Malindo Air is serving nasi kandar, spicy chicken and mutton curry, chicken kurma and achar on board its flights – a first for an airline – sasuke costume  prepared specially by the popular Original Penang Kayu Nasi Kandar restaurant chain.

The nasi kandar meals are free in Business Class and priced at RM12 each for economy class passengers.

“Travellers do not really like airline food so we decided to source for something different and since we introduced the nasi kandar meals last month, it has become the top selling meal on all our jet flights,’’ said Malindo chief executive officer Chandran Rama Muthy.

Original Penang Kayu Nasi Kandar managing director Burhan Mohamed said this was the chain’s first such arrangement with a commercial airline.

“We have been catering nasi kandar meals for VVIPs on private jets,’’ he said during a flight to Langkawi.

Burhan operates eight nasi kandar outlets in the country – one in Penang and seven in the Klang Valley.

Malindo passengers are given a 10% discount for a limited period for meals at the eight restaurants but they must show their boarding passes within 24 hours of their travel.

Malindo is Malaysia’s third airline which calls itself a hybrid airline – the in-between of full service and low cost airline – because it provides light snacks on board, offers 20kg free baggage, and free in-flight entertainment.

Malindo began operations seven months ago and now flies from Subang and KL Interna­tional Airport.

“Next, we are looking at introducing mamak mee goreng but that requires more planning,’’ Chandran said.

Malaysia Airlines has been serving its award-winning satay for several years now, while AirAsia serves the famous Hainanese Chicken Rice on its  sakura cosplay costume   flights.

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407 Responses to “Nasi kandar goes airborne on Malindo Air flights ”

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    Continue reading the main story“Start QuoteI think it makes more sense to see the human male preference for younger females largely as an evolved response to the menopause”
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    P. 1Chest X-ray InterpretationChest X-ray InterpretationRatings: (18)|Reads: 102,219|Likes: 57Published by Nuru99More info:Categories:Types, School Work, Study Guides, Notes, & QuizzesPublished by: Nuru99over 4 years agoCopyright:Attribution Non-commercialAvailability:Read on Scribd mobile: iPhone, iPadand Android.Flag for inappropriate content|Add to collectionAACN1904_444–47321/10/08
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    AACN Advanced Critical Care Volume 19, Number 4, pp.444–473 © 2008, AACN
    Chest Radiograph Evaluation and Interpretation
    Debra Siela, RN, PhD, CCNS, ACNS-BC, CCRN, CNE, RRT
    ABSTRACT
    Chest imaging is an important tool in managing critically ill patients. Basic chest radiology is still used to quickly detect abnormalities in the chest. Critical care nurses are often the ones who first read the radiologist’s report of chest radiograph results and provide their interpretation to a physician. Oftentimes, chest radiographs are obtained routinely on a daily basis for every critical care patient, with the goal of effective clinical management. Critical care nurses can confirm cardiopulmonary assessment findings by also evaluating their patient’s chest radiographs and reviewing the radiologist’s report. By learning some basic skills in interpreting and evaluating chest radiographs, nurses can recognize and localize gross pathologic changes visible on a chest radiograph. This article provides basic chest radiograph interpretation information that allows readers to review relevant anatomy and physiology, summarize normal and abnormal findings on chest radiographs, and describe radiographic findings in common pulmonary and cardiac disorders. Keywords: APN, chest imaging, chest radiograph, chest radiograph evaluation, chest radiograph interpretation, critical care nurses
    is important Chest imaging still an illtopatients.tool in managing critically Basic chest radiology is used quickly detect abnormalities in the chest. Critical care nurses are often the ones who first read the radiologist’s report of chest radiograph results and provide their interpretation to a physician. Oftentimes, chest radiographs are obtained routinely on a daily basis for every critical care patient with the goal of effective clinical management. Debate exists about the efficacy of daily or routine chest radiology for critically ill patients. It has been suggested that daily or routine serial chest radiographs are not needed. Some research supports obtaining daily routine chest radiographs for critically ill patients to be able to identify even subtle changes.1–3 Mettler4 supports daily chest radiographs in critically ill patients. Mettler reports that in daily chest radiographs, 60% do not disclose either new major or minor findings, 20% have new minor
    findings, and 20% have new major findings that are clinically unsuspected and are seen only on the radiograph.4 Other research supports discontinuing daily routine chest radiographs for critically ill patients because subtle changes may not be clinically significant and because of the use of resources and cost.5–7 Some consensus exists for routine but not daily chest radiographs depending on the nature of the acute illness.8 Many of these studies1,3,9 suggest using clinical assessment to guide the need to obtain confirmatory chest radiographs whether or not they are daily or routine. Critical care nurses can confirm cardiopulmonary assessment findings by also interpreting
    Debra Siela is Assistant Professor, Ball State University School of Nursing, and ICU Clinical Nurse Specialist, Ball Memorial Hospital, 2000 University Ave, Muncie, IN 47306 (dsiela@bsu.edu).
    444
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    VOLUME 19 • NUMBER 4 • OCTOBER–DECEMBER 2008
    C H E S T R A D I O G R A P H E VA L U AT I O N A N D I N T E R P R E TAT I O N
    their patient’s chest radiographs and reviewing the radiologist’s report. This process can aid in planning appropriate nursing care. This article provides information on basic chest radiology interpretation that will allow the reader to review relevant anatomy and physiology, summarize normal findings on chest radiographs, and describe radiographic findings in common pulmonary and cardiac disorders. Basic Chest Radiography X-rays are very short wavelengths of electromagnetic radiation that penetrate matter.4,10–12 A traditional radiograph is created when x-rays penetrate a structure and produce images on a piece of photographic film usually contained in a cassette. However, in most hospitals and medical centers, the traditional x-ray film has been replaced with digital images. Special detectors are used to replace the film in the cassettes and convert the x-ray energy into digital signals to construct a digital radiograph. The digital images are stored on and distributed on a picture archiving and communications system (PACS).4,10–13 A PACS allows viewing access far from the radiology department at any computer workstation at any time. Digital radiographs can be manipulated to alter contrast and brightness or magnify images to see any abnormality. Every sample radiograph included in this document is from a digital format. Each radiograph has a continuum of shades from black to white in its images due to the way the body structures or tissues absorb the x-ray beam.4,10–13 X-rays penetrate body tissues that have minimal tissue density, such as air or air-filled structures, and produce black or dark areas on the radiograph; these areas are referred to as radiolucent. Areas or body tissues that cannot be penetrated by x-rays are radiopaque and appear light or white on the radiograph. Thus, each body tissue or structure has different radiodensity. The 4 basic roentgen densities or radiodensities4,10–13 are • gas (air), which appears black or radiolucent; examples are gas or air in trachea, bronchi, or stomach; • fat, which appears gray or less radiolucent than air; an example is lipid tissue around muscle; • water (soft tissue), which appears white with slight radiopacity; examples are the
    heart, blood vessels, muscle, and diaphragm; and • bone (or metal), which appears all white or completely radiopaque; examples are bones, calcium deposits, prostheses, and contrast media. Figure 1 provides a review all of the chest tissues and structures basic radiodensities in a chest radiograph, and Figure 2 identifies each chest structure or tissue on a frontal chest radiograph (note that all figures appear at the end of the article). If 2 structures of equal density are adjacent to each other, the border of neither structure can be detected. This phenomenon, the silhouette sign, is used to identify normal chest structures and diagnose and localize lung diseases.4,10–13 The silhouette sign may be used to distinguish anterior from posterior structures on a chest radiograph.4,10–13 For example, a silhouette sign would be expected in an area of consolidation in the left upper lobe of the lung because this lobe borders the left sides of the atrium and the mediastinum. Because both the area of consolidation and the heart are water densities, the left border of the atrium cannot be distinguished from the border of the left upper lobe of the lung (Figure 3). Views of the Chest Two of the most common radiographs are posteroanterior (PA) and anteroposterior (AP) or frontal views of the chest.4,10–13 For PA views, the x-ray beam passes through the chest from the back to the front. For AP views, the beam passes through the chest from the front to the back. For acutely ill patients who cannot stand up for a PA view, AP views are obtained with a portable x-ray machine. Ketai and coworkers13 report that more than half of all chest radiographs in hospitals are performed at the bedside. Many of the sample radiographs in this article are AP views. The next most common view of the chest after the frontal view is the lateral view.9 Lateral views of the chest enable detection of lesions behind the heart, near the mediastinum, or near the diaphragm.10,12 The lateral view also allows for visualizing the tracheal air column, inferior vena cava, retrosternal space, posterior margin of the heart, and diaphragmatic contour.10,11 A patient’s frontal and lateral view radiographs allow the viewer to have a vision of the chest in 3 dimensions so that the viewer can more easily localize infiltrates and lesions.
    445
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    In addition, if ventricle enlargement is suspected on the frontal chest image, a lateral view may help confirm the finding. Portable lateral view chest images are also used to evaluate presence of pleural effusions that cannot be seen on frontal views because they are small in size.10 It takes 250 mL of fluid to blunt a lateral costophrenic sulcus on a frontal radiograph, but only 75 mL to blunt the posterior costophrenic sulcus on a lateral radiograph.10 Sometimes, a lateral decubitus view radiograph (patient lying either on one side or on the other) is obtained to evaluate possible pleural effusions and their fluid levels.13 Figure 4 shows lateral view chest structures and tissues. Technical Factors of Viewing Chest Radiographs It is necessary to consider whether each of the following factors are adequate or appropriate to accurately assess and evaluate normal and abnormal chest radiograph findings.10–13 Penetration X-rays must adequately penetrate body structures to visualize the structures. For example, one should be able to faintly see the thoracic spine through the heart shadow.10 If you cannot, the chest radiograph is underpenetrated or too light. In this situation, the left hemidiaphragm may not be visible because the left lung base can appear opaque, which may hide or mimic true disease in the left lower lung field.10 A lateral view will be necessary to confirm any abnormalities in the left lower lung field. In addition, the pulmonary markings may appear more prominent then they really are and may be interpreted as interstitial pulmonary edema or pulmonary fibrosis.10 Again, a lateral view will be necessary to confirm the interstitial findings. If the chest radiograph is overpenetrated or too dark, the lung markings may appear to be absent or decreased.10 It is then possible to make the judgment that the patient has emphysema or pneumothorax when in reality this pathophysiology does not exist.10 One could also miss a pulmonary nodule when the chest radiograph is overpenetrated.10 Inspiration A full-inspiration chest radiograph can be reproduced from one time to the next to eliminate the possibility of artifacts that may confuse the viewer to think that disease is present.10 If one can count 10 posterior ribs
    above the diaphragm, it is an excellent inspiratory film.10 When less than 10 ribs can be counted above the diaphragm, it is either poor inspiratory effort or a sign of low lung volume. Low lung volume from a poor inspiration effort can crowd and compress the lung markings, producing the impression that a lower lobe pneumonia is present. Rotation In AP radiographs, patient malposition or rotation may appear to indicate abnormalities in cardiac, vascular, or mediastinal contours when, in fact, they may not exist.11,13 The position of the clavicles help identify a patient’s rotation.11,13 If one clavicle appears to be shorter in length than the other, then one side of the chest may be rotated close to or away from the detector cassette, producing what appear to be abnormalities.11,13 Figure 9 shows a difference in clavicle length. Comparing the length of the clavicles in addition to comparing the symmetry of the distance between the spinal pedicles and clavicle heads as a method of identifying chest rotation is an important part of the radiograph examination. If one identifies asymmetry in the distance between the pedicles (outer edge of spinal vertebra) and the clavicle heads, the chest is likely rotated.10,13 Figure 9 shows an example of asymmetry between the spinal pedicles and the clavicle heads due to chest rotation. Magnification Anteroposterior views obtained with a portable machine have some disadvantages. Structures in the anterior part of the chest are magnified on AP views, so structures such as the heart are not as distinct as on PA views and may even be distorted.4,10–13 The heart and the mediastinum appear about 15% wider than on the PA view.13 This phenomenon occurs on an AP view mainly because of the shorter distance between the x-ray tube and the patient than occurs in a PA view.4,10,11 Angulation Posteroanterior views are sharper and more distinct with less chest rotation and have consistent clavicle placement because they are always obtained with the patient upright and 2 m (6 ft) away from the source of the x-rays and at a 90 angle to the beam, whereas angles less than 90 are often used for AP radiographs because of inability of critically ill patients to
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    be positioned at 90 .12 Thus, the x-ray beam ends up entering the chest with the patient’s head and chest tilted backward.10 This creates what is called an apical lordotic view of the chest.10 In a chest radiograph that is an apical lordotic view, the clavicles project at or above the posterior first ribs and make the clavicles appear to be straight.10 The apical lordotic view can create the illusion of cardiomegaly when, in fact, it does not exist.10 Systematic Method of Viewing A systematic method should be used to examine chest radiographs.4,10–12,14,15 Radiographs may be examined from side to side, from top to bottom, or structure by structure. Following is the suggested order for structure-by-structure examination of the frontal view (PA or AP) chest radiograph, which can all be viewed in Figure 2. 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. Soft tissues Trachea Bony thorax/ribs Intercostal spaces Diaphragm Structures below diaphragm Pleural surfaces Mediastinum Hila Lung fields Support catheters, tubes, wires, and lines
    neous layer of the skin or soft tissues.10 Subcutaneous emphysema commonly occurs from penetrating chest injury or a chest tube.10 Figure 6 shows subcutaneous emphysema. Trachea The trachea appears as a column of radiolucent tissues or gas density midway between the clavicles or over the spine. The carina is normally positioned approximately at the level of the sixth posterior rib or T4 (Figures 3 and 7).11–13 When an endotracheal (ET) tube is placed correctly, the tip of the tube is approximately 3 to 5 cm (approximately 2 in.) above the carina. Figure 8 shows a chest radiograph with an ET tube down in the right main stem bronchus. Tracheal deviation is present when the trachea is positioned to the right or to the left of the midline. A common cause of apparent tracheal deviation is chest rotation (Figure 9). True tracheal deviation may be caused by the presence of a tumor, mediastinal shift, pneumothorax, or major atelectasis. Figure 25 shows the tracheal deviation due to atelectasis. Bony Thorax The humeri, scapulae, clavicles, spine, and ribs should be identifiable as bone densities. On a radiograph obtained during inspiration, 9 to 10 posterior ribs to the lateral top of the diaphragm should be visible (Figure 2). Each rib should be followed along its course to assess for any notching or deformities; symmetry of rib structures should be assessed bilaterally. Radiographs of patients with chest trauma should be checked for evidence of rib fractures. Intercostal Spaces Each intercostal space is numbered according to the rib above it. The width of the intercostal spaces is determined by measuring the degree of the costovertebral angle relative to the posterior ribs. The normal angle is about 45 ; with widened intercostal spaces, the angle may double to more than 90 .11–13 Widened intercostal spaces occur in conditions such as chronic obstructive pulmonary disease, pneumothorax, and pleural effusion that increase lung volume.11–13 Figures 9 and 10 show an example of widened intercostal spaces. Narrowed intercostal spaces, such as that occurs in atelectasis and interstitial fibrosis, are associated with conditions that decrease lung volume.11–13 Figures 22 and 30 show an example of narrowed intercostal spaces.
