patients can change from minute to minute. Physicians depend on the physical examination of their patients, which is often quite difficult, and the portable chest radiograph to help understand the patient’s problems. While CT and ultrasound can be of enormous help with these sick patients, the portable chest radiograph is the most helpful and most commonly used x-ray examination. The malposition of lines, tubes, and catheters and cardiopulmonary complications, such as atelectasis, pneumonia, failure, and effusions, are often initially detected on the portable film.

One of the more frightening experiences for a 1st-year resident is to be summoned to the ICU in the middle of the night as the result of a marked deterioration of a patient. A portable chest x-ray is generally obtained, which reveals a plethora of tubes, lines, and mechanical-assist devices as well as a multitude of cardiopulmonary problems manifested in many different guises. Compounding the problem is the fact that a portable film often does not have the technical quality of films obtained in the radiology department, and there is no radiologist available to help the resident make important lifedeciding decisions.

Very little attention has been paid to teaching medical students, residents, and ICU nurses how to approach and read an ICU film. The purpose of this book is to address the more common problems a student will encounter. Attention to the issues and clinical problems that are displayed herein should provide the student with the framework for intelligent and, I hope, accurate interpretation of the changes seen on chest film found in these patients. This book should help the student identify and correct any abnormal positions in the various devices inserted into the vascular and respiratory systems and identify abnormalities of the cardiopulmonary system.

The book consists of a series of chapters discussing various issues, including how to obtain a proper film and the more common clinical problems encountered each day in an ICU. The accompanying CD has one to nine cases relating to the topics covered in each chapter. Cases are presented that simulate common problems in the ICU. Each case has a short clinical history followed by a portable radiograph. Each case is the result of a sudden change in a patient’s condition, which resulted in an x-ray being obtained. The reader is encouraged to look at the radiograph, identify the various problems, determine the clinical condition that caused the deterioration in the patient, and plan what to do about the problems discussed. I have been teaching this course as part of the 4th-year radiology elective at the University of Connecticut Health Center for 5 years. As I explain the situation to the students, it is 2:00 a.m. and the nurse in the ICU has just awakened you to tell you that one of your patients has crashed. The reader tells the nurse to get a chest radiograph and arrives 5 minutes later in the ICU. What do you see and what are you planning to do about it? That is the name of the game.

After studying at the radiograph, the student should turn to the discussion of the findings, which includes an interpretation of the problems found and an outline of the course of action to be followed. It is hoped that this will help the reader solidify the concepts presented in Section I of the book.

CHAPTER 2

PORTABLE CHEST TECHNIQUE IN THE ICU

The portable chest radiograph is the most common test used at the bedside to evaluate the cardiopulmonary status of patients in the ICU. On the portable film, one can detect the positions of lines, tubes, and monitoring devices as well as evaluate the patient’s disease status and response to therapy.1

Careful attention should be given to the technique used in obtaining a chest radiograph. The quality of the portable radiography is often highly variable and generally inferior to examinations performed in the main department. Poor technical quality of a portable chest radiograph may result in a delay or the inability to establish a diagnosis. Because of the portable film’s necessity and its variable quality, it is important for the reader to understand, and keep in mind, several important differences between routine chest films obtained in the x-ray department and those obtained portably.2

A portable chest radiograph is often of inferior quality because of (1) the difficulty controlling scattered radiation, (2) the wide range of densities that need to be demonstrated on a film, and (3) the inability of critically ill patients to cooperate. Furthermore, the portable machine is one of the most inefficient and technically least advanced pieces of imaging equipment in an x-ray department (Fig. 2.1).3

Figure 2.1 An x-ray tube.

A team approach is needed to obtain a portable chest radiograph, and the team should include technologists, radiologists, and ICU personnel. There should be close cooperation between ICU nurses, respiratory therapists, and other ICU personnel in assisting the technologist while positioning an unstable patient. They should help remove unnecessary and unwanted tubes and lines from the patient’s chest before taking the film because these can be misinterpreted and thought to be in the heart or lungs. Furthermore, every attempt must be made to obtain the film with the patient upright and at the end of deep inspiration. If the radiograph is obtained in expiration when the patient is supine, the findings can be misleading. Finally, it is imperative that there be rapid communication between the radiologist and the ICU team about the findings seen on a chest radiograph.4

Because the quality of the image often determines the diagnostic information that can be obtained from the radiograph, it is necessary to review the factors affecting the film, such as contrast, noise, and spatial resolution.

Contrast represents the variation of film density between one part of the film and another. Ideally one should obtain a film with the highest contrast throughout, and in the chest x-ray this is generally measured from the darkest area (Dmax), which is the lung, to the lightest, white area (Dmin), which is bone. Contrast is the result of the differences between tissues as an x-ray photon passes through the object. The important parameters are thickness and density of the material through which the x-ray passes and the amount of absorption of the photon that occurs. In the diagnostic radiology range (60-150 KVp