Petra Lewis MD
Professor of Radiology and OBGYN
Geisel School of Medicine at Dartmouth
Learning objectives
Understand who should get a pre-op CXR
Know what features affect how we manage SPNs
Know some of the ways that we can manage SPNs in
patients
 Understand the radiographic signs of atelectasis
 Be able to work out when atelectasis is present and what
lobe is involved
 Apply an algorithm to distinguishing the different causes
for an opacified hemithorax
 Recognize the features of a pneumothorax on different
views
 Recognize tension on a radiograph and how to treat it
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What questions/difficulties did
you have arising from the case
Who should get a pre-op CXR?
37 year old man with no cardiorespiratory
symptoms currently but a history of
asthma pre-op ACL repair
 70 year old asymptomatic woman pre-op
hip replacement
 45 year old diabetic man with no
cardiorespiratory symptoms currently preop renal transplant

Who should get a pre-op CXR?
Acute cardiopulmonary findings by
history or physical
 Chronic cardiopulmonary disease in the
elderly (>age 70), previous chest
radiograph within 6 months NOTE
available.
 Possibly:
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 Chronic cardiopulmonary disease in the
elderly (>age 70), previous chest radiograph
within 6 months available.
Solitary Pulmonary
Nodules
What factors might affect whether we
see a solitary pulmonary nodule?
Where might we miss a nodule?
What factors affect how we
manage a lung nodule?
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Patient factors
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Radiographic factors
How can we manage an SPN
seen on a CXR?
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Assess
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Follow up
Fleischner Criteria
.
McMahon et al. 2005 Radiology, 237, 395-400
Atelectasis
What are the characteristics of
atelectasis?
What are the causes of
atelectasis
What are the signs of volume loss?
RUL atelectasis
RUL atelectasis
RUL atelectasis
Pig Bronchus
Day 1
Day 2
LUL atelectasis
Total lung atelectasis
Total lung atelectasis
DDx of unilateral hemithorax
opacification
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Causes
Pneumothorax
What are the signs of a
pneumothorax
What can we do to see
pneumothoraces better?
So you find a pneumothorax…
What is your next question
ALWAYS?
What are the signs of tension?

Clinical

Radiographic
You think your patient has a
tension pneumothorax? What
will you do?
www.brooksidepress.org
Note, this should be a clinical
diagnosis! Don’t wait for the CXR
http://handbook.muh.ie
Appendix
Learning Objectives
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Know the current recommendations for preoperative chest radiographs in people who
are healthy and in those with underlying chest and cardiac diseases
Understand some of the challenges in detecting small nodules on chest radiographs.
Have a concept of the different appearances of pulmonary nodules and their prognostic
significance
Understand the current status of low dose CT imaging for lung cancer screening.
Understand some of the management issues related to pulmonary nodules (including
the Fleischner Society recommendations).
Have a basic understanding of the use of FDG PET imaging in the management of
nodules and lung malignancies.
Have reviewed the methods available for nodule biopsy
Will understand indications for needle biopsy, how the procedure is done, and the
possible complications.
Be able to recognize a pneumothorax and understand the meaning and
consequences of a tension pneumothorax.
Know the options for treating a pneumothorax.
Understand the purpose of TNM tumor staging and implications for long term survival
Recognize the common appearances of lobar atelectasis on chest radiographs.
Recognize the common appearances of linear and subsegmental atelectasis on chest
radiographs.
Know the different etiologies that may cause complete opacification of a hemithorax
Know the expected postoperative appearance of the chest after pneumonectomy.