Drs. Escobar, Pikus, and Blackwell’s CMC X-Ray Mastery Project: March Cases

Adult Chest X-Rays Of The Month
Daniel Escobar, MD, Angela Pikus, MD,
Alex Blackwell, MD
Department of Emergency Medicine
Carolinas Medical Center & Levine Children’s Hospital
Michael Gibbs, MD - Faculty Editor
CMC Imaging Mastery Project
March 2022

Disclosures
 This ongoing chest X-ray interpretation series is proudly sponsored by the
Emergency Medicine Residency Program at Carolinas Medical Center.
 The goal is to promote widespread mastery of CXR interpretation.
 There is no personal health information [PHI] within, and ages have been
changed to protect patient confidentiality.

Visit Our Website
www.EMGuidewire.com
For A Complete Archive Of Imaging Presentations And Much More!

Airway
Bones
Cardiac
Diaphragm
Effusion
Foreign body
Gastric
Hilum

This Presentation Will Review Imaging Case
Studies In Adult Patients With Lobar Pneumonia.

A-1 CDC EPIC Study1 New England Journal of Medicine 2015
A-2 ATS/IDSA Management Guidelines Am J Resp Crit Care Med 2019
A-3 ACEP Clinical Practice Guidelines Annals of Emergency Medicine 2021
A-4 ATS Testing Guidelines Current Opinions In Infectious Disease 2022
A-5 Antimicrobial Therapies The Medical Letter 2021
1EPIC Study – prospective, multicenter study designed to CAP pathogens in U.S. adults
ATS/IDSA – American Thoracic Society/Infectious Disease Society of America
ACEP – American College of Emergency Physicians
At The End You Will Find Several Articles Addressing The
Assessment & Management Of Community Acquired Pneumonia.

The CXR Demonstrates:
a. RUL Pneumonia
b. RML Pneumonia
c. RLL Pneumonia
d. LUL Pneumonia
e. LLL Pneumonia
42-Year-Old With Cough
And Fatigue.

Prior CXR
Now
www.EMguidewire.com March 2019
54-Year-Old With Diabetes Presents With Fever, Hypoxia, Altered Mental Status
Right Upper Lobe Pneumonia
Arrows Point To
The Minor Fissure

68-Year-Old
Diabetic With
Cough And Fever
Right-Sided Infiltrates – Primarily RUL

Cough, Fever, Dyspnea
www.EMguidewire.com April 2019

www.EMguidewire.com April 2019 Right Upper Lobe Pneumonia

Cases Studies From
Our Emergency
Medicine Colleagues
In Brazil
A 43-Year-Old
Presents To An
Outpatient Clinic
After A Syncopal
Episode.
He Has Normal
Labs, A Normal ECG
And This Chest X-
Ray.
He Was Sent Home.
www.EMguidewire.com July 2019

Right Upper Lobe Pneumonia
www.EMguidewire.com July 2019
A 43-Year-Old Seen
In An Outpatient
Clinic After A
Syncopal Episode.
Four Days Later
He Now Presents
To The ED With
Fever & Rigors.
Cases Studies From
Our Emergency
Medicine Colleagues
In Brazil

A 43-Year-Old Seen
In An Outpatient
Clinic After A
Syncopal Episode.
Let’s Take Another
Look At His First
Chest X-Ray.
Subtle Pneumonias Can Be Missed (Especially With Overlapping Structures
Nearby), Be Sure You Are Comparing Each Lung Field With The Other Side.
Cases Studies From
Our Emergency
Medicine Colleagues
In Brazil

www.EMguidewire.com February 2019
a. RUL Pneumonia
b. RML Pneumonia
c. RLL Pneumonia
d. LUL Pneumonia
e. LLL Pneumonia
57-Year-Old With Cough
And Shortness Of Breath.

Right Middle Lobe Pneumonia
• Blurred right heart boarder
• Lateral diaphragm clear
• Often seen best on the lateral

Right Middle Lobe Infiltrate

www.EMguidewire.com February 2019 Right Middle Lobe Infiltrate

73-Year-Old With
Fever, Cough And
Confusion
www.EMguidewire.com March 2019 Right Middle Lobe Infiltrate

a. RUL Pneumonia
b. RML Pneumonia
c. RLL Pneumonia
d. LUL Pneumonia
e. LLL Pneumonia
69-Year-Old Complains Of
Right Upper Quadrant
Pain.
www.EMguidewire.com November 2019

RLL Pneumonia With Loss Of The Right Hemidiaphragm

Healthy 20-Year-Old With Cough.
What Do You See?