    Following is the suggested order for viewing lateral view structures, which all can be seen in Figure 4. 1. 2. 3. 4. 5. 6. 7. Bones Mediastinum Hilum Heart Diaphragm/pleura Lung fields Support catheters, tubes, wires, and lines
    Viewing of Normal Chest Structures Soft Tissues The soft tissues of the chest consist mainly of fat and some water densities.4 The tissues should appear symmetric when compared side to side. Breast tissue is an example of soft tissue. Sometimes, breast tissue shadows obscure the lower lung tissue (Figure 5).4 Subcutaneous emphysema results from air in the subcuta-
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    Diaphragm The diaphragm has a water density, and each hemidiaphragm is dome-shaped. The right hemidiaphragm is normally higher in the chest than is the left hemidiaphragm because of the liver (Figure 2).11–13 Diaphragmatic elevation is evident when fewer than 9 to 10 ribs are visible and can be caused by abdominal distension, phrenic nerve compression, or lung collapse (atelectasis; Figures 22, 24, and 28).11–13 Diaphragmatic depression is present when 11 to 12 ribs are visible.11–13 Depression or flattening of the diaphragm is associated with hyperinflation of the lung or thorax as in chronic obstructive pulmonary disease and pneumothorax.11–13 See examples of diaphragm depression (flattening in chronic obstructive pulmonary disease, Figure 9, and also in a pneumothorax, Figure 10). Structures Below the Diaphragm Almost all of the structures below the diaphragm are primarily water densities. The exception is the gastric air bubble, which may be visible in many frontal radiographs (Figure 2).11–13 Pleural Surfaces The pleurae normally appear as thin, hairlike lines along the lateral edges of the chest and along the diaphragm. When the pleural line deviates medially and appears in the lung fields, a pneumothorax may be present.11–13 When a pneumothorax is present, the area outside the line to the lateral edge of the chest (eg, the pleural space) will appear more radiolucent or completely black.11–13 The costophrenic sulcus (angle) may also be displaced inferiorly and increase the lucency at the same time in a large pneumothorax. This is termed the deep sulcus sign.10 The lung itself will appear more radiopaque or more dense (Figure 10). Mediastinal shift toward the affected lung may also occur in a large pneumothorax. In contrast, in tension pneumothorax, the mediastinum shifts away from the affected lung, and the diaphragm commonly is depressed on the affected side.12 See reinflated left lung with chest tubes in Figure 11. The costophrenic sulcus/angle (Figure 2) should appear as deep sharp points like a V on a frontal view. If the costophrenic sulcus are not distinct deep points on the lateral sides of the chest and appear blunted, a pleural effusion may be the cause.11–13 If a horizontal fluid level or meniscus can be visualized in the area
    of the costophrenic sulcus, a pleural effusion most likely has occurred.11–13 It takes approximately 250 mL of fluid to blunt the costophrenic sulcus on a frontal view radiograph.10 Right-side pleural effusions occur frequently in heart failure. Figures 8, 12, and 32 show pleural effusions. Mediastinum The mediastinum includes the heart, major blood vessels,canada goose outlet, the trachea, and the right and left main bronchi. The heart and blood vessels are water densities, whereas the trachea and bronchi are air densities. The right atrium forms the right border of the heart. The right ventricle cannot be detected directly on a chest radiograph because this structure is located in the center of the heart shadow. The superior vena cava is visualized above the ascending aorta shadow in the right chest.12 An indentation can be located down in the mid-hilar area that marks the junction of the right atrium and superior vena cava (Figure 2). This is the area where the tips of central venous catheters should be located and where a pulmonary artery catheter should enter the right side of the heart.10 The left atrium and the left ventricle form the left border of the heart. The aortic arch is visible as the aortic knob on the frontal view. The descending aorta is about 3 cm above and to the left of the carina (Figure 3).11–13 The main pulmonary artery is the next shadow contour below the aortic knob on a frontal view radiograph.10 Sometimes, the left descending pulmonary artery can be seen as far down as the next contour shadow following the main left pulmonary artery (Figure 2). The cardiothoracic ratio can be determined to assess the overall size of the heart.11–13 This ratio is determined by measuring the horizontal width of the heart and dividing that width by the widest interval of the thorax. The normal cardiothoracic ratio is 1:2 or less (Figure 13).11–13 A cardiothoracic ratio greater than 1:2 is suggestive of cardiac enlargement.11–13 Cardiac enlargement can be determined more precisely by comparing the findings on serial radiographs.13 An increase in the diameter of the heart of 1 cm or greater is considered cardiac enlargement.13 If cardiac enlargement appears to be present, right ventricular enlargement must be distinguished from left ventricular enlargement. Frontal view radiographs show the following during left and right ventricular enlargement:
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    • The left lower border of the heart is moved laterally and becomes rounded in left ventricular enlargement (Figure 14).12,13 • The right atrium protrudes into the right side of the chest and becomes more convex in right ventricular enlargement (Figure 15).12,13 Left and right cardiac enlargement is likely in the lateral view when • the left heart border moves inferoposteriorly beyond the inferior cava toward the spine in left ventricular enlargement (Figure 16).12,13 • the right ventricle shows enlargement by moving anteriorly and superiorly with filling of the anterior retrosternal clear space. Normally, on the lateral view, the lower one third of the right ventricle contacts the sternum (Figure 4). Whereas, in right ventricle enlargement, the right ventricle contacts the lower one half of the sternum.12,13 See Figure 17. The mediastinum can also be widened for many reasons, including focal masses or fluid infiltration. Focal masses usually cause sharp and convex mediastinal widening.12 Mediastinal infiltrations come from hemorrhage or infection and produce widening that appears generalized and diffuse.12 See Figure 18, which shows a wide mediastinum for a new postoperative cardiac surgery patient. Figure 19 shows a thoracic aortic aneurysm, which may be suspected because of the widened thoracic aorta, which also widens the mediastinum. Hila The hila consist of the pulmonary arteries and veins and appear blotchy because of various areas of radiopacity associated with different sizes and thickness of blood vessels. The heart shadow obscures the left hilar area and makes the left hilum appear smaller and higher than the right hilum.13 The left hilum is positioned slightly higher than the right hilum in 97% of all individuals.12 Bronchovascular markings refer to blood vessels and bronchi that branch out from the hila to the periphery of the lung fields (Figure 2).12 As the markings extend out into the lung fields and gradually taper off in the periphery, the structures consist of mainly pulmonary blood vessels and no bronchi. The pattern of pulmonary venous hypertension is seen in patients with elevated pulmonary venous pressure, which is usually caused by left ventricular failure and increased hydrostatic
    pressure.16 You will note increased prominence and thickening of the upper lobe blood vessels in the hila,parajumpers parka, decreased prominence of the lower lobe blood vessels, and haziness of the hilar vessels, which is the process of cephalization.10,11 Figure 20 shows pulmonary venous hypertension. Pulmonary artery hypertension is caused by conditions that decrease the flow of blood through the pulmonary capillary bed such as emphysema, pulmonary emboli, and vasoconstrictive states.16 The hilar trunks are enormously dilated in response to the constricted arterial bed.11 See Figure 21 to view pulmonary arterial hypertension. Hilar elevation is usually present in collapse of the upper lobes of the lung, whereas hilar depression occurs in collapse of the lower lobes of the lung.13 Collapse of the right middle lobe does not cause hilar displacement.13 Lung Fields The lung fields consist mainly of air and very little tissue or blood.11–13 As a result, lung fields should be visualized as an air/gas density or as a completely radiolucent area. Abnormalities of the lung fields on chest radiographs include interstitial patterns and alveolar consolidation patterns. See further descriptions of interstitial and alveolar consolidation patterns under radiographic signs of cardiac and pulmonary disease. Determining the locations of the various lobes of the lungs is useful for diagnosing and localizing pulmonary disease.11–15 The right middle lobe is located anteriorly, adjacent to the right side of the heart. The left lingular lobe is in direct contact with the left border of the heart.12 The upper lobes and the right middle lobes of the lung are primarily anterior thoracic structures, whereas the lower lobes are primarily posterior structures. Knowing the different locations of the lung lobes makes it possible to use the silhouette sign. See Figure 3 for a left upper lobe lung consolidation that borders the left heart. See Figure 21 for a right lower lobe pneumonia where the right-sided heart border is distinct. See Figure 28 for a left lower lobe infiltrates with distinct left-sided heart border. See Figure 30 for an example of complete consolidation where the heart cannot be identified. Fissures are separations or spaces between the lung lobes and appear as narrow white lines on a chest radiograph.11–13 Fissures are normally the thickness of a sharpened pencil line.10 In frontal and lateral views, the area
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    where the minor fissure separates the right middle lobe from the right upper lobe may be visible. The minor fissure is located almost in the middle of the right lung fields, where it appears as a horizontal line on the frontal radiograph (Figure 22).12 One of the direct signs of lung collapse in the right upper lobe on a frontal radiograph is elevation of the minor fissure (Figure 23).11–13 In collapse of the right middle lobe, downward displacement of the minor fissure may be evident. The major or oblique fissures separate the upper lobes of the lung from the lower lobes. The major fissures cannot be seen on a frontal view but are visible on a lateral view.13 See Figure 4 to view the major fissure. Support Catheters, Tubes, Wires, and Lines Critically ill patients commonly have support catheters, tubes, wires, and lines. This invasive support equipment includes, for example, ET tubes, tracheostomy tubes, chest tubes, nasogastric or feeding tubes, central line catheters, peripherally inserted central catheter lines, pulmonary artery catheters, and pacemaker wires. Invasive support equipment is often evaluated as to its position in the chest or abdomen on a chest radiograph. See Table 1 for a list of common catheters,canada goose parka, tubes, wires, and lines that are inserted in the chest with their proper location in a chest radiograph. Nurses should be aware of the correct positions of this support equipment in the chest and abdomen and on a radiograph. The radiographs in Figures 24 and 25 contain various support equipment in both correct and incorrect positions. Several other examples of chest radiographs also show support equipment in both correct and incorrect positions (Figures 3, 6, 8, 16, 18, 27, 32, and 35). However, identifying that a catheter, tube, wire, or line is in a correct position in the chest or abdomen will also require confirmation by a radiologist and the nurse should rely on his or her evaluation. Alveolar and Capillary Anatomy and Physiology An understanding of alveolar and capillary anatomy and physiology is essential for interpreting radiographic indications of pulmonary disease of the air spaces and interstitium. Alveoli consist of 2 different types of cells. Most alveoli are lined with type I cells, which are flat, squamous cells. The corners of alveoli contain
    type II cells, which produce surfactant. Alveolar macrophages are phagocytic cells that clear particles from these air spaces. Openings between alveoli (pores of Kohn) permit movement of gases between adjacent alveoli.16,17 Many structures and substances, such as fluid, connective tissues, leukocytes, and macrophages, are located in the walls between alveoli.16,17 Capillaries are interposed between alveoli in a network. The contact of alveolar surfaces with capillary surfaces forms the alveolarcapillary membrane, the structure through which gas exchange occurs. The alveolar-capillary membrane has a thin side and a thick side.16,17 The thin side bulges into the alveolus and is the primary site for gas exchange. The fusion of alveolar and capillary basement membranes creates the thin side. The thick side includes the alveolar and capillary basement membrane separated by the alveolar interstitial space. The alveolar interstitial space is made of connective tissue such as elastic fibers, collagen fibrils, and fibroblasts. The thick side of the alveolar-capillary membrane does not conduct gas exchange as easily as the thin side does; rather, it promotes fluid exchange in the lung.16,17 Excess fluid in an alveolus is drained via the alveolar interstitial space into the nearby lymphatic system and/or into the connective tissue fibers.16,17 The connective tissues of the alveolar interstitial space form the support system for the alveolar and pulmonary capillaries. Excess fluid in the alveolar interstitial space fluid is drained via the connective tissue fibers into the potential peribronchial and perivascular interstitial space.16,17 The peribronchial and perivascular interstitial spaces surround the bronchioles, bronchi, pulmonary arterioles, and pulmonary arteries interspersed between alveoli in a network. The contact of alveolar surfaces with capillary surfaces forms the alveolar-capillary membrane through which gas exchange occurs. Radiographic Signs of Pulmonary Disease Most pulmonary diseases are associated with increased density of the lung fields on chest radiographs.12 Increased density involves changes in the interstitium, the air spaces, or both. Interstitial Pulmonary Disease In interstitial pulmonary disease, the volume of the alveolar interstitium increases with no
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    Table 1: Support Catheters, Tubes, Wires, and Lines in Chest Radiographs
    Support Equipment ET tube Proper Position 3 to 5 cm from the carina Half the distance between the medial ends of the clavicle and carina Carina is over T5 to T7 Additional Information ET tube tends to slide into the right main bronchus because of a shallower angle ET tube can descend 2 cm during neck flexion ET tube can ascend 2 cm during neck extension TT TT tip should be halfway between the stoma in which the tube was inserted and the carina TT tip should be at about T3 CVC Reach the medial end of clavicle before descending If CVC tip descends beyond the indentation that marks the junction of the right atrium and superior vena cava, it is in the right atrium Descend lateral to spine CVC tip should be in the superior vena cava and not into the right atrium PICC PICC tip should be within the superior vena cava, which should be above the indentation that marks the junction of the right atrium and superior vena cava May be difficult to visualize Pulmonary artery catheter (Swan Ganz Catheter) Tip should be in the proximal left or right pulmonary artery Tip should be about 2 cm from the hilum Insertion into right jugular vein most commonly Temporary catheter tips should be in superior vena cava Permanent catheter tips should be in the right atrium Pleural drainage tubes: Chest tubes and thoracotomy tubes For pleural effusion, tubes should be placed posteriorly and inferiorly For pneumothorax, tube tips should be placed anteriorly and superiorly Ideal position is anterosuperior for evacuating a pneumothorax Ideal position is posteroinferior for evacuating a pleural effusion (continues) If side hole extends outside chest wall, an air leak may occur causing subcutaneous emphysema Rapid lung reexpansion can cause reexpansion pulmonary edema Pulmonary artery catheter tip should not be located in a peripheral or distal artery because of the increased risk of infarction PICC may migrate over time, so monitoring its position is important Incorrect positioning of a TT could penetrate the trachea and cause pneumothorax and subcutaneous emphysema Common malpositioning of a CVC includes placement in the right atrium and internal jugular vein Pneumothorax occurs in 5% of all CVC insertions10 Should obtain chest radiograph postinsertion
    Double lumen catheters: “Quinton” hemodialysis catheters
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    Table 1: Support Catheters, Tubes, Wires, and Lines in Chest Radiographs (Continued)
    Support Equipment Pacemakers Proper Position Implanted subcutaneously in left anterior chest wall Tip of one lead is almost always located in the apex of the right ventricle Two lead pacemakers have 1 lead in the right atrium and 1 in the right ventricle Three lead pacemakers have 1 lead in the right atrium, 1 lead in the right ventricle, and 1 lead in the coronary sinus All leads should have gentle curves AICDs AICDs can be differentiated from pacemakers by the wider and more opaque segment of at least 1 of the electrodes One lead is placed in the superior vena cava or brachiocephalic vein If has another lead, it is placed in the apex of right ventricle Bends in leads should be smooth curves, not sharp kinks Intra-aortic counter pulsation balloon pump (IABP) Placed in descending thoracic aorta Tip should lie distal to origin of the left subclavian artery Metallic marker may point slightly toward the right in the region of the aortic arch When inflated, the balloon may appear as an air-containing sausage in the thoracic aorta NG tube Tip and all side holes should extend about 10 cm into the stomach beyond the EG junction to prevent aspiration from the administration of the feeding into esophagus The EG junction is usually located at the junction of the left hemidiaphragm and the left side of the thoracic spine (left cardiophrenic angle) Dobbhoff feeding tubes Tip of feeding tube should be in duodenum so as to reduce the risk of aspiration Tip is recognizable by a weighted metallic end NG tubes are the most commonly malpositioned of all tubes; always check with a radiograph to confirm the location When malpositioned, NG tubes are frequently coiled in the esophagus If inserted in the trachea, the NG tube can extend into a bronchus and to the periphery of the lung Placement in the stomach is common Placement in the trachea can occur Confirmatory radiograph is needed after placement before beginning feedings If catheter is too proximal, balloon may occlude great vessels leading to stroke If balloon is too distal, device has decreased effectiveness Visible complications can include lead breakage and dislodgement Additional Information Pneumothoraces occur during insertion Fracture of leads may occur
    Abbreviations: AICD, automatic implantable cardiac defibrillators; CVC, central venous catheter; EG, esophagogastric; ET tube, endotracheal tube; NG tube, nasogastric tubes; PICC, peripherally inserted central catheter; TT, tracheostomy tube.
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    change in the alveolar air volume. The alveolar interstitial space increases in size because of fluid, fibrosis, inflammation, or abnormal tissue growth.12 Chronic diffuse interstitial lung disease is usually caused by pulmonary fibrosis.12 In chronic interstitial pulmonary disease, the markings are sharp and the branching is irregular.12 See Figure 26 to view an interstitial pulmonary pattern. Acute diffuse interstitial lung disease is usually due to cardiogenic or noncardiogenic pulmonary edema such as that associated with acute respiratory distress syndrome (ARDS), viral/mycoplasmal pneumonia, or heart failure.12 In ARDS, interstitial edema is caused by direct injury of pulmonary endothelial cells by inflammatory mediators. Gas exchange is impaired by thickening of the thin side of the alveolar-capillary membrane, which increases the distance that oxygen and carbon dioxide diffuse between the alveoli and the capillaries. In acute interstitial pulmonary disease, the markings are hazy with normal branching of the vascular bed and bronchi.12 In interstitial lung disease with normal aeration of the alveoli, chest radiographs typically show increased vascular markings due to more prominent blood vessels.11–13 In addition, lines may be visible in the upper or lower lobes because of thickening of fissure lines. Depending on the type of interstitial lung disease, the markings are as follows11–13: • reticular or linear, which appear as small lines or sometimes as a mesh such as in interstitial pulmonary edema and pulmonary fibrosis; • nodular, which appear as small round dense opacities; examples include bronchogenic cancer and lung metastases; and • reticulonodular, which are a combination of reticular and nodular markings and is the most common type, which includes sarcoidosis. Air Space Disease (Alveoli) Air space or alveolar disease involves reduction of air because of alveolar consolidation, atelectasis, or both. In alveolar consolidation, also termed infiltrates, tissue or fluid replaces all of the air in the alveoli and the lung tissue appears opacified or a water density.12 An alveolar pattern occurs when many alveoli are
    filled with fluid or tissue creating a water density or fluffy appearance. However, in an alveolar pattern, not all alveoli in 1 lung area are filled with fluid or tissue, so the infiltrates appear as “patchy” water densities. Signs of alveolar consolidation on a chest radiograph include the silhouette sign and the air bronchogram sign.11–13 An air bronchogram sign is the radiographic shadow (a radiolucent area) of an air-filled bronchus running through an airless area of lung, which appears opacified (Figure 27).11–13 Figure 3 illustrates a silhouette sign with no clear left-sided heart border caused by left upper lobe pneumonia and consolidation. Decreased lung air volume in alveolar consolidation decreases respiratory gas exchange of oxygen.16 Common causes of consolidation are bacterial pneumonias, cardiogenic pulmonary edema, and noncardiogenic edema such as ARDS.11–13 In cardiogenic pulmonary edema, increased hydrostatic pressure in the blood forces fluid out into the interstitium and alveoli, which can cause alveolar consolidation.10 In ARDS or noncardiogenic edema, direct injury to the alveoli increases permeability of the alveolar-capillary membrane, which over the next 48 hours allows fluid to fill the alveoli and can cause complete lung consolidation.10,16 This complete consolidation can be visualized as a complete whiteout on chest radiographs for ARDS or cardiogenic pulmonary edema (Figures 30 and 35).10–13 Atelectasis is caused by the following 4 pathophysiologic conditions10,13: 1. Air is absorbed from the alveoli (resorptive), usually because of lack of ventilation from an obstruction above the alveoli such as a mucus plug, tumor, foreign body, or occluding inflammation or edema. 2. Alveoli are compressed because of increased intrathoracic pressure (relaxation or passive), such as the opposite lung compressed from a tension pneumothorax. 3. Alveoli collapse from fibrosis or scarring, which is termed cicatrization. 4. Alveoli collapse from loss of surfactant (adhesive) like in ARDS. Hypoventilation can also cause alveoli to lose air volume and become atelectic. Left lower lobe atelectasis is very common following coronary artery bypass surgery.13 One should expect to view signs of left lower lobe atelectasis on these patients’ postoperative
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    radiographs. In all instances of atelectasis, diminished tissue oxygenation occurs because of lack of oxygen in the alveoli. Direct signs of atelectasis on a chest radiograph include displaced fissures, crowded bronchovascular markings, and shifted position of a marker structure such as a scar,parajumpers jacket, nodule, or granuloma.12 Indirect signs of atelectasis are structural shifts in the positions of the hila, diaphragm, and mediastinum and increased density or radiopacity of the lung tissue.12,13 Figure 23 shows both direct and indirect signs of atelectasis. When atelectasis is localized, oblique or horizontal lines may appear. These radiograph changes are called discoid, subsegmental, or plate-like atelectasis (Figure 31).13 Keep in mind that to confirm atelectasis in a lower lobe, a lateral view radiograph may be necessary.13 Two other airspace deformities that are seen on chest radiographs are blebs and bullae. Blebs and bullae are thin-walled air-filled spaces commonly located in the upper lobes and are radiolucent.10 These develop because of alveolar destruction associated with emphysema. Blebs are relatively small air cavities of size less than 1 cm.4 A bulla is greater than 1 cm and often much larger.4 See Figure 9 for examples of bullae. Air Space Disease and Noncardiogenic Pulmonary Edema (ARDS) Patients with ARDS can have a combination of air space disease with both alveolar consolidation and atelectasis.13 Diffuse and patchy alveolar infiltrates occur beginning in the periphery about 12 hours after the insult to the alveolar-capillary membrane (Figure 28).10 Chest radiographs show a primary alveolar pattern with additional signs of atelectasis caused by reduced lung volume from loss of surfactant within 24 to 48 hours postinsult (Figure 29).10,11 Air bronchograms are commonly seen during this stage.10 Complete alveolar consolidation may also occur (Figure 30). In addition,canada goose norge, most likely both indirect and direct lung injury coexist in ARDS.10 However, the consolidation pattern of direct injury usually predominates over the interstitial pattern attributable to indirect injury.13 When a patient survives ARDS, a chronic interstitial pattern due to pulmonary fibrosis often becomes apparent on chest radiographs obtained 1 week or more after the acute stage or diagnosis of ARDS.10,11 The chest radiograph of a post-ARDS patient may look similar to that of Figure 26.