Healthy 20-Year-Old With Cough.
Right Lower Lobe Pneumonia

Healthy 27-Old-Male With Severe Right Pleuritic Chest Pain And Cough
What Do You See?

Subtle RLL Infiltrate

www.EMguidewire.com April 2019
Right Lower Lobe Pneumonia

Pneumonia Of The Superior Segment Of The RLL

What Do You See?

RLL Pneumonia – The Lateral View Helps Differentiate RLL From RML Involvement

a. RUL Pneumonia
b. RML Pneumonia
c. RLL Pneumonia
d. LUL Pneumonia
e. LLL Pneumonia
42-Year-Old With Cough,
Fever And Dyspnea.

51-Year-Old
With Cough &
Fever.
Findings Can Be Subtle On The PA View

Left Lower Lobe Pneumonia

Two Different Patients With Left Lower Lobe Pneumonia

55-Year-Old
With Fever And
Dyspnea.
A Single
Portable CXR
Is Obtained At
The Bedside.
What Do You See?

55-Year-Old
With Fever And
Dyspnea.
A Single
Portable CXR
Is Obtained At
The Bedside.
What Do You See?
The Left
Hemidiaphragm
Is Indistinct

40-Year-Old
With Fever And
Dyspnea.
A Single
Portable CXR
Is Obtained At
The Bedside.
What Do You See?

40-Year-Old
With Fever And
Dyspnea.
A Single
Portable CXR
Is Obtained At
The Bedside.
What Do You See?
The Left
Hemidiaphragm Is
Indistinct

 In patients who may be too sick to travel to the Radiology suite – we often start
with a single-view AP chest X-ray in the ED.
 In our two cases the “next step taken” was a CT scan of the chest.
 Another option would be to obtain a two-view chest X-ray once the patient is
more stable – this provides the benefit of a higher quality PA view along with the
lateral projection.

CMC/LCH Imaging Technical Charges – May 2022
1 view chest X-ray $296
2 view chest X-ray $369
CT chest with contrast $2,628
CT chest with contrast - angiogram $3,398

Lingular Pneumonia
• The lingula describes the two most
infero-anterior segments of the left
upper lobe of the lung
• This represents an embryologic
“mirror image” of the RML
• Lingular pneumonia is best seen on
the lateral projection.

a. RUL Pneumonia
b. RML Pneumonia
c. RLL Pneumonia
d. LUL Pneumonia
e. LLL Pneumonia
64-Year-Old With COPD
Presents With Cough.

A-1 CDC EPIC Study1 New England Journal of Medicine 2015
A-2 ATS/IDSA Management Guidelines Am J Resp Crit Care Med 2019
A-3 ACEP Clinical Practice Guidelines Annals of Emergency Medicine 2021
A-4 ATS Testing Guidelines Current Opinions In Infectious Disease 2022
A-5 Antimicrobial Therapies The Medical Letter 2021
1EPIC Study – prospective, multicenter study designed to CAP pathogens in U.S. adults
ATS/IDSA – American Thoracic Society/Infectious Disease Society of America
ACEP – American College of Emergency Physicians
Community Acquired Pneumonia
Concise Literature Review

Remember that pneumonia:
• Remains in the “top 10” most common causes of death in the U.S.
• Is the most common cause of death from infection (excluding COVID)
• Is especially lethal in the elderly

A-1
Prospective study of adults hospitalized with community-acquired pneumonia
(CAP) in five hospitals in Chicago and Nashville. Serologic and radiologic studies
were evaluated to calculate the incidence rates of CAP according to age and
pathogen. 2259 patients had radiographic evidence of pneumonia and specimens
available for both bacterial and viral testing.