    Radiographic Signs of Cardiac Disease Radiographic signs of cardiac disease are similar but also differ from those of pulmonary disease. Following are descriptions of radiographic signs of cardiac disease. Heart Failure and Cardiogenic Pulmonary Edema In addition to left ventricular enlargement, cephalization or vascular redistribution is an indication of left ventricular failure.11–13 In a patient standing upright, the pulmonary blood vessels are larger in the lower lobes of the lung than in the upper lobes. If the blood vessels in the upper lobes are larger than the blood vessels in the lower lobes, the condition is termed cephalization or vascular redistribution.12 Cephalization occurs because of increasing left ventricular pressure. When pulmonary capillary wedge pressure (PCWP) becomes elevated or left atrial pressure is greater between 10 and 15, cephalization occurs.10,11 In addition, if hydrostatic pressure increases to greater than 10, fluid leaks into the interstitium.10 See Figures 20 and 32 to view cephalization. In addition, as PCWP continues to increase to 19 to 20 mm Hg, interstitial edema begins (Figure 33).10 Kerley lines are a radiographic sign with interstitial pulmonary edema. They are thin linear pulmonary opacities caused by fluid or cellular infiltration into the interstitium of the lungs. There are 3 types of Kerley lines with Kerley B being the most common. Kerley B lines are due to thickening of interlobular septa caused by increased tissue or fluid, as in interstitial pulmonary edema.10,13 Kerley B lines are seen as horizontal lines no more than 2 cm long that appear in the lung periphery near the costophrenic angles and lateral wall (Figure 33). Kerley A lines are caused by distension of channels that connect the peripheral and central lymphatics of the lungs. Kerley A lines appear as oblique lines approximately 2 to 6 cm long that course diagonally toward the hila from the periphery in the upper lobes.10,11 One does not see Kerley A lines without Kerley B lines (Figure 33).10 Kerley C lines supposedly represent thickening of lymphatics that appear as short fine lines throughout the lungs with a reticular appearance. Some radiologists claim that Kerley C lines do not actually exist.10 It is also suggested that what is thought to be Kerley C lines are a combination of Kerley A and Kerley B lines.10
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    Peribronchial cuffing may also be seen in interstitial pulmonary edema. Normal bronchial walls appear as pencil-point thin when viewed end-on.13 Interstitial edema widens the bronchial walls and makes their margins appear indistinct, which is termed peribronchial cuffing.13 Some radiologists describe peribronchial cuffing as appearing as small doughnut densities on the radiograph.10 See Figures 12, 14, 30, 33, and 34 for examples of peribronchial cuffing. In addition, a butterfly or batwing pattern may become apparent on chest radiographs during interstitial pulmonary edema due to heart failure (Figure 34).10,11 The butterfly pattern is due to the fluid engorgement of the interstitium adjacent to the hilar blood vessels.13 Lower lung zones are usually much more affected than upper lung zones.10 Once edema due to heart failure involves the entire alveolar interstitium as a result of increasing PCWP and increased left ventricular pressure, the alveoli start to become edematous.13 At this point, the PCWP is usually greater than 25 mm Hg.10,11 At this time, an alveolar consolidation pattern becomes evident on chest radiographs (Figure 35).10,11 When resolution of this alveolar edema begins, it clears from the periphery and moves centrally.10 However, not all patients with high PCWP have evidence of heart failure on chest radiographs. Pleural effusions are also common in moderate to severe heart failure as indicated by a shallow costophrenic sulcus. The 3 classic stages of cardiogenic pulmonary edema are cephalization (Figure 32), interstitial edema (Figures 33 and 34), and alveolar edema (Figure 35). However, radiographic findings often differ between acute heart failure and chronic heart failure.13 For example, interstitial edema and Kerley B lines do not seem to occur until venous pressures are higher in chronic heart failure than in acute heart failure.13 Radiographs of chronic heart failure are more likely to show cephalization (vascular redistribution) than interstitial edema, whereas in acute heart failure, one is more likely to view interstitial edema.13 Radiographic Sign Differences of Cardiogenic and Noncardiogenic Pulmonary Edema Radiographic signs differ between cardiogenic and noncardiogenic pulmonary edema. Kerley B lines and peribronchial cuffing are seen in
    radiographs of cardiogenic pulmonary edema but not in ARDS radiographs.10 The distribution of pulmonary edema tends to be even in cardiogenic pulmonary edema but is distributed more to the periphery in ARDS.10 Air bronchograms are seen commonly in ARDS radiographs, whereas they are not commonly seen in cardiogenic pulmonary edema radiographs.10 Pleural effusions are much more likely to be seen on cardiogenic pulmonary edema radiographs than on ARDS radiographs.10 Implications for Nurses Signs and symptoms that patients have during acute illness may be indicative of many different types of pathophysiologic or disease processes. Critical care nurses can use chest radiographs as an additional bedside assessment tool to assist in determining pathophysiologic abnormalities and to confirm other assessment findings. By learning some basic skills in interpreting chest radiographs, nurses can recognize and localize gross pathological changes visible on a chest radiograph. Nurses are the care providers who are consistently present at the bedside and have up-todate information on patients’ clinical status. For example, changes in densities in the lung fields on a patient’s chest radiograph along with auscultation of crackles, pulse oximeter oxygen saturation of 88%, and a PCWP pressure of 25 mm Hg may prompt changes in fluid management and supplemental oxygen for the patient. Using a stethoscope, oxygenation status, hemodynamic information, and chest radiographs together for cardiopulmonary assessments enables nurses to recognize additional important clues concerning a patient’s current clinical status. Nurses analyze these findings and develop a plan of care for their patients. For example, a nurse may have determined that a primary goal is to improve lung function and oxygenation. Thus, their plan of care may include interventions related to therapeutic body position such as head-of-bed elevation, good lung down, use of lateral rotation or kinetic therapy, and determination of an optimal body position for chest physiotherapy. By incorporating the chest radiograph as an additional bedside assessment tool, critical care nurses and advanced practice nurses can more completely monitor patients’ clinical status and be able to plan and prioritize nursing interventions.
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    Figure 1: Chest radiodensities.
    Figure 2: Chest structures, frontal view.
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    Figure 3: Silhouette sign, left upper lobe pneumonia, PAC, ETT, and sternal wires. Abbreviations: ETT, endotracheal tube; PAC, pulmonary artery catheter.
    Figure 4: Chest structures left lateral view.
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    Figure 5: Breast tissue.
    Figure 6: Subcutaneous emphysema and 2 chest tubes.
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    Figure 7: Carina and left and right bronchus.
    Figure 8: Endotracheal tube in right main stem bronchus, CVC, left pleural effusion. Abbreviations: ETT, endotracheal tube; CVC, central venous catheter.
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    Figure 9: Chronic obstructive pulmonary disease, flattened diaphragms, hyperinflation, widened intercostal spaces, apical bullae, and chest rotation.
    Figure 10: Left pneumothorax, hyperlucency, and widened intercostal spaces.
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    Figure 11: Chest tubes in left thorax with reinflated left lung and right lower lobe atelectasis.
    Figure 12: Bilateral pleural effusions with peribronchial cuffing and interstitial edema.
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    Figure 13: Measurements for cardiothoracic ratio.
    Figure 14: Left ventricle enlargement, interstitial edema, beginning butterfly pattern of cardiogenic pulmonary edema, and peribronchial cuffing.
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    Figure 15: Left and right ventricle enlargement.
    Figure 16: Left ventricle enlargement and NGT on left lateral view. Abbreviation: NGT, nasogastric tube.
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    Figure 17: Left and right ventricle enlargement and sterna wires on left lateral view.
    Figure 18: Diffuse generalized mediastinal widening in a postoperative cardiac surgery patient, PAC, ETT, and right atelectasis. Abbreviations: ETT, endotracheal tube; PAC, pulmonary artery catheter.
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    Figure 19: Widened descending aorta indicating thoracic aortic aneurysm.
    Figure 20: Pulmonary venous hypertension (cephalization) with biventricular enlargement.
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    Figure 21: Pulmonary artery hypertension, dilated hilar trunks, and probable left ventricle enlargement.
    Figure 22: Right lower lobe pneumonia with minor fissure visualized,canada goose outlet.
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    Figure 23: Right upper lobe atelectasis with elevation of right diaphragm and narrowed intercostals spaces. Abbreviation: RUL, right upper lobe.
    Figure 24: Pulmonary artery catheter, ETT, and left chest tube. Abbreviations: ETT, endotracheal tube; PAC, pulmonary artery catheter.
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    Figure 25: Central venous catheter, ETT, NGT, atelectasis in RLL, and mediastinal shift. Abbreviations: CVC, central venous catheter; ETT, endotracheal tube; NGT, nasogastric tube; RLL, right lower lobe.
    Figure 26: Interstitial pulmonary edema.
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    Figure 27: Air bronchogram sign, NGT, sternal wires, and jugular PAC. Abbreviations: NGT, nasogastric tube; PAC, pulmonary artery catheter.
    Figure 28: Beginning acute respiratory distress syndrome, soon after hospital admission, patchy infiltrates, alveolar filling in left lower lobe, bilateral atelectasis, and elevated diaphragms.
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    Figure 29: Acute respiratory distress syndrome progressing with increased alveolar filling and atelectasis, 10 hours after the radiograph in Figure 28.
    Figure 30: Acute respiratory distress syndrome with whiteout to almost complete alveolar consolidation, noncardiogenic pulmonary edema, atelectasis, 20 hours after the radiograph in Figure 29.
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    Figure 31: Plate-like atelectasis with diaphragm elevation with narrowed intercostal spaces.
    Figure 32: Cephalization, interstitial edema of cardiogenic pulmonary edema, beginning pleural effusions, and PICC. Abbreviation: PICC, peripheral inserted central catheter.
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    Figure 33: Kerley A and B lines, peribronchial cuffing, and interstitial pattern of cardiogenic pulmonary edema.
    Figure 34: Beginning butterfly pattern of interstitial edema and peribronchial cuffing in cardiogenic pulmonary edema.
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    Figure 35: Alveolar edema in cardiogenic pulmonary edema; note the increased edema in bases versus upper lobes, left ventricle enlargement, and automatic implantable cardiac defibrillator.
    References
    1. Martin GS, Ely EW, Carroll FE, Bernard GR. Findings on the portable chest radiograph correlate with fluid balance in critically ill patients. Chest. 2002;122: 2087–2095. 2. Marik PE, Janower MJ. The impact of routine chest radiography on ICU management decisions: an observational study. Am J Crit Care. 1997;6:95–98. 3. Brainsky A, Fletcher RH, Click HA, Lanken PN, Williams SV, Kundel HL. Routine portable chest radiographs in the medical intensive care unit: effects and costs. Crit Care Med. 1997;25:801–805. 4. Mettler FA Jr. Essentials of Radiology. 2nd ed. Philadelphia, PA: Elsevier Saunders; 2005. 5. Hendrikse KA, Gratama JWC, Hove WM, Rommes JH, Schultz MJ, Spronk PE. Low value of routine chest radiographs in a mixed medical-surgical ICU. Chest. 2007; 132:823–828. 6. Houghton D, Cohn S, Schell V, Cohn K, Varon A. Routine daily chest radiography in patients with pulmonary artery catheters. Am J Crit Care. 2002;11:262–265. 7. Krivopal M, Shlobin OA, Schwartzstein RM. Utility of daily routine portable chest radiographs in mechanically ventilated patients in the medical ICU. Chest. 2003;123: 1607–1614.
    8. Chahine-Malus N, Stewart T, Lapinsky SE, et al. Utility of routine chest radiographs in a medical-surgical intensive care unit: a quality assurance survey. Crit Care. 2001;5:271–275. 9. Graat ME, Stoker J, Vroom MB, Schultz MJ. Can we abandon daily routine chest radiography in intensive care patients? J Intensive Care Med. 2005;20:238–246. 10. Herring W. Learning Radiology: Recognizing the Basics. Philadelphia, PA: Mosby Elsevier; 2007. 11. Novelline R. Squire’s Fundamentals of Radiology. 6th ed. Cambridge, MA: Harvard University Press; 2004. 12. Goodman LR. Felson’s Principles of Chest Roentgenology. 3rd ed. Philadelphia, PA: WB Saunders Co; 2007. 13. Ketai L, Lofgren R, Meholic A. Fundamentals of Chest Radiology. 2nd ed. Philadelphia, PA: Elsevier Saunders; 2006. 14. Connolly MA. Black, white, and shades of gray: common abnormalities in chest radiographs. AACN Clin Issues. 2001;12(2):259–269. 15. Siela D. Using chest radiography in the intensive care unit. Crit Care Nurse. 2002;22(4):18–27. 16. West JB. Pulmonary Pathophysiology: The Essentials. 7th ed. Philadelphia, PA: Wolters Kluwer Health | Lippincott Williams & Wilkins; 2008. 17. West IB. Respiratory Physiology: The Essentials. 8th ed. Philadelphia, PA: Wolters Kluwer Health | Lippincott Williams & Wilkins; 2008.
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    P. 1Chest X-ray InterpretationChest X-ray InterpretationRatings: (18)|Reads: 102,219|Likes: 57Published by Nuru99More info:Categories:Types, School Work, Study Guides, Notes, & QuizzesPublished by: Nuru99over 4 years agoCopyright:Attribution Non-commercialAvailability:Read on Scribd mobile: iPhone, iPadand Android.Flag for inappropriate content|Add to collectionAACN1904_444–47321/10/08
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    Chest Radiograph Evaluation and Interpretation
    Debra Siela, RN, PhD, CCNS, ACNS-BC, CCRN, CNE, RRT
    ABSTRACT
    Chest imaging is an important tool in managing critically ill patients. Basic chest radiology is still used to quickly detect abnormalities in the chest. Critical care nurses are often the ones who first read the radiologist’s report of chest radiograph results and provide their interpretation to a physician. Oftentimes, chest radiographs are obtained routinely on a daily basis for every critical care patient, with the goal of effective clinical management. Critical care nurses can confirm cardiopulmonary assessment findings by also evaluating their patient’s chest radiographs and reviewing the radiologist’s report. By learning some basic skills in interpreting and evaluating chest radiographs, nurses can recognize and localize gross pathologic changes visible on a chest radiograph. This article provides basic chest radiograph interpretation information that allows readers to review relevant anatomy and physiology, summarize normal and abnormal findings on chest radiographs, and describe radiographic findings in common pulmonary and cardiac disorders. Keywords: APN, chest imaging, chest radiograph, chest radiograph evaluation, chest radiograph interpretation, critical care nurses
    is important Chest imaging still an illtopatients.tool in managing critically Basic chest radiology is used quickly detect abnormalities in the chest. Critical care nurses are often the ones who first read the radiologist’s report of chest radiograph results and provide their interpretation to a physician. Oftentimes, chest radiographs are obtained routinely on a daily basis for every critical care patient with the goal of effective clinical management. Debate exists about the efficacy of daily or routine chest radiology for critically ill patients. It has been suggested that daily or routine serial chest radiographs are not needed. Some research supports obtaining daily routine chest radiographs for critically ill patients to be able to identify even subtle changes.1–3 Mettler4 supports daily chest radiographs in critically ill patients. Mettler reports that in daily chest radiographs, 60% do not disclose either new major or minor findings, 20% have new minor
    findings, and 20% have new major findings that are clinically unsuspected and are seen only on the radiograph.4 Other research supports discontinuing daily routine chest radiographs for critically ill patients because subtle changes may not be clinically significant and because of the use of resources and cost.5–7 Some consensus exists for routine but not daily chest radiographs depending on the nature of the acute illness.8 Many of these studies1,3,9 suggest using clinical assessment to guide the need to obtain confirmatory chest radiographs whether or not they are daily or routine. Critical care nurses can confirm cardiopulmonary assessment findings by also interpreting
    Debra Siela is Assistant Professor, Ball State University School of Nursing, and ICU Clinical Nurse Specialist, Ball Memorial Hospital, 2000 University Ave, Muncie, IN 47306 (dsiela@bsu.edu).
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    their patient’s chest radiographs and reviewing the radiologist’s report. This process can aid in planning appropriate nursing care. This article provides information on basic chest radiology interpretation that will allow the reader to review relevant anatomy and physiology, summarize normal findings on chest radiographs, and describe radiographic findings in common pulmonary and cardiac disorders. Basic Chest Radiography X-rays are very short wavelengths of electromagnetic radiation that penetrate matter.4,10–12 A traditional radiograph is created when x-rays penetrate a structure and produce images on a piece of photographic film usually contained in a cassette. However, in most hospitals and medical centers, the traditional x-ray film has been replaced with digital images. Special detectors are used to replace the film in the cassettes and convert the x-ray energy into digital signals to construct a digital radiograph. The digital images are stored on and distributed on a picture archiving and communications system (PACS).4,10–13 A PACS allows viewing access far from the radiology department at any computer workstation at any time. Digital radiographs can be manipulated to alter contrast and brightness or magnify images to see any abnormality. Every sample radiograph included in this document is from a digital format. Each radiograph has a continuum of shades from black to white in its images due to the way the body structures or tissues absorb the x-ray beam.4,10–13 X-rays penetrate body tissues that have minimal tissue density, such as air or air-filled structures, and produce black or dark areas on the radiograph; these areas are referred to as radiolucent. Areas or body tissues that cannot be penetrated by x-rays are radiopaque and appear light or white on the radiograph. Thus, each body tissue or structure has different radiodensity. The 4 basic roentgen densities or radiodensities4,10–13 are • gas (air), which appears black or radiolucent; examples are gas or air in trachea, bronchi, or stomach; • fat, which appears gray or less radiolucent than air; an example is lipid tissue around muscle; • water (soft tissue), which appears white with slight radiopacity; examples are the
    heart, blood vessels, muscle, and diaphragm; and • bone (or metal), which appears all white or completely radiopaque; examples are bones, calcium deposits, prostheses, and contrast media. Figure 1 provides a review all of the chest tissues and structures basic radiodensities in a chest radiograph, and Figure 2 identifies each chest structure or tissue on a frontal chest radiograph (note that all figures appear at the end of the article). If 2 structures of equal density are adjacent to each other, the border of neither structure can be detected. This phenomenon, the silhouette sign, is used to identify normal chest structures and diagnose and localize lung diseases.4,10–13 The silhouette sign may be used to distinguish anterior from posterior structures on a chest radiograph.4,10–13 For example, a silhouette sign would be expected in an area of consolidation in the left upper lobe of the lung because this lobe borders the left sides of the atrium and the mediastinum. Because both the area of consolidation and the heart are water densities, the left border of the atrium cannot be distinguished from the border of the left upper lobe of the lung (Figure 3). Views of the Chest Two of the most common radiographs are posteroanterior (PA) and anteroposterior (AP) or frontal views of the chest.4,10–13 For PA views, the x-ray beam passes through the chest from the back to the front. For AP views, the beam passes through the chest from the front to the back. For acutely ill patients who cannot stand up for a PA view, AP views are obtained with a portable x-ray machine. Ketai and coworkers13 report that more than half of all chest radiographs in hospitals are performed at the bedside. Many of the sample radiographs in this article are AP views. The next most common view of the chest after the frontal view is the lateral view.9 Lateral views of the chest enable detection of lesions behind the heart, near the mediastinum, or near the diaphragm.10,12 The lateral view also allows for visualizing the tracheal air column, inferior vena cava, retrosternal space, posterior margin of the heart, and diaphragmatic contour.10,11 A patient’s frontal and lateral view radiographs allow the viewer to have a vision of the chest in 3 dimensions so that the viewer can more easily localize infiltrates and lesions.
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    In addition, if ventricle enlargement is suspected on the frontal chest image, a lateral view may help confirm the finding. Portable lateral view chest images are also used to evaluate presence of pleural effusions that cannot be seen on frontal views because they are small in size.10 It takes 250 mL of fluid to blunt a lateral costophrenic sulcus on a frontal radiograph, but only 75 mL to blunt the posterior costophrenic sulcus on a lateral radiograph.10 Sometimes, a lateral decubitus view radiograph (patient lying either on one side or on the other) is obtained to evaluate possible pleural effusions and their fluid levels.13 Figure 4 shows lateral view chest structures and tissues. Technical Factors of Viewing Chest Radiographs It is necessary to consider whether each of the following factors are adequate or appropriate to accurately assess and evaluate normal and abnormal chest radiograph findings.10–13 Penetration X-rays must adequately penetrate body structures to visualize the structures. For example, one should be able to faintly see the thoracic spine through the heart shadow.10 If you cannot, the chest radiograph is underpenetrated or too light. In this situation, the left hemidiaphragm may not be visible because the left lung base can appear opaque, which may hide or mimic true disease in the left lower lung field.10 A lateral view will be necessary to confirm any abnormalities in the left lower lung field. In addition, the pulmonary markings may appear more prominent then they really are and may be interpreted as interstitial pulmonary edema or pulmonary fibrosis.10 Again, a lateral view will be necessary to confirm the interstitial findings. If the chest radiograph is overpenetrated or too dark, the lung markings may appear to be absent or decreased.10 It is then possible to make the judgment that the patient has emphysema or pneumothorax when in reality this pathophysiology does not exist.10 One could also miss a pulmonary nodule when the chest radiograph is overpenetrated.10 Inspiration A full-inspiration chest radiograph can be reproduced from one time to the next to eliminate the possibility of artifacts that may confuse the viewer to think that disease is present.10 If one can count 10 posterior ribs
    above the diaphragm, it is an excellent inspiratory film.10 When less than 10 ribs can be counted above the diaphragm, it is either poor inspiratory effort or a sign of low lung volume. Low lung volume from a poor inspiration effort can crowd and compress the lung markings, producing the impression that a lower lobe pneumonia is present. Rotation In AP radiographs, patient malposition or rotation may appear to indicate abnormalities in cardiac, vascular, or mediastinal contours when, in fact, they may not exist.11,13 The position of the clavicles help identify a patient’s rotation.11,13 If one clavicle appears to be shorter in length than the other, then one side of the chest may be rotated close to or away from the detector cassette, producing what appear to be abnormalities.11,13 Figure 9 shows a difference in clavicle length. Comparing the length of the clavicles in addition to comparing the symmetry of the distance between the spinal pedicles and clavicle heads as a method of identifying chest rotation is an important part of the radiograph examination. If one identifies asymmetry in the distance between the pedicles (outer edge of spinal vertebra) and the clavicle heads, the chest is likely rotated.10,13 Figure 9 shows an example of asymmetry between the spinal pedicles and the clavicle heads due to chest rotation. Magnification Anteroposterior views obtained with a portable machine have some disadvantages. Structures in the anterior part of the chest are magnified on AP views, so structures such as the heart are not as distinct as on PA views and may even be distorted.4,10–13 The heart and the mediastinum appear about 15% wider than on the PA view.13 This phenomenon occurs on an AP view mainly because of the shorter distance between the x-ray tube and the patient than occurs in a PA view.4,10,11 Angulation Posteroanterior views are sharper and more distinct with less chest rotation and have consistent clavicle placement because they are always obtained with the patient upright and 2 m (6 ft) away from the source of the x-rays and at a 90 angle to the beam, whereas angles less than 90 are often used for AP radiographs because of inability of critically ill patients to
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    be positioned at 90 .12 Thus, the x-ray beam ends up entering the chest with the patient’s head and chest tilted backward.10 This creates what is called an apical lordotic view of the chest.10 In a chest radiograph that is an apical lordotic view, the clavicles project at or above the posterior first ribs and make the clavicles appear to be straight.10 The apical lordotic view can create the illusion of cardiomegaly when, in fact, it does not exist.10 Systematic Method of Viewing A systematic method should be used to examine chest radiographs.4,10–12,14,15 Radiographs may be examined from side to side, from top to bottom, or structure by structure. Following is the suggested order for structure-by-structure examination of the frontal view (PA or AP) chest radiograph, which can all be viewed in Figure 2. 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. Soft tissues Trachea Bony thorax/ribs Intercostal spaces Diaphragm Structures below diaphragm Pleural surfaces Mediastinum Hila Lung fields Support catheters, tubes, wires, and lines
    neous layer of the skin or soft tissues.10 Subcutaneous emphysema commonly occurs from penetrating chest injury or a chest tube.10 Figure 6 shows subcutaneous emphysema. Trachea The trachea appears as a column of radiolucent tissues or gas density midway between the clavicles or over the spine. The carina is normally positioned approximately at the level of the sixth posterior rib or T4 (Figures 3 and 7).11–13 When an endotracheal (ET) tube is placed correctly, the tip of the tube is approximately 3 to 5 cm (approximately 2 in.) above the carina. Figure 8 shows a chest radiograph with an ET tube down in the right main stem bronchus. Tracheal deviation is present when the trachea is positioned to the right or to the left of the midline. A common cause of apparent tracheal deviation is chest rotation (Figure 9). True tracheal deviation may be caused by the presence of a tumor, mediastinal shift, pneumothorax, or major atelectasis. Figure 25 shows the tracheal deviation due to atelectasis. Bony Thorax The humeri, scapulae, clavicles, spine, and ribs should be identifiable as bone densities. On a radiograph obtained during inspiration, 9 to 10 posterior ribs to the lateral top of the diaphragm should be visible (Figure 2). Each rib should be followed along its course to assess for any notching or deformities; symmetry of rib structures should be assessed bilaterally. Radiographs of patients with chest trauma should be checked for evidence of rib fractures. Intercostal Spaces Each intercostal space is numbered according to the rib above it. The width of the intercostal spaces is determined by measuring the degree of the costovertebral angle relative to the posterior ribs. The normal angle is about 45 ; with widened intercostal spaces, the angle may double to more than 90 .11–13 Widened intercostal spaces occur in conditions such as chronic obstructive pulmonary disease, pneumothorax, and pleural effusion that increase lung volume.11–13 Figures 9 and 10 show an example of widened intercostal spaces. Narrowed intercostal spaces, such as that occurs in atelectasis and interstitial fibrosis, are associated with conditions that decrease lung volume.11–13 Figures 22 and 30 show an example of narrowed intercostal spaces.
    Following is the suggested order for viewing lateral view structures, which all can be seen in Figure 4. 1. 2. 3. 4. 5. 6. 7. Bones Mediastinum Hilum Heart Diaphragm/pleura Lung fields Support catheters, tubes, wires, and lines
    Viewing of Normal Chest Structures Soft Tissues The soft tissues of the chest consist mainly of fat and some water densities.4 The tissues should appear symmetric when compared side to side. Breast tissue is an example of soft tissue. Sometimes, breast tissue shadows obscure the lower lung tissue (Figure 5).4 Subcutaneous emphysema results from air in the subcuta-
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    Diaphragm The diaphragm has a water density, and each hemidiaphragm is dome-shaped. The right hemidiaphragm is normally higher in the chest than is the left hemidiaphragm because of the liver (Figure 2).11–13 Diaphragmatic elevation is evident when fewer than 9 to 10 ribs are visible and can be caused by abdominal distension, phrenic nerve compression, or lung collapse (atelectasis; Figures 22, 24, and 28).11–13 Diaphragmatic depression is present when 11 to 12 ribs are visible.11–13 Depression or flattening of the diaphragm is associated with hyperinflation of the lung or thorax as in chronic obstructive pulmonary disease and pneumothorax.11–13 See examples of diaphragm depression (flattening in chronic obstructive pulmonary disease, Figure 9, and also in a pneumothorax, Figure 10). Structures Below the Diaphragm Almost all of the structures below the diaphragm are primarily water densities. The exception is the gastric air bubble, which may be visible in many frontal radiographs (Figure 2).11–13 Pleural Surfaces The pleurae normally appear as thin, hairlike lines along the lateral edges of the chest and along the diaphragm. When the pleural line deviates medially and appears in the lung fields, a pneumothorax may be present.11–13 When a pneumothorax is present, the area outside the line to the lateral edge of the chest (eg, the pleural space) will appear more radiolucent or completely black.11–13 The costophrenic sulcus (angle) may also be displaced inferiorly and increase the lucency at the same time in a large pneumothorax. This is termed the deep sulcus sign.10 The lung itself will appear more radiopaque or more dense (Figure 10). Mediastinal shift toward the affected lung may also occur in a large pneumothorax. In contrast, in tension pneumothorax, the mediastinum shifts away from the affected lung, and the diaphragm commonly is depressed on the affected side.12 See reinflated left lung with chest tubes in Figure 11. The costophrenic sulcus/angle (Figure 2) should appear as deep sharp points like a V on a frontal view. If the costophrenic sulcus are not distinct deep points on the lateral sides of the chest and appear blunted, a pleural effusion may be the cause.11–13 If a horizontal fluid level or meniscus can be visualized in the area
    of the costophrenic sulcus, a pleural effusion most likely has occurred.11–13 It takes approximately 250 mL of fluid to blunt the costophrenic sulcus on a frontal view radiograph.10 Right-side pleural effusions occur frequently in heart failure. Figures 8, 12, and 32 show pleural effusions. Mediastinum The mediastinum includes the heart, major blood vessels,canada goose outlet, the trachea, and the right and left main bronchi. The heart and blood vessels are water densities, whereas the trachea and bronchi are air densities. The right atrium forms the right border of the heart. The right ventricle cannot be detected directly on a chest radiograph because this structure is located in the center of the heart shadow. The superior vena cava is visualized above the ascending aorta shadow in the right chest.12 An indentation can be located down in the mid-hilar area that marks the junction of the right atrium and superior vena cava (Figure 2). This is the area where the tips of central venous catheters should be located and where a pulmonary artery catheter should enter the right side of the heart.10 The left atrium and the left ventricle form the left border of the heart. The aortic arch is visible as the aortic knob on the frontal view. The descending aorta is about 3 cm above and to the left of the carina (Figure 3).11–13 The main pulmonary artery is the next shadow contour below the aortic knob on a frontal view radiograph.10 Sometimes, the left descending pulmonary artery can be seen as far down as the next contour shadow following the main left pulmonary artery (Figure 2). The cardiothoracic ratio can be determined to assess the overall size of the heart.11–13 This ratio is determined by measuring the horizontal width of the heart and dividing that width by the widest interval of the thorax. The normal cardiothoracic ratio is 1:2 or less (Figure 13).11–13 A cardiothoracic ratio greater than 1:2 is suggestive of cardiac enlargement.11–13 Cardiac enlargement can be determined more precisely by comparing the findings on serial radiographs.13 An increase in the diameter of the heart of 1 cm or greater is considered cardiac enlargement.13 If cardiac enlargement appears to be present, right ventricular enlargement must be distinguished from left ventricular enlargement. Frontal view radiographs show the following during left and right ventricular enlargement:
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    • The left lower border of the heart is moved laterally and becomes rounded in left ventricular enlargement (Figure 14).12,13 • The right atrium protrudes into the right side of the chest and becomes more convex in right ventricular enlargement (Figure 15).12,13 Left and right cardiac enlargement is likely in the lateral view when • the left heart border moves inferoposteriorly beyond the inferior cava toward the spine in left ventricular enlargement (Figure 16).12,13 • the right ventricle shows enlargement by moving anteriorly and superiorly with filling of the anterior retrosternal clear space. Normally, on the lateral view, the lower one third of the right ventricle contacts the sternum (Figure 4). Whereas, in right ventricle enlargement, the right ventricle contacts the lower one half of the sternum.12,13 See Figure 17. The mediastinum can also be widened for many reasons, including focal masses or fluid infiltration. Focal masses usually cause sharp and convex mediastinal widening.12 Mediastinal infiltrations come from hemorrhage or infection and produce widening that appears generalized and diffuse.12 See Figure 18, which shows a wide mediastinum for a new postoperative cardiac surgery patient. Figure 19 shows a thoracic aortic aneurysm, which may be suspected because of the widened thoracic aorta, which also widens the mediastinum. Hila The hila consist of the pulmonary arteries and veins and appear blotchy because of various areas of radiopacity associated with different sizes and thickness of blood vessels. The heart shadow obscures the left hilar area and makes the left hilum appear smaller and higher than the right hilum.13 The left hilum is positioned slightly higher than the right hilum in 97% of all individuals.12 Bronchovascular markings refer to blood vessels and bronchi that branch out from the hila to the periphery of the lung fields (Figure 2).12 As the markings extend out into the lung fields and gradually taper off in the periphery, the structures consist of mainly pulmonary blood vessels and no bronchi. The pattern of pulmonary venous hypertension is seen in patients with elevated pulmonary venous pressure, which is usually caused by left ventricular failure and increased hydrostatic
    pressure.16 You will note increased prominence and thickening of the upper lobe blood vessels in the hila,parajumpers parka, decreased prominence of the lower lobe blood vessels, and haziness of the hilar vessels, which is the process of cephalization.10,11 Figure 20 shows pulmonary venous hypertension. Pulmonary artery hypertension is caused by conditions that decrease the flow of blood through the pulmonary capillary bed such as emphysema, pulmonary emboli, and vasoconstrictive states.16 The hilar trunks are enormously dilated in response to the constricted arterial bed.11 See Figure 21 to view pulmonary arterial hypertension. Hilar elevation is usually present in collapse of the upper lobes of the lung, whereas hilar depression occurs in collapse of the lower lobes of the lung.13 Collapse of the right middle lobe does not cause hilar displacement.13 Lung Fields The lung fields consist mainly of air and very little tissue or blood.11–13 As a result, lung fields should be visualized as an air/gas density or as a completely radiolucent area. Abnormalities of the lung fields on chest radiographs include interstitial patterns and alveolar consolidation patterns. See further descriptions of interstitial and alveolar consolidation patterns under radiographic signs of cardiac and pulmonary disease. Determining the locations of the various lobes of the lungs is useful for diagnosing and localizing pulmonary disease.11–15 The right middle lobe is located anteriorly, adjacent to the right side of the heart. The left lingular lobe is in direct contact with the left border of the heart.12 The upper lobes and the right middle lobes of the lung are primarily anterior thoracic structures, whereas the lower lobes are primarily posterior structures. Knowing the different locations of the lung lobes makes it possible to use the silhouette sign. See Figure 3 for a left upper lobe lung consolidation that borders the left heart. See Figure 21 for a right lower lobe pneumonia where the right-sided heart border is distinct. See Figure 28 for a left lower lobe infiltrates with distinct left-sided heart border. See Figure 30 for an example of complete consolidation where the heart cannot be identified. Fissures are separations or spaces between the lung lobes and appear as narrow white lines on a chest radiograph.11–13 Fissures are normally the thickness of a sharpened pencil line.10 In frontal and lateral views, the area