A-1
Main Results:
• 2259 patients included
• Median age was 57
• 498 patients (21%) required ICU care and 52 (2%) died
• A pathogen was detected in 853 (38%)
• The incidence of pneumonia/100,000 population increased with age
Human rhinovirus 9%
Influenza virus 6%
Streptococcus pneumoniae 5%

A-1
Punchline? In hospitalized patients with community acquired pneumonia:
• Specific pathogens are only identified in 38% of cases
• Viral pneumonia plays a significant role
• Broad coverage of potential bacterial pathogens + liberal influenza testing is recommended
N=2259

“In a departure from the prior CAP guidelines, the panel did not give a strong
recommendation for routine use of a macrolide antibiotic as monotherapy for
outpatient community acquired pneumonia. This was based on studies of macrolide
failures in patients with macrolide-resistant S. pneumonia1,2, in combination with a
macrolide resistance rate of >30% among S. pneumonia isolates in the United States, of
which is high-level resistance3.”
1Lonks JR. Clin Infect Dis 2002;35:556-564.
2Daneman N. Clin Infect Dis 2006; 43:432-438.
3CDC. Active Bacteria Core Surveillance (ABCs) Report - 2015. Report Accessed 2019.
PUNCH LINE?
 Pneumococcal resistance makes macrolide monotherapy risky.
 Know your local resistance patterns.
 Choose double therapy if atypical pneumonia is a possibility.
A-2

Question #1:
In adults with CAP, should gram stain and cultures of lower respiratory secretions be
obtained at the time of diagnosis?
 Recommend not obtaining sputum Gram stain and cultures routinely in adults with
CAP managed in the outpatient setting.
 Recommend obtaining Gram stain and cultures in adults with CAP who: (1) have
severe CAP* [especially if intubated], or (2) are being treated empirically for MRSA or
P. aeruginosa.
*See next slide for IDSA/ATS definition of “severe community-acquired pneumonia.”
A-2

Question #2:
In adults with CAP, should blood cultures be obtained at the time of diagnosis?
 Recommend not obtaining blood cultures in adults with CAP managed in the
outpatient setting.
 Recommend obtaining blood cultures in adults with CAP managed in the hospital who:
(1) are classified as severe CAP, (2) are being treated empirically for MRSA or P.
aeruginosa, (3) were previously infected with MRSA or P. aeruginosa, (4) were
hospitalized and received parenteral antibiotics in the last 90 days.
A-2

Question #3:
In adults with CAP, should Legionella and Pneumococcal urinary antigen testing be
performed at the time of diagnosis?
Recommend not routinely testing adults with CAP, except in: (1) patients with severe CAP,
and/or (2) in cases where this is indicated by epidemiological factors such as exposure to
a Legionella outbreak, or recent travel.
A-2

Questions #4, #5, #6:
In adults with CAP:
 Should a respiratory sample be tested for Influenza virus at the time of diagnosis?
 Should influenza treatment be initiated for adults with a [+] test?
 Should influenza [+] adults being treated with an antiviral also be treated with an
antibacterial regimen?
 When influenza is circulating in the community, a rapid influenza molecular assay is
recommended.
 For [+] tests, treatment with oseltamivir is recommended.
 For [+] tests, standard antibacterial treatment is recommended.
A-2

Question #7:
In adults with CAP, should serum procalcitonin plus clinical judgment versus clinical
judgment alone be used to withhold initiation of antibiotic treatment?
Recommend that empiric antibiotic therapy should be initiated in adults with clinically
suspected and radiographically confirmed CAP regardless of initial serum procalcitonin
level.
A-2

Question #8, 9:
Should a clinical prediction rule for prognosis plus clinical judgment versus clinical
judgment alone be used to determine: (1) inpatient versus outpatient treatment location
for adults with CAP, and (2) the best site of treatment [floor vs. Step-Down vs. ICU]?
 In addition to clinical judgement clinicians should use a validated clinical prediction
rule for prognosis, preferentially the Pneumonia Severity Index (PSI).
 When compared with CURB-65, PSI identifies larger proportions of patients as low
risk, and has a higher discriminative power in predicting mortality.
 Compared with PSI, there is less evidence that CURB-65 is effective as a decision aid in
guiding the initial site of treatment.
A-2

Question #10:
In the outpatient setting, which antibiotics are recommended for empiric treatment of
CAP in adults?
For healthy outpatient adults: (1) amoxicillin 1 g TID, or (2) doxycycline 100 mg BID, or (3)
azithromycin 500 mg on first day then 250 mg daily, or (4) clarithromycin 500 BID.
For outpatient adults with comorbidities (heart failure, liver or renal disease, diabetes,
alcoholism, malignancy or asplenia):
 Amoxicillin/clavulanate 500mg/125 mg TID, or a cephalosporin, AND a macrolide
(azithromycin, clarithromycin, or
 Monotherapy with a respiratory fluoroquinolone: levofloxacin 750 mg QD, or
moxifloxacin 400 mg QD, or gemifloxacin 320 mg QD.
A-2