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    where the minor fissure separates the right middle lobe from the right upper lobe may be visible. The minor fissure is located almost in the middle of the right lung fields, where it appears as a horizontal line on the frontal radiograph (Figure 22).12 One of the direct signs of lung collapse in the right upper lobe on a frontal radiograph is elevation of the minor fissure (Figure 23).11–13 In collapse of the right middle lobe, downward displacement of the minor fissure may be evident. The major or oblique fissures separate the upper lobes of the lung from the lower lobes. The major fissures cannot be seen on a frontal view but are visible on a lateral view.13 See Figure 4 to view the major fissure. Support Catheters, Tubes, Wires, and Lines Critically ill patients commonly have support catheters, tubes, wires, and lines. This invasive support equipment includes, for example, ET tubes, tracheostomy tubes, chest tubes, nasogastric or feeding tubes, central line catheters, peripherally inserted central catheter lines, pulmonary artery catheters, and pacemaker wires. Invasive support equipment is often evaluated as to its position in the chest or abdomen on a chest radiograph. See Table 1 for a list of common catheters,canada goose parka, tubes, wires, and lines that are inserted in the chest with their proper location in a chest radiograph. Nurses should be aware of the correct positions of this support equipment in the chest and abdomen and on a radiograph. The radiographs in Figures 24 and 25 contain various support equipment in both correct and incorrect positions. Several other examples of chest radiographs also show support equipment in both correct and incorrect positions (Figures 3, 6, 8, 16, 18, 27, 32, and 35). However, identifying that a catheter, tube, wire, or line is in a correct position in the chest or abdomen will also require confirmation by a radiologist and the nurse should rely on his or her evaluation. Alveolar and Capillary Anatomy and Physiology An understanding of alveolar and capillary anatomy and physiology is essential for interpreting radiographic indications of pulmonary disease of the air spaces and interstitium. Alveoli consist of 2 different types of cells. Most alveoli are lined with type I cells, which are flat, squamous cells. The corners of alveoli contain
    type II cells, which produce surfactant. Alveolar macrophages are phagocytic cells that clear particles from these air spaces. Openings between alveoli (pores of Kohn) permit movement of gases between adjacent alveoli.16,17 Many structures and substances, such as fluid, connective tissues, leukocytes, and macrophages, are located in the walls between alveoli.16,17 Capillaries are interposed between alveoli in a network. The contact of alveolar surfaces with capillary surfaces forms the alveolarcapillary membrane, the structure through which gas exchange occurs. The alveolar-capillary membrane has a thin side and a thick side.16,17 The thin side bulges into the alveolus and is the primary site for gas exchange. The fusion of alveolar and capillary basement membranes creates the thin side. The thick side includes the alveolar and capillary basement membrane separated by the alveolar interstitial space. The alveolar interstitial space is made of connective tissue such as elastic fibers, collagen fibrils, and fibroblasts. The thick side of the alveolar-capillary membrane does not conduct gas exchange as easily as the thin side does; rather, it promotes fluid exchange in the lung.16,17 Excess fluid in an alveolus is drained via the alveolar interstitial space into the nearby lymphatic system and/or into the connective tissue fibers.16,17 The connective tissues of the alveolar interstitial space form the support system for the alveolar and pulmonary capillaries. Excess fluid in the alveolar interstitial space fluid is drained via the connective tissue fibers into the potential peribronchial and perivascular interstitial space.16,17 The peribronchial and perivascular interstitial spaces surround the bronchioles, bronchi, pulmonary arterioles, and pulmonary arteries interspersed between alveoli in a network. The contact of alveolar surfaces with capillary surfaces forms the alveolar-capillary membrane through which gas exchange occurs. Radiographic Signs of Pulmonary Disease Most pulmonary diseases are associated with increased density of the lung fields on chest radiographs.12 Increased density involves changes in the interstitium, the air spaces, or both. Interstitial Pulmonary Disease In interstitial pulmonary disease, the volume of the alveolar interstitium increases with no
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    Table 1: Support Catheters, Tubes, Wires, and Lines in Chest Radiographs
    Support Equipment ET tube Proper Position 3 to 5 cm from the carina Half the distance between the medial ends of the clavicle and carina Carina is over T5 to T7 Additional Information ET tube tends to slide into the right main bronchus because of a shallower angle ET tube can descend 2 cm during neck flexion ET tube can ascend 2 cm during neck extension TT TT tip should be halfway between the stoma in which the tube was inserted and the carina TT tip should be at about T3 CVC Reach the medial end of clavicle before descending If CVC tip descends beyond the indentation that marks the junction of the right atrium and superior vena cava, it is in the right atrium Descend lateral to spine CVC tip should be in the superior vena cava and not into the right atrium PICC PICC tip should be within the superior vena cava, which should be above the indentation that marks the junction of the right atrium and superior vena cava May be difficult to visualize Pulmonary artery catheter (Swan Ganz Catheter) Tip should be in the proximal left or right pulmonary artery Tip should be about 2 cm from the hilum Insertion into right jugular vein most commonly Temporary catheter tips should be in superior vena cava Permanent catheter tips should be in the right atrium Pleural drainage tubes: Chest tubes and thoracotomy tubes For pleural effusion, tubes should be placed posteriorly and inferiorly For pneumothorax, tube tips should be placed anteriorly and superiorly Ideal position is anterosuperior for evacuating a pneumothorax Ideal position is posteroinferior for evacuating a pleural effusion (continues) If side hole extends outside chest wall, an air leak may occur causing subcutaneous emphysema Rapid lung reexpansion can cause reexpansion pulmonary edema Pulmonary artery catheter tip should not be located in a peripheral or distal artery because of the increased risk of infarction PICC may migrate over time, so monitoring its position is important Incorrect positioning of a TT could penetrate the trachea and cause pneumothorax and subcutaneous emphysema Common malpositioning of a CVC includes placement in the right atrium and internal jugular vein Pneumothorax occurs in 5% of all CVC insertions10 Should obtain chest radiograph postinsertion
    Double lumen catheters: “Quinton” hemodialysis catheters
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    Table 1: Support Catheters, Tubes, Wires, and Lines in Chest Radiographs (Continued)
    Support Equipment Pacemakers Proper Position Implanted subcutaneously in left anterior chest wall Tip of one lead is almost always located in the apex of the right ventricle Two lead pacemakers have 1 lead in the right atrium and 1 in the right ventricle Three lead pacemakers have 1 lead in the right atrium, 1 lead in the right ventricle, and 1 lead in the coronary sinus All leads should have gentle curves AICDs AICDs can be differentiated from pacemakers by the wider and more opaque segment of at least 1 of the electrodes One lead is placed in the superior vena cava or brachiocephalic vein If has another lead, it is placed in the apex of right ventricle Bends in leads should be smooth curves, not sharp kinks Intra-aortic counter pulsation balloon pump (IABP) Placed in descending thoracic aorta Tip should lie distal to origin of the left subclavian artery Metallic marker may point slightly toward the right in the region of the aortic arch When inflated, the balloon may appear as an air-containing sausage in the thoracic aorta NG tube Tip and all side holes should extend about 10 cm into the stomach beyond the EG junction to prevent aspiration from the administration of the feeding into esophagus The EG junction is usually located at the junction of the left hemidiaphragm and the left side of the thoracic spine (left cardiophrenic angle) Dobbhoff feeding tubes Tip of feeding tube should be in duodenum so as to reduce the risk of aspiration Tip is recognizable by a weighted metallic end NG tubes are the most commonly malpositioned of all tubes; always check with a radiograph to confirm the location When malpositioned, NG tubes are frequently coiled in the esophagus If inserted in the trachea, the NG tube can extend into a bronchus and to the periphery of the lung Placement in the stomach is common Placement in the trachea can occur Confirmatory radiograph is needed after placement before beginning feedings If catheter is too proximal, balloon may occlude great vessels leading to stroke If balloon is too distal, device has decreased effectiveness Visible complications can include lead breakage and dislodgement Additional Information Pneumothoraces occur during insertion Fracture of leads may occur
    Abbreviations: AICD, automatic implantable cardiac defibrillators; CVC, central venous catheter; EG, esophagogastric; ET tube, endotracheal tube; NG tube, nasogastric tubes; PICC, peripherally inserted central catheter; TT, tracheostomy tube.
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    change in the alveolar air volume. The alveolar interstitial space increases in size because of fluid, fibrosis, inflammation, or abnormal tissue growth.12 Chronic diffuse interstitial lung disease is usually caused by pulmonary fibrosis.12 In chronic interstitial pulmonary disease, the markings are sharp and the branching is irregular.12 See Figure 26 to view an interstitial pulmonary pattern. Acute diffuse interstitial lung disease is usually due to cardiogenic or noncardiogenic pulmonary edema such as that associated with acute respiratory distress syndrome (ARDS), viral/mycoplasmal pneumonia, or heart failure.12 In ARDS, interstitial edema is caused by direct injury of pulmonary endothelial cells by inflammatory mediators. Gas exchange is impaired by thickening of the thin side of the alveolar-capillary membrane, which increases the distance that oxygen and carbon dioxide diffuse between the alveoli and the capillaries. In acute interstitial pulmonary disease, the markings are hazy with normal branching of the vascular bed and bronchi.12 In interstitial lung disease with normal aeration of the alveoli, chest radiographs typically show increased vascular markings due to more prominent blood vessels.11–13 In addition, lines may be visible in the upper or lower lobes because of thickening of fissure lines. Depending on the type of interstitial lung disease, the markings are as follows11–13: • reticular or linear, which appear as small lines or sometimes as a mesh such as in interstitial pulmonary edema and pulmonary fibrosis; • nodular, which appear as small round dense opacities; examples include bronchogenic cancer and lung metastases; and • reticulonodular, which are a combination of reticular and nodular markings and is the most common type, which includes sarcoidosis. Air Space Disease (Alveoli) Air space or alveolar disease involves reduction of air because of alveolar consolidation, atelectasis, or both. In alveolar consolidation, also termed infiltrates, tissue or fluid replaces all of the air in the alveoli and the lung tissue appears opacified or a water density.12 An alveolar pattern occurs when many alveoli are
    filled with fluid or tissue creating a water density or fluffy appearance. However, in an alveolar pattern, not all alveoli in 1 lung area are filled with fluid or tissue, so the infiltrates appear as “patchy” water densities. Signs of alveolar consolidation on a chest radiograph include the silhouette sign and the air bronchogram sign.11–13 An air bronchogram sign is the radiographic shadow (a radiolucent area) of an air-filled bronchus running through an airless area of lung, which appears opacified (Figure 27).11–13 Figure 3 illustrates a silhouette sign with no clear left-sided heart border caused by left upper lobe pneumonia and consolidation. Decreased lung air volume in alveolar consolidation decreases respiratory gas exchange of oxygen.16 Common causes of consolidation are bacterial pneumonias, cardiogenic pulmonary edema, and noncardiogenic edema such as ARDS.11–13 In cardiogenic pulmonary edema, increased hydrostatic pressure in the blood forces fluid out into the interstitium and alveoli, which can cause alveolar consolidation.10 In ARDS or noncardiogenic edema, direct injury to the alveoli increases permeability of the alveolar-capillary membrane, which over the next 48 hours allows fluid to fill the alveoli and can cause complete lung consolidation.10,16 This complete consolidation can be visualized as a complete whiteout on chest radiographs for ARDS or cardiogenic pulmonary edema (Figures 30 and 35).10–13 Atelectasis is caused by the following 4 pathophysiologic conditions10,13: 1. Air is absorbed from the alveoli (resorptive), usually because of lack of ventilation from an obstruction above the alveoli such as a mucus plug, tumor, foreign body, or occluding inflammation or edema. 2. Alveoli are compressed because of increased intrathoracic pressure (relaxation or passive), such as the opposite lung compressed from a tension pneumothorax. 3. Alveoli collapse from fibrosis or scarring, which is termed cicatrization. 4. Alveoli collapse from loss of surfactant (adhesive) like in ARDS. Hypoventilation can also cause alveoli to lose air volume and become atelectic. Left lower lobe atelectasis is very common following coronary artery bypass surgery.13 One should expect to view signs of left lower lobe atelectasis on these patients’ postoperative
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    radiographs. In all instances of atelectasis, diminished tissue oxygenation occurs because of lack of oxygen in the alveoli. Direct signs of atelectasis on a chest radiograph include displaced fissures, crowded bronchovascular markings, and shifted position of a marker structure such as a scar,parajumpers jacket, nodule, or granuloma.12 Indirect signs of atelectasis are structural shifts in the positions of the hila, diaphragm, and mediastinum and increased density or radiopacity of the lung tissue.12,13 Figure 23 shows both direct and indirect signs of atelectasis. When atelectasis is localized, oblique or horizontal lines may appear. These radiograph changes are called discoid, subsegmental, or plate-like atelectasis (Figure 31).13 Keep in mind that to confirm atelectasis in a lower lobe, a lateral view radiograph may be necessary.13 Two other airspace deformities that are seen on chest radiographs are blebs and bullae. Blebs and bullae are thin-walled air-filled spaces commonly located in the upper lobes and are radiolucent.10 These develop because of alveolar destruction associated with emphysema. Blebs are relatively small air cavities of size less than 1 cm.4 A bulla is greater than 1 cm and often much larger.4 See Figure 9 for examples of bullae. Air Space Disease and Noncardiogenic Pulmonary Edema (ARDS) Patients with ARDS can have a combination of air space disease with both alveolar consolidation and atelectasis.13 Diffuse and patchy alveolar infiltrates occur beginning in the periphery about 12 hours after the insult to the alveolar-capillary membrane (Figure 28).10 Chest radiographs show a primary alveolar pattern with additional signs of atelectasis caused by reduced lung volume from loss of surfactant within 24 to 48 hours postinsult (Figure 29).10,11 Air bronchograms are commonly seen during this stage.10 Complete alveolar consolidation may also occur (Figure 30). In addition,canada goose norge, most likely both indirect and direct lung injury coexist in ARDS.10 However, the consolidation pattern of direct injury usually predominates over the interstitial pattern attributable to indirect injury.13 When a patient survives ARDS, a chronic interstitial pattern due to pulmonary fibrosis often becomes apparent on chest radiographs obtained 1 week or more after the acute stage or diagnosis of ARDS.10,11 The chest radiograph of a post-ARDS patient may look similar to that of Figure 26.
    Radiographic Signs of Cardiac Disease Radiographic signs of cardiac disease are similar but also differ from those of pulmonary disease. Following are descriptions of radiographic signs of cardiac disease. Heart Failure and Cardiogenic Pulmonary Edema In addition to left ventricular enlargement, cephalization or vascular redistribution is an indication of left ventricular failure.11–13 In a patient standing upright, the pulmonary blood vessels are larger in the lower lobes of the lung than in the upper lobes. If the blood vessels in the upper lobes are larger than the blood vessels in the lower lobes, the condition is termed cephalization or vascular redistribution.12 Cephalization occurs because of increasing left ventricular pressure. When pulmonary capillary wedge pressure (PCWP) becomes elevated or left atrial pressure is greater between 10 and 15, cephalization occurs.10,11 In addition, if hydrostatic pressure increases to greater than 10, fluid leaks into the interstitium.10 See Figures 20 and 32 to view cephalization. In addition, as PCWP continues to increase to 19 to 20 mm Hg, interstitial edema begins (Figure 33).10 Kerley lines are a radiographic sign with interstitial pulmonary edema. They are thin linear pulmonary opacities caused by fluid or cellular infiltration into the interstitium of the lungs. There are 3 types of Kerley lines with Kerley B being the most common. Kerley B lines are due to thickening of interlobular septa caused by increased tissue or fluid, as in interstitial pulmonary edema.10,13 Kerley B lines are seen as horizontal lines no more than 2 cm long that appear in the lung periphery near the costophrenic angles and lateral wall (Figure 33). Kerley A lines are caused by distension of channels that connect the peripheral and central lymphatics of the lungs. Kerley A lines appear as oblique lines approximately 2 to 6 cm long that course diagonally toward the hila from the periphery in the upper lobes.10,11 One does not see Kerley A lines without Kerley B lines (Figure 33).10 Kerley C lines supposedly represent thickening of lymphatics that appear as short fine lines throughout the lungs with a reticular appearance. Some radiologists claim that Kerley C lines do not actually exist.10 It is also suggested that what is thought to be Kerley C lines are a combination of Kerley A and Kerley B lines.10
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    Peribronchial cuffing may also be seen in interstitial pulmonary edema. Normal bronchial walls appear as pencil-point thin when viewed end-on.13 Interstitial edema widens the bronchial walls and makes their margins appear indistinct, which is termed peribronchial cuffing.13 Some radiologists describe peribronchial cuffing as appearing as small doughnut densities on the radiograph.10 See Figures 12, 14, 30, 33, and 34 for examples of peribronchial cuffing. In addition, a butterfly or batwing pattern may become apparent on chest radiographs during interstitial pulmonary edema due to heart failure (Figure 34).10,11 The butterfly pattern is due to the fluid engorgement of the interstitium adjacent to the hilar blood vessels.13 Lower lung zones are usually much more affected than upper lung zones.10 Once edema due to heart failure involves the entire alveolar interstitium as a result of increasing PCWP and increased left ventricular pressure, the alveoli start to become edematous.13 At this point, the PCWP is usually greater than 25 mm Hg.10,11 At this time, an alveolar consolidation pattern becomes evident on chest radiographs (Figure 35).10,11 When resolution of this alveolar edema begins, it clears from the periphery and moves centrally.10 However, not all patients with high PCWP have evidence of heart failure on chest radiographs. Pleural effusions are also common in moderate to severe heart failure as indicated by a shallow costophrenic sulcus. The 3 classic stages of cardiogenic pulmonary edema are cephalization (Figure 32), interstitial edema (Figures 33 and 34), and alveolar edema (Figure 35). However, radiographic findings often differ between acute heart failure and chronic heart failure.13 For example, interstitial edema and Kerley B lines do not seem to occur until venous pressures are higher in chronic heart failure than in acute heart failure.13 Radiographs of chronic heart failure are more likely to show cephalization (vascular redistribution) than interstitial edema, whereas in acute heart failure, one is more likely to view interstitial edema.13 Radiographic Sign Differences of Cardiogenic and Noncardiogenic Pulmonary Edema Radiographic signs differ between cardiogenic and noncardiogenic pulmonary edema. Kerley B lines and peribronchial cuffing are seen in
    radiographs of cardiogenic pulmonary edema but not in ARDS radiographs.10 The distribution of pulmonary edema tends to be even in cardiogenic pulmonary edema but is distributed more to the periphery in ARDS.10 Air bronchograms are seen commonly in ARDS radiographs, whereas they are not commonly seen in cardiogenic pulmonary edema radiographs.10 Pleural effusions are much more likely to be seen on cardiogenic pulmonary edema radiographs than on ARDS radiographs.10 Implications for Nurses Signs and symptoms that patients have during acute illness may be indicative of many different types of pathophysiologic or disease processes. Critical care nurses can use chest radiographs as an additional bedside assessment tool to assist in determining pathophysiologic abnormalities and to confirm other assessment findings. By learning some basic skills in interpreting chest radiographs, nurses can recognize and localize gross pathological changes visible on a chest radiograph. Nurses are the care providers who are consistently present at the bedside and have up-todate information on patients’ clinical status. For example, changes in densities in the lung fields on a patient’s chest radiograph along with auscultation of crackles, pulse oximeter oxygen saturation of 88%, and a PCWP pressure of 25 mm Hg may prompt changes in fluid management and supplemental oxygen for the patient. Using a stethoscope, oxygenation status, hemodynamic information, and chest radiographs together for cardiopulmonary assessments enables nurses to recognize additional important clues concerning a patient’s current clinical status. Nurses analyze these findings and develop a plan of care for their patients. For example, a nurse may have determined that a primary goal is to improve lung function and oxygenation. Thus, their plan of care may include interventions related to therapeutic body position such as head-of-bed elevation, good lung down, use of lateral rotation or kinetic therapy, and determination of an optimal body position for chest physiotherapy. By incorporating the chest radiograph as an additional bedside assessment tool, critical care nurses and advanced practice nurses can more completely monitor patients’ clinical status and be able to plan and prioritize nursing interventions.
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    Figure 1: Chest radiodensities.
    Figure 2: Chest structures, frontal view.
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    Figure 3: Silhouette sign, left upper lobe pneumonia, PAC, ETT, and sternal wires. Abbreviations: ETT, endotracheal tube; PAC, pulmonary artery catheter.
    Figure 4: Chest structures left lateral view.
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    Figure 5: Breast tissue.
    Figure 6: Subcutaneous emphysema and 2 chest tubes.
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    Figure 7: Carina and left and right bronchus.
    Figure 8: Endotracheal tube in right main stem bronchus, CVC, left pleural effusion. Abbreviations: ETT, endotracheal tube; CVC, central venous catheter.
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    Figure 9: Chronic obstructive pulmonary disease, flattened diaphragms, hyperinflation, widened intercostal spaces, apical bullae, and chest rotation.
    Figure 10: Left pneumothorax, hyperlucency, and widened intercostal spaces.
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    Figure 11: Chest tubes in left thorax with reinflated left lung and right lower lobe atelectasis.
    Figure 12: Bilateral pleural effusions with peribronchial cuffing and interstitial edema.
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    Figure 13: Measurements for cardiothoracic ratio.
    Figure 14: Left ventricle enlargement, interstitial edema, beginning butterfly pattern of cardiogenic pulmonary edema, and peribronchial cuffing.
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    Figure 15: Left and right ventricle enlargement.
    Figure 16: Left ventricle enlargement and NGT on left lateral view. Abbreviation: NGT, nasogastric tube.
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    Figure 17: Left and right ventricle enlargement and sterna wires on left lateral view.
    Figure 18: Diffuse generalized mediastinal widening in a postoperative cardiac surgery patient, PAC, ETT, and right atelectasis. Abbreviations: ETT, endotracheal tube; PAC, pulmonary artery catheter.
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    Figure 19: Widened descending aorta indicating thoracic aortic aneurysm.
    Figure 20: Pulmonary venous hypertension (cephalization) with biventricular enlargement.
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    Figure 21: Pulmonary artery hypertension, dilated hilar trunks, and probable left ventricle enlargement.
    Figure 22: Right lower lobe pneumonia with minor fissure visualized,canada goose outlet.
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    Figure 23: Right upper lobe atelectasis with elevation of right diaphragm and narrowed intercostals spaces. Abbreviation: RUL, right upper lobe.
    Figure 24: Pulmonary artery catheter, ETT, and left chest tube. Abbreviations: ETT, endotracheal tube; PAC, pulmonary artery catheter.
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    Figure 25: Central venous catheter, ETT, NGT, atelectasis in RLL, and mediastinal shift. Abbreviations: CVC, central venous catheter; ETT, endotracheal tube; NGT, nasogastric tube; RLL, right lower lobe.
    Figure 26: Interstitial pulmonary edema.
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    Figure 27: Air bronchogram sign, NGT, sternal wires, and jugular PAC. Abbreviations: NGT, nasogastric tube; PAC, pulmonary artery catheter.
    Figure 28: Beginning acute respiratory distress syndrome, soon after hospital admission, patchy infiltrates, alveolar filling in left lower lobe, bilateral atelectasis, and elevated diaphragms.
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    Figure 29: Acute respiratory distress syndrome progressing with increased alveolar filling and atelectasis, 10 hours after the radiograph in Figure 28.
    Figure 30: Acute respiratory distress syndrome with whiteout to almost complete alveolar consolidation, noncardiogenic pulmonary edema, atelectasis, 20 hours after the radiograph in Figure 29.
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    Figure 31: Plate-like atelectasis with diaphragm elevation with narrowed intercostal spaces.
    Figure 32: Cephalization, interstitial edema of cardiogenic pulmonary edema, beginning pleural effusions, and PICC. Abbreviation: PICC, peripheral inserted central catheter.
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    Figure 33: Kerley A and B lines, peribronchial cuffing, and interstitial pattern of cardiogenic pulmonary edema.
    Figure 34: Beginning butterfly pattern of interstitial edema and peribronchial cuffing in cardiogenic pulmonary edema.
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    Figure 35: Alveolar edema in cardiogenic pulmonary edema; note the increased edema in bases versus upper lobes, left ventricle enlargement, and automatic implantable cardiac defibrillator.
    References
    1. Martin GS, Ely EW, Carroll FE, Bernard GR. Findings on the portable chest radiograph correlate with fluid balance in critically ill patients. Chest. 2002;122: 2087–2095. 2. Marik PE, Janower MJ. The impact of routine chest radiography on ICU management decisions: an observational study. Am J Crit Care. 1997;6:95–98. 3. Brainsky A, Fletcher RH, Click HA, Lanken PN, Williams SV, Kundel HL. Routine portable chest radiographs in the medical intensive care unit: effects and costs. Crit Care Med. 1997;25:801–805. 4. Mettler FA Jr. Essentials of Radiology. 2nd ed. Philadelphia, PA: Elsevier Saunders; 2005. 5. Hendrikse KA, Gratama JWC, Hove WM, Rommes JH, Schultz MJ, Spronk PE. Low value of routine chest radiographs in a mixed medical-surgical ICU. Chest. 2007; 132:823–828. 6. Houghton D, Cohn S, Schell V, Cohn K, Varon A. Routine daily chest radiography in patients with pulmonary artery catheters. Am J Crit Care. 2002;11:262–265. 7. Krivopal M, Shlobin OA, Schwartzstein RM. Utility of daily routine portable chest radiographs in mechanically ventilated patients in the medical ICU. Chest. 2003;123: 1607–1614.
    8. Chahine-Malus N, Stewart T, Lapinsky SE, et al. Utility of routine chest radiographs in a medical-surgical intensive care unit: a quality assurance survey. Crit Care. 2001;5:271–275. 9. Graat ME, Stoker J, Vroom MB, Schultz MJ. Can we abandon daily routine chest radiography in intensive care patients? J Intensive Care Med. 2005;20:238–246. 10. Herring W. Learning Radiology: Recognizing the Basics. Philadelphia, PA: Mosby Elsevier; 2007. 11. Novelline R. Squire’s Fundamentals of Radiology. 6th ed. Cambridge, MA: Harvard University Press; 2004. 12. Goodman LR. Felson’s Principles of Chest Roentgenology. 3rd ed. Philadelphia, PA: WB Saunders Co; 2007. 13. Ketai L, Lofgren R, Meholic A. Fundamentals of Chest Radiology. 2nd ed. Philadelphia, PA: Elsevier Saunders; 2006. 14. Connolly MA. Black, white, and shades of gray: common abnormalities in chest radiographs. AACN Clin Issues. 2001;12(2):259–269. 15. Siela D. Using chest radiography in the intensive care unit. Crit Care Nurse. 2002;22(4):18–27. 16. West JB. Pulmonary Pathophysiology: The Essentials. 7th ed. Philadelphia, PA: Wolters Kluwer Health | Lippincott Williams & Wilkins; 2008. 17. West IB. Respiratory Physiology: The Essentials. 8th ed. Philadelphia, PA: Wolters Kluwer Health | Lippincott Williams & Wilkins; 2008.
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    P. 1Chest X-ray InterpretationChest X-ray InterpretationRatings: (18)|Reads: 102,219|Likes: 57Published by Nuru99More info:Categories:Types, School Work, Study Guides, Notes, & QuizzesPublished by: Nuru99over 4 years agoCopyright:Attribution Non-commercialAvailability:Read on Scribd mobile: iPhone, iPadand Android.Flag for inappropriate content|Add to collectionAACN1904_444–47321/10/08
    09:26 PM
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    AACN Advanced Critical Care Volume 19, Number 4, pp.444–473 © 2008, AACN
    Chest Radiograph Evaluation and Interpretation
    Debra Siela, RN, PhD, CCNS, ACNS-BC, CCRN, CNE, RRT
    ABSTRACT
    Chest imaging is an important tool in managing critically ill patients. Basic chest radiology is still used to quickly detect abnormalities in the chest. Critical care nurses are often the ones who first read the radiologist’s report of chest radiograph results and provide their interpretation to a physician. Oftentimes, chest radiographs are obtained routinely on a daily basis for every critical care patient, with the goal of effective clinical management. Critical care nurses can confirm cardiopulmonary assessment findings by also evaluating their patient’s chest radiographs and reviewing the radiologist’s report. By learning some basic skills in interpreting and evaluating chest radiographs, nurses can recognize and localize gross pathologic changes visible on a chest radiograph. This article provides basic chest radiograph interpretation information that allows readers to review relevant anatomy and physiology, summarize normal and abnormal findings on chest radiographs, and describe radiographic findings in common pulmonary and cardiac disorders. Keywords: APN, chest imaging, chest radiograph, chest radiograph evaluation, chest radiograph interpretation, critical care nurses
    is important Chest imaging still an illtopatients.tool in managing critically Basic chest radiology is used quickly detect abnormalities in the chest. Critical care nurses are often the ones who first read the radiologist’s report of chest radiograph results and provide their interpretation to a physician. Oftentimes, chest radiographs are obtained routinely on a daily basis for every critical care patient with the goal of effective clinical management. Debate exists about the efficacy of daily or routine chest radiology for critically ill patients. It has been suggested that daily or routine serial chest radiographs are not needed. Some research supports obtaining daily routine chest radiographs for critically ill patients to be able to identify even subtle changes.1–3 Mettler4 supports daily chest radiographs in critically ill patients. Mettler reports that in daily chest radiographs, 60% do not disclose either new major or minor findings, 20% have new minor
    findings, and 20% have new major findings that are clinically unsuspected and are seen only on the radiograph.4 Other research supports discontinuing daily routine chest radiographs for critically ill patients because subtle changes may not be clinically significant and because of the use of resources and cost.5–7 Some consensus exists for routine but not daily chest radiographs depending on the nature of the acute illness.8 Many of these studies1,3,9 suggest using clinical assessment to guide the need to obtain confirmatory chest radiographs whether or not they are daily or routine. Critical care nurses can confirm cardiopulmonary assessment findings by also interpreting
    Debra Siela is Assistant Professor, Ball State University School of Nursing, and ICU Clinical Nurse Specialist, Ball Memorial Hospital, 2000 University Ave, Muncie, IN 47306 (dsiela@bsu.edu).
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    their patient’s chest radiographs and reviewing the radiologist’s report. This process can aid in planning appropriate nursing care. This article provides information on basic chest radiology interpretation that will allow the reader to review relevant anatomy and physiology, summarize normal findings on chest radiographs, and describe radiographic findings in common pulmonary and cardiac disorders. Basic Chest Radiography X-rays are very short wavelengths of electromagnetic radiation that penetrate matter.4,10–12 A traditional radiograph is created when x-rays penetrate a structure and produce images on a piece of photographic film usually contained in a cassette. However, in most hospitals and medical centers, the traditional x-ray film has been replaced with digital images. Special detectors are used to replace the film in the cassettes and convert the x-ray energy into digital signals to construct a digital radiograph. The digital images are stored on and distributed on a picture archiving and communications system (PACS).4,10–13 A PACS allows viewing access far from the radiology department at any computer workstation at any time. Digital radiographs can be manipulated to alter contrast and brightness or magnify images to see any abnormality. Every sample radiograph included in this document is from a digital format. Each radiograph has a continuum of shades from black to white in its images due to the way the body structures or tissues absorb the x-ray beam.4,10–13 X-rays penetrate body tissues that have minimal tissue density, such as air or air-filled structures, and produce black or dark areas on the radiograph; these areas are referred to as radiolucent. Areas or body tissues that cannot be penetrated by x-rays are radiopaque and appear light or white on the radiograph. Thus, each body tissue or structure has different radiodensity. The 4 basic roentgen densities or radiodensities4,10–13 are • gas (air), which appears black or radiolucent; examples are gas or air in trachea, bronchi, or stomach; • fat, which appears gray or less radiolucent than air; an example is lipid tissue around muscle; • water (soft tissue), which appears white with slight radiopacity; examples are the
    heart, blood vessels, muscle, and diaphragm; and • bone (or metal), which appears all white or completely radiopaque; examples are bones, calcium deposits, prostheses, and contrast media. Figure 1 provides a review all of the chest tissues and structures basic radiodensities in a chest radiograph, and Figure 2 identifies each chest structure or tissue on a frontal chest radiograph (note that all figures appear at the end of the article). If 2 structures of equal density are adjacent to each other, the border of neither structure can be detected. This phenomenon, the silhouette sign, is used to identify normal chest structures and diagnose and localize lung diseases.4,10–13 The silhouette sign may be used to distinguish anterior from posterior structures on a chest radiograph.4,10–13 For example, a silhouette sign would be expected in an area of consolidation in the left upper lobe of the lung because this lobe borders the left sides of the atrium and the mediastinum. Because both the area of consolidation and the heart are water densities, the left border of the atrium cannot be distinguished from the border of the left upper lobe of the lung (Figure 3). Views of the Chest Two of the most common radiographs are posteroanterior (PA) and anteroposterior (AP) or frontal views of the chest.4,10–13 For PA views, the x-ray beam passes through the chest from the back to the front. For AP views, the beam passes through the chest from the front to the back. For acutely ill patients who cannot stand up for a PA view, AP views are obtained with a portable x-ray machine. Ketai and coworkers13 report that more than half of all chest radiographs in hospitals are performed at the bedside. Many of the sample radiographs in this article are AP views. The next most common view of the chest after the frontal view is the lateral view.9 Lateral views of the chest enable detection of lesions behind the heart, near the mediastinum, or near the diaphragm.10,12 The lateral view also allows for visualizing the tracheal air column, inferior vena cava, retrosternal space, posterior margin of the heart, and diaphragmatic contour.10,11 A patient’s frontal and lateral view radiographs allow the viewer to have a vision of the chest in 3 dimensions so that the viewer can more easily localize infiltrates and lesions.