Question #11:
In the inpatient setting, which antibiotics are recommended for empiric treatment of
CAP in adults without risk factors for MRSA and P. aeruginosa?
In inpatients with non-severe CAP:
 A 𝛽-lactam + a macrolide, or
 Monotherapy with a respiratory fluoroquinolone, or
 A 𝛽-lactam + doxycycline [if macrolides & fluoroquinolones are not tolerated]
In patients with severe CAP:
 A 𝛽-lactam + a macrolide, or
 A 𝛽-lactam + a respiratory fluoroquinolone
A-2

Question #12:
In the inpatient setting, should patients with suspected aspiration pneumonia receive
additional anaerobic coverage beyond standard empiric treatment?
Recommend not routinely adding anaerobic coverage for suspected aspiration
pneumonia unless lung abscess or empyema is suspected.
A-2

Question #13:
In the inpatient setting, should adults with CAP and risk factors for MRSA or P. aeruginosa
be treated with extended-spectrum antibiotic therapy instead of standard CAP regimens?
Recommend that clinicians only cover empirically for MRSA or P. aeruginosa in adults
with CAP if locally validated risk factors for either pathogen are present.
MRSA Vancomycin (15 mg/kg), or linezolid (600 mg BID)
P. aeruginosa Piperacillin-tazobactam (4.5 grams Qº6), or cefepime (2 grams Qº8), or
aztreonam (2 grams Qº8), or imipenem 500 mg Qº6)
A-2

Question #14:
In outpatient and inpatient adults with CAP who are improving, what is the appropriate
duration of antibiotic therapy?
Recommend that the duration of antibiotic therapy should be guided by a validated
measure of clinical stability (resolution of vital sign abnormalities, ability to eat, and
normal mentation), and antibiotic therapy should be continued until the patient achieves
stability for no less than 5 days.
A-2

Question #15:
In the inpatient setting, should adults with CAP be treated with corticosteroids?
 Recommend not routinely using corticosteroids in adults with non-severe CAP.
 Recommend not routinely using corticosteroids in adults with severe CAP.
 Recommend not routinely using corticosteroids in adults with severe influenza CAP.
 Endorse the Surviving Sepsis Campaign recommendations on the use of corticosteroids
in patients with CAP and refractory septic shock.
A-2

A systematic literature review was conducted to derive evidence-based
recommendations to answer the following clinical questions for the adult ED patient
with community acquired pneumonia (CAP):
1. Which clinical decision aids can inform the determination of patient disposition?
2. What biomarkers can be used to direct initial antimicrobial therapy?
3. Does a single dose of parenteral antibiotics followed by oral treatment versus oral
treatment alone improve outcomes?
A-3

In The ED Patient With Community Acquired Pneumonia, Which Clinical Decision
Aids Can Inform The Determination Of Patient Disposition?
Level B Recommendation
The Pneumonia Severity Index (PSI) and CURB-65 decision aids can support clinical
judgement by identifying patients at low risk of mortality who may be appropriate for
outpatient management. Although both decision aids are acceptable, the PSI is supported
by a larger body of evidence and is preferred by other societies (2019 ATS/IDSA Guideline).
Level C Recommendation
Among patients not requiring vasopressors or mechanical ventilation, use the 2007 ATS/IDA
Minor Criteria to help determine which patient require ICU care.
Use CAP clinical decision aids in conjunction with clinician judgement in the context of each
patient’s circumstances to make disposition decision.
A-3

In The ED Patient With Community Acquired Pneumonia, Which Biomarkers
Can Be Used To Direct Initial Antimicrobial Therapy?
Do not rely upon any current laboratory test(s), such as procalcitonin, and/or C-reactive
protein to distinguish a viral pathogen from a bacterial pathogen, when deciding on
administration of antimicrobials in the ED patient with CAP.
In The ED Patient With Community Acquired Pneumonia, Does A Single Dose Of Parenteral
Antibiotics Followed By Oral Treatment Versus Oral Treatment Alone Improve Outcomes?
Given the lack of evidence, the decision to administer a single dose of parenteral antibiotics
prior to oral therapy should be guided by the patient risk profile and preferences.
A-3

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