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    In addition, if ventricle enlargement is suspected on the frontal chest image, a lateral view may help confirm the finding. Portable lateral view chest images are also used to evaluate presence of pleural effusions that cannot be seen on frontal views because they are small in size.10 It takes 250 mL of fluid to blunt a lateral costophrenic sulcus on a frontal radiograph, but only 75 mL to blunt the posterior costophrenic sulcus on a lateral radiograph.10 Sometimes, a lateral decubitus view radiograph (patient lying either on one side or on the other) is obtained to evaluate possible pleural effusions and their fluid levels.13 Figure 4 shows lateral view chest structures and tissues. Technical Factors of Viewing Chest Radiographs It is necessary to consider whether each of the following factors are adequate or appropriate to accurately assess and evaluate normal and abnormal chest radiograph findings.10–13 Penetration X-rays must adequately penetrate body structures to visualize the structures. For example, one should be able to faintly see the thoracic spine through the heart shadow.10 If you cannot, the chest radiograph is underpenetrated or too light. In this situation, the left hemidiaphragm may not be visible because the left lung base can appear opaque, which may hide or mimic true disease in the left lower lung field.10 A lateral view will be necessary to confirm any abnormalities in the left lower lung field. In addition, the pulmonary markings may appear more prominent then they really are and may be interpreted as interstitial pulmonary edema or pulmonary fibrosis.10 Again, a lateral view will be necessary to confirm the interstitial findings. If the chest radiograph is overpenetrated or too dark, the lung markings may appear to be absent or decreased.10 It is then possible to make the judgment that the patient has emphysema or pneumothorax when in reality this pathophysiology does not exist.10 One could also miss a pulmonary nodule when the chest radiograph is overpenetrated.10 Inspiration A full-inspiration chest radiograph can be reproduced from one time to the next to eliminate the possibility of artifacts that may confuse the viewer to think that disease is present.10 If one can count 10 posterior ribs
    above the diaphragm, it is an excellent inspiratory film.10 When less than 10 ribs can be counted above the diaphragm, it is either poor inspiratory effort or a sign of low lung volume. Low lung volume from a poor inspiration effort can crowd and compress the lung markings, producing the impression that a lower lobe pneumonia is present. Rotation In AP radiographs, patient malposition or rotation may appear to indicate abnormalities in cardiac, vascular, or mediastinal contours when, in fact, they may not exist.11,13 The position of the clavicles help identify a patient’s rotation.11,13 If one clavicle appears to be shorter in length than the other, then one side of the chest may be rotated close to or away from the detector cassette, producing what appear to be abnormalities.11,13 Figure 9 shows a difference in clavicle length. Comparing the length of the clavicles in addition to comparing the symmetry of the distance between the spinal pedicles and clavicle heads as a method of identifying chest rotation is an important part of the radiograph examination. If one identifies asymmetry in the distance between the pedicles (outer edge of spinal vertebra) and the clavicle heads, the chest is likely rotated.10,13 Figure 9 shows an example of asymmetry between the spinal pedicles and the clavicle heads due to chest rotation. Magnification Anteroposterior views obtained with a portable machine have some disadvantages. Structures in the anterior part of the chest are magnified on AP views, so structures such as the heart are not as distinct as on PA views and may even be distorted.4,10–13 The heart and the mediastinum appear about 15% wider than on the PA view.13 This phenomenon occurs on an AP view mainly because of the shorter distance between the x-ray tube and the patient than occurs in a PA view.4,10,11 Angulation Posteroanterior views are sharper and more distinct with less chest rotation and have consistent clavicle placement because they are always obtained with the patient upright and 2 m (6 ft) away from the source of the x-rays and at a 90 angle to the beam, whereas angles less than 90 are often used for AP radiographs because of inability of critically ill patients to
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    be positioned at 90 .12 Thus, the x-ray beam ends up entering the chest with the patient’s head and chest tilted backward.10 This creates what is called an apical lordotic view of the chest.10 In a chest radiograph that is an apical lordotic view, the clavicles project at or above the posterior first ribs and make the clavicles appear to be straight.10 The apical lordotic view can create the illusion of cardiomegaly when, in fact, it does not exist.10 Systematic Method of Viewing A systematic method should be used to examine chest radiographs.4,10–12,14,15 Radiographs may be examined from side to side, from top to bottom, or structure by structure. Following is the suggested order for structure-by-structure examination of the frontal view (PA or AP) chest radiograph, which can all be viewed in Figure 2. 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. Soft tissues Trachea Bony thorax/ribs Intercostal spaces Diaphragm Structures below diaphragm Pleural surfaces Mediastinum Hila Lung fields Support catheters, tubes, wires, and lines
    neous layer of the skin or soft tissues.10 Subcutaneous emphysema commonly occurs from penetrating chest injury or a chest tube.10 Figure 6 shows subcutaneous emphysema. Trachea The trachea appears as a column of radiolucent tissues or gas density midway between the clavicles or over the spine. The carina is normally positioned approximately at the level of the sixth posterior rib or T4 (Figures 3 and 7).11–13 When an endotracheal (ET) tube is placed correctly, the tip of the tube is approximately 3 to 5 cm (approximately 2 in.) above the carina. Figure 8 shows a chest radiograph with an ET tube down in the right main stem bronchus. Tracheal deviation is present when the trachea is positioned to the right or to the left of the midline. A common cause of apparent tracheal deviation is chest rotation (Figure 9). True tracheal deviation may be caused by the presence of a tumor, mediastinal shift, pneumothorax, or major atelectasis. Figure 25 shows the tracheal deviation due to atelectasis. Bony Thorax The humeri, scapulae, clavicles, spine, and ribs should be identifiable as bone densities. On a radiograph obtained during inspiration, 9 to 10 posterior ribs to the lateral top of the diaphragm should be visible (Figure 2). Each rib should be followed along its course to assess for any notching or deformities; symmetry of rib structures should be assessed bilaterally. Radiographs of patients with chest trauma should be checked for evidence of rib fractures. Intercostal Spaces Each intercostal space is numbered according to the rib above it. The width of the intercostal spaces is determined by measuring the degree of the costovertebral angle relative to the posterior ribs. The normal angle is about 45 ; with widened intercostal spaces, the angle may double to more than 90 .11–13 Widened intercostal spaces occur in conditions such as chronic obstructive pulmonary disease, pneumothorax, and pleural effusion that increase lung volume.11–13 Figures 9 and 10 show an example of widened intercostal spaces. Narrowed intercostal spaces, such as that occurs in atelectasis and interstitial fibrosis, are associated with conditions that decrease lung volume.11–13 Figures 22 and 30 show an example of narrowed intercostal spaces.
    Following is the suggested order for viewing lateral view structures, which all can be seen in Figure 4. 1. 2. 3. 4. 5. 6. 7. Bones Mediastinum Hilum Heart Diaphragm/pleura Lung fields Support catheters, tubes, wires, and lines
    Viewing of Normal Chest Structures Soft Tissues The soft tissues of the chest consist mainly of fat and some water densities.4 The tissues should appear symmetric when compared side to side. Breast tissue is an example of soft tissue. Sometimes, breast tissue shadows obscure the lower lung tissue (Figure 5).4 Subcutaneous emphysema results from air in the subcuta-
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    Diaphragm The diaphragm has a water density, and each hemidiaphragm is dome-shaped. The right hemidiaphragm is normally higher in the chest than is the left hemidiaphragm because of the liver (Figure 2).11–13 Diaphragmatic elevation is evident when fewer than 9 to 10 ribs are visible and can be caused by abdominal distension, phrenic nerve compression, or lung collapse (atelectasis; Figures 22, 24, and 28).11–13 Diaphragmatic depression is present when 11 to 12 ribs are visible.11–13 Depression or flattening of the diaphragm is associated with hyperinflation of the lung or thorax as in chronic obstructive pulmonary disease and pneumothorax.11–13 See examples of diaphragm depression (flattening in chronic obstructive pulmonary disease, Figure 9, and also in a pneumothorax, Figure 10). Structures Below the Diaphragm Almost all of the structures below the diaphragm are primarily water densities. The exception is the gastric air bubble, which may be visible in many frontal radiographs (Figure 2).11–13 Pleural Surfaces The pleurae normally appear as thin, hairlike lines along the lateral edges of the chest and along the diaphragm. When the pleural line deviates medially and appears in the lung fields, a pneumothorax may be present.11–13 When a pneumothorax is present, the area outside the line to the lateral edge of the chest (eg, the pleural space) will appear more radiolucent or completely black.11–13 The costophrenic sulcus (angle) may also be displaced inferiorly and increase the lucency at the same time in a large pneumothorax. This is termed the deep sulcus sign.10 The lung itself will appear more radiopaque or more dense (Figure 10). Mediastinal shift toward the affected lung may also occur in a large pneumothorax. In contrast, in tension pneumothorax, the mediastinum shifts away from the affected lung, and the diaphragm commonly is depressed on the affected side.12 See reinflated left lung with chest tubes in Figure 11. The costophrenic sulcus/angle (Figure 2) should appear as deep sharp points like a V on a frontal view. If the costophrenic sulcus are not distinct deep points on the lateral sides of the chest and appear blunted, a pleural effusion may be the cause.11–13 If a horizontal fluid level or meniscus can be visualized in the area
    of the costophrenic sulcus, a pleural effusion most likely has occurred.11–13 It takes approximately 250 mL of fluid to blunt the costophrenic sulcus on a frontal view radiograph.10 Right-side pleural effusions occur frequently in heart failure. Figures 8, 12, and 32 show pleural effusions. Mediastinum The mediastinum includes the heart, major blood vessels,canada goose outlet, the trachea, and the right and left main bronchi. The heart and blood vessels are water densities, whereas the trachea and bronchi are air densities. The right atrium forms the right border of the heart. The right ventricle cannot be detected directly on a chest radiograph because this structure is located in the center of the heart shadow. The superior vena cava is visualized above the ascending aorta shadow in the right chest.12 An indentation can be located down in the mid-hilar area that marks the junction of the right atrium and superior vena cava (Figure 2). This is the area where the tips of central venous catheters should be located and where a pulmonary artery catheter should enter the right side of the heart.10 The left atrium and the left ventricle form the left border of the heart. The aortic arch is visible as the aortic knob on the frontal view. The descending aorta is about 3 cm above and to the left of the carina (Figure 3).11–13 The main pulmonary artery is the next shadow contour below the aortic knob on a frontal view radiograph.10 Sometimes, the left descending pulmonary artery can be seen as far down as the next contour shadow following the main left pulmonary artery (Figure 2). The cardiothoracic ratio can be determined to assess the overall size of the heart.11–13 This ratio is determined by measuring the horizontal width of the heart and dividing that width by the widest interval of the thorax. The normal cardiothoracic ratio is 1:2 or less (Figure 13).11–13 A cardiothoracic ratio greater than 1:2 is suggestive of cardiac enlargement.11–13 Cardiac enlargement can be determined more precisely by comparing the findings on serial radiographs.13 An increase in the diameter of the heart of 1 cm or greater is considered cardiac enlargement.13 If cardiac enlargement appears to be present, right ventricular enlargement must be distinguished from left ventricular enlargement. Frontal view radiographs show the following during left and right ventricular enlargement:
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    • The left lower border of the heart is moved laterally and becomes rounded in left ventricular enlargement (Figure 14).12,13 • The right atrium protrudes into the right side of the chest and becomes more convex in right ventricular enlargement (Figure 15).12,13 Left and right cardiac enlargement is likely in the lateral view when • the left heart border moves inferoposteriorly beyond the inferior cava toward the spine in left ventricular enlargement (Figure 16).12,13 • the right ventricle shows enlargement by moving anteriorly and superiorly with filling of the anterior retrosternal clear space. Normally, on the lateral view, the lower one third of the right ventricle contacts the sternum (Figure 4). Whereas, in right ventricle enlargement, the right ventricle contacts the lower one half of the sternum.12,13 See Figure 17. The mediastinum can also be widened for many reasons, including focal masses or fluid infiltration. Focal masses usually cause sharp and convex mediastinal widening.12 Mediastinal infiltrations come from hemorrhage or infection and produce widening that appears generalized and diffuse.12 See Figure 18, which shows a wide mediastinum for a new postoperative cardiac surgery patient. Figure 19 shows a thoracic aortic aneurysm, which may be suspected because of the widened thoracic aorta, which also widens the mediastinum. Hila The hila consist of the pulmonary arteries and veins and appear blotchy because of various areas of radiopacity associated with different sizes and thickness of blood vessels. The heart shadow obscures the left hilar area and makes the left hilum appear smaller and higher than the right hilum.13 The left hilum is positioned slightly higher than the right hilum in 97% of all individuals.12 Bronchovascular markings refer to blood vessels and bronchi that branch out from the hila to the periphery of the lung fields (Figure 2).12 As the markings extend out into the lung fields and gradually taper off in the periphery, the structures consist of mainly pulmonary blood vessels and no bronchi. The pattern of pulmonary venous hypertension is seen in patients with elevated pulmonary venous pressure, which is usually caused by left ventricular failure and increased hydrostatic
    pressure.16 You will note increased prominence and thickening of the upper lobe blood vessels in the hila,parajumpers parka, decreased prominence of the lower lobe blood vessels, and haziness of the hilar vessels, which is the process of cephalization.10,11 Figure 20 shows pulmonary venous hypertension. Pulmonary artery hypertension is caused by conditions that decrease the flow of blood through the pulmonary capillary bed such as emphysema, pulmonary emboli, and vasoconstrictive states.16 The hilar trunks are enormously dilated in response to the constricted arterial bed.11 See Figure 21 to view pulmonary arterial hypertension. Hilar elevation is usually present in collapse of the upper lobes of the lung, whereas hilar depression occurs in collapse of the lower lobes of the lung.13 Collapse of the right middle lobe does not cause hilar displacement.13 Lung Fields The lung fields consist mainly of air and very little tissue or blood.11–13 As a result, lung fields should be visualized as an air/gas density or as a completely radiolucent area. Abnormalities of the lung fields on chest radiographs include interstitial patterns and alveolar consolidation patterns. See further descriptions of interstitial and alveolar consolidation patterns under radiographic signs of cardiac and pulmonary disease. Determining the locations of the various lobes of the lungs is useful for diagnosing and localizing pulmonary disease.11–15 The right middle lobe is located anteriorly, adjacent to the right side of the heart. The left lingular lobe is in direct contact with the left border of the heart.12 The upper lobes and the right middle lobes of the lung are primarily anterior thoracic structures, whereas the lower lobes are primarily posterior structures. Knowing the different locations of the lung lobes makes it possible to use the silhouette sign. See Figure 3 for a left upper lobe lung consolidation that borders the left heart. See Figure 21 for a right lower lobe pneumonia where the right-sided heart border is distinct. See Figure 28 for a left lower lobe infiltrates with distinct left-sided heart border. See Figure 30 for an example of complete consolidation where the heart cannot be identified. Fissures are separations or spaces between the lung lobes and appear as narrow white lines on a chest radiograph.11–13 Fissures are normally the thickness of a sharpened pencil line.10 In frontal and lateral views, the area
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    where the minor fissure separates the right middle lobe from the right upper lobe may be visible. The minor fissure is located almost in the middle of the right lung fields, where it appears as a horizontal line on the frontal radiograph (Figure 22).12 One of the direct signs of lung collapse in the right upper lobe on a frontal radiograph is elevation of the minor fissure (Figure 23).11–13 In collapse of the right middle lobe, downward displacement of the minor fissure may be evident. The major or oblique fissures separate the upper lobes of the lung from the lower lobes. The major fissures cannot be seen on a frontal view but are visible on a lateral view.13 See Figure 4 to view the major fissure. Support Catheters, Tubes, Wires, and Lines Critically ill patients commonly have support catheters, tubes, wires, and lines. This invasive support equipment includes, for example, ET tubes, tracheostomy tubes, chest tubes, nasogastric or feeding tubes, central line catheters, peripherally inserted central catheter lines, pulmonary artery catheters, and pacemaker wires. Invasive support equipment is often evaluated as to its position in the chest or abdomen on a chest radiograph. See Table 1 for a list of common catheters,canada goose parka, tubes, wires, and lines that are inserted in the chest with their proper location in a chest radiograph. Nurses should be aware of the correct positions of this support equipment in the chest and abdomen and on a radiograph. The radiographs in Figures 24 and 25 contain various support equipment in both correct and incorrect positions. Several other examples of chest radiographs also show support equipment in both correct and incorrect positions (Figures 3, 6, 8, 16, 18, 27, 32, and 35). However, identifying that a catheter, tube, wire, or line is in a correct position in the chest or abdomen will also require confirmation by a radiologist and the nurse should rely on his or her evaluation. Alveolar and Capillary Anatomy and Physiology An understanding of alveolar and capillary anatomy and physiology is essential for interpreting radiographic indications of pulmonary disease of the air spaces and interstitium. Alveoli consist of 2 different types of cells. Most alveoli are lined with type I cells, which are flat, squamous cells. The corners of alveoli contain
    type II cells, which produce surfactant. Alveolar macrophages are phagocytic cells that clear particles from these air spaces. Openings between alveoli (pores of Kohn) permit movement of gases between adjacent alveoli.16,17 Many structures and substances, such as fluid, connective tissues, leukocytes, and macrophages, are located in the walls between alveoli.16,17 Capillaries are interposed between alveoli in a network. The contact of alveolar surfaces with capillary surfaces forms the alveolarcapillary membrane, the structure through which gas exchange occurs. The alveolar-capillary membrane has a thin side and a thick side.16,17 The thin side bulges into the alveolus and is the primary site for gas exchange. The fusion of alveolar and capillary basement membranes creates the thin side. The thick side includes the alveolar and capillary basement membrane separated by the alveolar interstitial space. The alveolar interstitial space is made of connective tissue such as elastic fibers, collagen fibrils, and fibroblasts. The thick side of the alveolar-capillary membrane does not conduct gas exchange as easily as the thin side does; rather, it promotes fluid exchange in the lung.16,17 Excess fluid in an alveolus is drained via the alveolar interstitial space into the nearby lymphatic system and/or into the connective tissue fibers.16,17 The connective tissues of the alveolar interstitial space form the support system for the alveolar and pulmonary capillaries. Excess fluid in the alveolar interstitial space fluid is drained via the connective tissue fibers into the potential peribronchial and perivascular interstitial space.16,17 The peribronchial and perivascular interstitial spaces surround the bronchioles, bronchi, pulmonary arterioles, and pulmonary arteries interspersed between alveoli in a network. The contact of alveolar surfaces with capillary surfaces forms the alveolar-capillary membrane through which gas exchange occurs. Radiographic Signs of Pulmonary Disease Most pulmonary diseases are associated with increased density of the lung fields on chest radiographs.12 Increased density involves changes in the interstitium, the air spaces, or both. Interstitial Pulmonary Disease In interstitial pulmonary disease, the volume of the alveolar interstitium increases with no
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    Table 1: Support Catheters, Tubes, Wires, and Lines in Chest Radiographs
    Support Equipment ET tube Proper Position 3 to 5 cm from the carina Half the distance between the medial ends of the clavicle and carina Carina is over T5 to T7 Additional Information ET tube tends to slide into the right main bronchus because of a shallower angle ET tube can descend 2 cm during neck flexion ET tube can ascend 2 cm during neck extension TT TT tip should be halfway between the stoma in which the tube was inserted and the carina TT tip should be at about T3 CVC Reach the medial end of clavicle before descending If CVC tip descends beyond the indentation that marks the junction of the right atrium and superior vena cava, it is in the right atrium Descend lateral to spine CVC tip should be in the superior vena cava and not into the right atrium PICC PICC tip should be within the superior vena cava, which should be above the indentation that marks the junction of the right atrium and superior vena cava May be difficult to visualize Pulmonary artery catheter (Swan Ganz Catheter) Tip should be in the proximal left or right pulmonary artery Tip should be about 2 cm from the hilum Insertion into right jugular vein most commonly Temporary catheter tips should be in superior vena cava Permanent catheter tips should be in the right atrium Pleural drainage tubes: Chest tubes and thoracotomy tubes For pleural effusion, tubes should be placed posteriorly and inferiorly For pneumothorax, tube tips should be placed anteriorly and superiorly Ideal position is anterosuperior for evacuating a pneumothorax Ideal position is posteroinferior for evacuating a pleural effusion (continues) If side hole extends outside chest wall, an air leak may occur causing subcutaneous emphysema Rapid lung reexpansion can cause reexpansion pulmonary edema Pulmonary artery catheter tip should not be located in a peripheral or distal artery because of the increased risk of infarction PICC may migrate over time, so monitoring its position is important Incorrect positioning of a TT could penetrate the trachea and cause pneumothorax and subcutaneous emphysema Common malpositioning of a CVC includes placement in the right atrium and internal jugular vein Pneumothorax occurs in 5% of all CVC insertions10 Should obtain chest radiograph postinsertion
    Double lumen catheters: “Quinton” hemodialysis catheters
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    Table 1: Support Catheters, Tubes, Wires, and Lines in Chest Radiographs (Continued)
    Support Equipment Pacemakers Proper Position Implanted subcutaneously in left anterior chest wall Tip of one lead is almost always located in the apex of the right ventricle Two lead pacemakers have 1 lead in the right atrium and 1 in the right ventricle Three lead pacemakers have 1 lead in the right atrium, 1 lead in the right ventricle, and 1 lead in the coronary sinus All leads should have gentle curves AICDs AICDs can be differentiated from pacemakers by the wider and more opaque segment of at least 1 of the electrodes One lead is placed in the superior vena cava or brachiocephalic vein If has another lead, it is placed in the apex of right ventricle Bends in leads should be smooth curves, not sharp kinks Intra-aortic counter pulsation balloon pump (IABP) Placed in descending thoracic aorta Tip should lie distal to origin of the left subclavian artery Metallic marker may point slightly toward the right in the region of the aortic arch When inflated, the balloon may appear as an air-containing sausage in the thoracic aorta NG tube Tip and all side holes should extend about 10 cm into the stomach beyond the EG junction to prevent aspiration from the administration of the feeding into esophagus The EG junction is usually located at the junction of the left hemidiaphragm and the left side of the thoracic spine (left cardiophrenic angle) Dobbhoff feeding tubes Tip of feeding tube should be in duodenum so as to reduce the risk of aspiration Tip is recognizable by a weighted metallic end NG tubes are the most commonly malpositioned of all tubes; always check with a radiograph to confirm the location When malpositioned, NG tubes are frequently coiled in the esophagus If inserted in the trachea, the NG tube can extend into a bronchus and to the periphery of the lung Placement in the stomach is common Placement in the trachea can occur Confirmatory radiograph is needed after placement before beginning feedings If catheter is too proximal, balloon may occlude great vessels leading to stroke If balloon is too distal, device has decreased effectiveness Visible complications can include lead breakage and dislodgement Additional Information Pneumothoraces occur during insertion Fracture of leads may occur
    Abbreviations: AICD, automatic implantable cardiac defibrillators; CVC, central venous catheter; EG, esophagogastric; ET tube, endotracheal tube; NG tube, nasogastric tubes; PICC, peripherally inserted central catheter; TT, tracheostomy tube.
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    change in the alveolar air volume. The alveolar interstitial space increases in size because of fluid, fibrosis, inflammation, or abnormal tissue growth.12 Chronic diffuse interstitial lung disease is usually caused by pulmonary fibrosis.12 In chronic interstitial pulmonary disease, the markings are sharp and the branching is irregular.12 See Figure 26 to view an interstitial pulmonary pattern. Acute diffuse interstitial lung disease is usually due to cardiogenic or noncardiogenic pulmonary edema such as that associated with acute respiratory distress syndrome (ARDS), viral/mycoplasmal pneumonia, or heart failure.12 In ARDS, interstitial edema is caused by direct injury of pulmonary endothelial cells by inflammatory mediators. Gas exchange is impaired by thickening of the thin side of the alveolar-capillary membrane, which increases the distance that oxygen and carbon dioxide diffuse between the alveoli and the capillaries. In acute interstitial pulmonary disease, the markings are hazy with normal branching of the vascular bed and bronchi.12 In interstitial lung disease with normal aeration of the alveoli, chest radiographs typically show increased vascular markings due to more prominent blood vessels.11–13 In addition, lines may be visible in the upper or lower lobes because of thickening of fissure lines. Depending on the type of interstitial lung disease, the markings are as follows11–13: • reticular or linear, which appear as small lines or sometimes as a mesh such as in interstitial pulmonary edema and pulmonary fibrosis; • nodular, which appear as small round dense opacities; examples include bronchogenic cancer and lung metastases; and • reticulonodular, which are a combination of reticular and nodular markings and is the most common type, which includes sarcoidosis. Air Space Disease (Alveoli) Air space or alveolar disease involves reduction of air because of alveolar consolidation, atelectasis, or both. In alveolar consolidation, also termed infiltrates, tissue or fluid replaces all of the air in the alveoli and the lung tissue appears opacified or a water density.12 An alveolar pattern occurs when many alveoli are
    filled with fluid or tissue creating a water density or fluffy appearance. However, in an alveolar pattern, not all alveoli in 1 lung area are filled with fluid or tissue, so the infiltrates appear as “patchy” water densities. Signs of alveolar consolidation on a chest radiograph include the silhouette sign and the air bronchogram sign.11–13 An air bronchogram sign is the radiographic shadow (a radiolucent area) of an air-filled bronchus running through an airless area of lung, which appears opacified (Figure 27).11–13 Figure 3 illustrates a silhouette sign with no clear left-sided heart border caused by left upper lobe pneumonia and consolidation. Decreased lung air volume in alveolar consolidation decreases respiratory gas exchange of oxygen.16 Common causes of consolidation are bacterial pneumonias, cardiogenic pulmonary edema, and noncardiogenic edema such as ARDS.11–13 In cardiogenic pulmonary edema, increased hydrostatic pressure in the blood forces fluid out into the interstitium and alveoli, which can cause alveolar consolidation.10 In ARDS or noncardiogenic edema, direct injury to the alveoli increases permeability of the alveolar-capillary membrane, which over the next 48 hours allows fluid to fill the alveoli and can cause complete lung consolidation.10,16 This complete consolidation can be visualized as a complete whiteout on chest radiographs for ARDS or cardiogenic pulmonary edema (Figures 30 and 35).10–13 Atelectasis is caused by the following 4 pathophysiologic conditions10,13: 1. Air is absorbed from the alveoli (resorptive), usually because of lack of ventilation from an obstruction above the alveoli such as a mucus plug, tumor, foreign body, or occluding inflammation or edema. 2. Alveoli are compressed because of increased intrathoracic pressure (relaxation or passive), such as the opposite lung compressed from a tension pneumothorax. 3. Alveoli collapse from fibrosis or scarring, which is termed cicatrization. 4. Alveoli collapse from loss of surfactant (adhesive) like in ARDS. Hypoventilation can also cause alveoli to lose air volume and become atelectic. Left lower lobe atelectasis is very common following coronary artery bypass surgery.13 One should expect to view signs of left lower lobe atelectasis on these patients’ postoperative
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    radiographs. In all instances of atelectasis, diminished tissue oxygenation occurs because of lack of oxygen in the alveoli. Direct signs of atelectasis on a chest radiograph include displaced fissures, crowded bronchovascular markings, and shifted position of a marker structure such as a scar,parajumpers jacket, nodule, or granuloma.12 Indirect signs of atelectasis are structural shifts in the positions of the hila, diaphragm, and mediastinum and increased density or radiopacity of the lung tissue.12,13 Figure 23 shows both direct and indirect signs of atelectasis. When atelectasis is localized, oblique or horizontal lines may appear. These radiograph changes are called discoid, subsegmental, or plate-like atelectasis (Figure 31).13 Keep in mind that to confirm atelectasis in a lower lobe, a lateral view radiograph may be necessary.13 Two other airspace deformities that are seen on chest radiographs are blebs and bullae. Blebs and bullae are thin-walled air-filled spaces commonly located in the upper lobes and are radiolucent.10 These develop because of alveolar destruction associated with emphysema. Blebs are relatively small air cavities of size less than 1 cm.4 A bulla is greater than 1 cm and often much larger.4 See Figure 9 for examples of bullae. Air Space Disease and Noncardiogenic Pulmonary Edema (ARDS) Patients with ARDS can have a combination of air space disease with both alveolar consolidation and atelectasis.13 Diffuse and patchy alveolar infiltrates occur beginning in the periphery about 12 hours after the insult to the alveolar-capillary membrane (Figure 28).10 Chest radiographs show a primary alveolar pattern with additional signs of atelectasis caused by reduced lung volume from loss of surfactant within 24 to 48 hours postinsult (Figure 29).10,11 Air bronchograms are commonly seen during this stage.10 Complete alveolar consolidation may also occur (Figure 30). In addition,canada goose norge, most likely both indirect and direct lung injury coexist in ARDS.10 However, the consolidation pattern of direct injury usually predominates over the interstitial pattern attributable to indirect injury.13 When a patient survives ARDS, a chronic interstitial pattern due to pulmonary fibrosis often becomes apparent on chest radiographs obtained 1 week or more after the acute stage or diagnosis of ARDS.10,11 The chest radiograph of a post-ARDS patient may look similar to that of Figure 26.
    Radiographic Signs of Cardiac Disease Radiographic signs of cardiac disease are similar but also differ from those of pulmonary disease. Following are descriptions of radiographic signs of cardiac disease. Heart Failure and Cardiogenic Pulmonary Edema In addition to left ventricular enlargement, cephalization or vascular redistribution is an indication of left ventricular failure.11–13 In a patient standing upright, the pulmonary blood vessels are larger in the lower lobes of the lung than in the upper lobes. If the blood vessels in the upper lobes are larger than the blood vessels in the lower lobes, the condition is termed cephalization or vascular redistribution.12 Cephalization occurs because of increasing left ventricular pressure. When pulmonary capillary wedge pressure (PCWP) becomes elevated or left atrial pressure is greater between 10 and 15, cephalization occurs.10,11 In addition, if hydrostatic pressure increases to greater than 10, fluid leaks into the interstitium.10 See Figures 20 and 32 to view cephalization. In addition, as PCWP continues to increase to 19 to 20 mm Hg, interstitial edema begins (Figure 33).10 Kerley lines are a radiographic sign with interstitial pulmonary edema. They are thin linear pulmonary opacities caused by fluid or cellular infiltration into the interstitium of the lungs. There are 3 types of Kerley lines with Kerley B being the most common. Kerley B lines are due to thickening of interlobular septa caused by increased tissue or fluid, as in interstitial pulmonary edema.10,13 Kerley B lines are seen as horizontal lines no more than 2 cm long that appear in the lung periphery near the costophrenic angles and lateral wall (Figure 33). Kerley A lines are caused by distension of channels that connect the peripheral and central lymphatics of the lungs. Kerley A lines appear as oblique lines approximately 2 to 6 cm long that course diagonally toward the hila from the periphery in the upper lobes.10,11 One does not see Kerley A lines without Kerley B lines (Figure 33).10 Kerley C lines supposedly represent thickening of lymphatics that appear as short fine lines throughout the lungs with a reticular appearance. Some radiologists claim that Kerley C lines do not actually exist.10 It is also suggested that what is thought to be Kerley C lines are a combination of Kerley A and Kerley B lines.10
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    Peribronchial cuffing may also be seen in interstitial pulmonary edema. Normal bronchial walls appear as pencil-point thin when viewed end-on.13 Interstitial edema widens the bronchial walls and makes their margins appear indistinct, which is termed peribronchial cuffing.13 Some radiologists describe peribronchial cuffing as appearing as small doughnut densities on the radiograph.10 See Figures 12, 14, 30, 33, and 34 for examples of peribronchial cuffing. In addition, a butterfly or batwing pattern may become apparent on chest radiographs during interstitial pulmonary edema due to heart failure (Figure 34).10,11 The butterfly pattern is due to the fluid engorgement of the interstitium adjacent to the hilar blood vessels.13 Lower lung zones are usually much more affected than upper lung zones.10 Once edema due to heart failure involves the entire alveolar interstitium as a result of increasing PCWP and increased left ventricular pressure, the alveoli start to become edematous.13 At this point, the PCWP is usually greater than 25 mm Hg.10,11 At this time, an alveolar consolidation pattern becomes evident on chest radiographs (Figure 35).10,11 When resolution of this alveolar edema begins, it clears from the periphery and moves centrally.10 However, not all patients with high PCWP have evidence of heart failure on chest radiographs. Pleural effusions are also common in moderate to severe heart failure as indicated by a shallow costophrenic sulcus. The 3 classic stages of cardiogenic pulmonary edema are cephalization (Figure 32), interstitial edema (Figures 33 and 34), and alveolar edema (Figure 35). However, radiographic findings often differ between acute heart failure and chronic heart failure.13 For example, interstitial edema and Kerley B lines do not seem to occur until venous pressures are higher in chronic heart failure than in acute heart failure.13 Radiographs of chronic heart failure are more likely to show cephalization (vascular redistribution) than interstitial edema, whereas in acute heart failure, one is more likely to view interstitial edema.13 Radiographic Sign Differences of Cardiogenic and Noncardiogenic Pulmonary Edema Radiographic signs differ between cardiogenic and noncardiogenic pulmonary edema. Kerley B lines and peribronchial cuffing are seen in
    radiographs of cardiogenic pulmonary edema but not in ARDS radiographs.10 The distribution of pulmonary edema tends to be even in cardiogenic pulmonary edema but is distributed more to the periphery in ARDS.10 Air bronchograms are seen commonly in ARDS radiographs, whereas they are not commonly seen in cardiogenic pulmonary edema radiographs.10 Pleural effusions are much more likely to be seen on cardiogenic pulmonary edema radiographs than on ARDS radiographs.10 Implications for Nurses Signs and symptoms that patients have during acute illness may be indicative of many different types of pathophysiologic or disease processes. Critical care nurses can use chest radiographs as an additional bedside assessment tool to assist in determining pathophysiologic abnormalities and to confirm other assessment findings. By learning some basic skills in interpreting chest radiographs, nurses can recognize and localize gross pathological changes visible on a chest radiograph. Nurses are the care providers who are consistently present at the bedside and have up-todate information on patients’ clinical status. For example, changes in densities in the lung fields on a patient’s chest radiograph along with auscultation of crackles, pulse oximeter oxygen saturation of 88%, and a PCWP pressure of 25 mm Hg may prompt changes in fluid management and supplemental oxygen for the patient. Using a stethoscope, oxygenation status, hemodynamic information, and chest radiographs together for cardiopulmonary assessments enables nurses to recognize additional important clues concerning a patient’s current clinical status. Nurses analyze these findings and develop a plan of care for their patients. For example, a nurse may have determined that a primary goal is to improve lung function and oxygenation. Thus, their plan of care may include interventions related to therapeutic body position such as head-of-bed elevation, good lung down, use of lateral rotation or kinetic therapy, and determination of an optimal body position for chest physiotherapy. By incorporating the chest radiograph as an additional bedside assessment tool, critical care nurses and advanced practice nurses can more completely monitor patients’ clinical status and be able to plan and prioritize nursing interventions.
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    Figure 1: Chest radiodensities.
    Figure 2: Chest structures, frontal view.
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    Figure 3: Silhouette sign, left upper lobe pneumonia, PAC, ETT, and sternal wires. Abbreviations: ETT, endotracheal tube; PAC, pulmonary artery catheter.
    Figure 4: Chest structures left lateral view.
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    Figure 5: Breast tissue.
    Figure 6: Subcutaneous emphysema and 2 chest tubes.
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    Figure 7: Carina and left and right bronchus.
    Figure 8: Endotracheal tube in right main stem bronchus, CVC, left pleural effusion. Abbreviations: ETT, endotracheal tube; CVC, central venous catheter.
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    Figure 9: Chronic obstructive pulmonary disease, flattened diaphragms, hyperinflation, widened intercostal spaces, apical bullae, and chest rotation.
    Figure 10: Left pneumothorax, hyperlucency, and widened intercostal spaces.
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    Figure 11: Chest tubes in left thorax with reinflated left lung and right lower lobe atelectasis.
    Figure 12: Bilateral pleural effusions with peribronchial cuffing and interstitial edema.
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    Figure 13: Measurements for cardiothoracic ratio.
    Figure 14: Left ventricle enlargement, interstitial edema, beginning butterfly pattern of cardiogenic pulmonary edema, and peribronchial cuffing.
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    Figure 15: Left and right ventricle enlargement.
    Figure 16: Left ventricle enlargement and NGT on left lateral view. Abbreviation: NGT, nasogastric tube.
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    Figure 17: Left and right ventricle enlargement and sterna wires on left lateral view.
    Figure 18: Diffuse generalized mediastinal widening in a postoperative cardiac surgery patient, PAC, ETT, and right atelectasis. Abbreviations: ETT, endotracheal tube; PAC, pulmonary artery catheter.
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    Figure 19: Widened descending aorta indicating thoracic aortic aneurysm.
    Figure 20: Pulmonary venous hypertension (cephalization) with biventricular enlargement.
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    Figure 21: Pulmonary artery hypertension, dilated hilar trunks, and probable left ventricle enlargement.
    Figure 22: Right lower lobe pneumonia with minor fissure visualized,canada goose outlet.
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    Figure 23: Right upper lobe atelectasis with elevation of right diaphragm and narrowed intercostals spaces. Abbreviation: RUL, right upper lobe.
    Figure 24: Pulmonary artery catheter, ETT, and left chest tube. Abbreviations: ETT, endotracheal tube; PAC, pulmonary artery catheter.
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    Figure 25: Central venous catheter, ETT, NGT, atelectasis in RLL, and mediastinal shift. Abbreviations: CVC, central venous catheter; ETT, endotracheal tube; NGT, nasogastric tube; RLL, right lower lobe.
    Figure 26: Interstitial pulmonary edema.
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    Figure 27: Air bronchogram sign, NGT, sternal wires, and jugular PAC. Abbreviations: NGT, nasogastric tube; PAC, pulmonary artery catheter.
    Figure 28: Beginning acute respiratory distress syndrome, soon after hospital admission, patchy infiltrates, alveolar filling in left lower lobe, bilateral atelectasis, and elevated diaphragms.
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    Figure 29: Acute respiratory distress syndrome progressing with increased alveolar filling and atelectasis, 10 hours after the radiograph in Figure 28.
    Figure 30: Acute respiratory distress syndrome with whiteout to almost complete alveolar consolidation, noncardiogenic pulmonary edema, atelectasis, 20 hours after the radiograph in Figure 29.
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    Figure 31: Plate-like atelectasis with diaphragm elevation with narrowed intercostal spaces.
    Figure 32: Cephalization, interstitial edema of cardiogenic pulmonary edema, beginning pleural effusions, and PICC. Abbreviation: PICC, peripheral inserted central catheter.
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    Figure 33: Kerley A and B lines, peribronchial cuffing, and interstitial pattern of cardiogenic pulmonary edema.
    Figure 34: Beginning butterfly pattern of interstitial edema and peribronchial cuffing in cardiogenic pulmonary edema.
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    Figure 35: Alveolar edema in cardiogenic pulmonary edema; note the increased edema in bases versus upper lobes, left ventricle enlargement, and automatic implantable cardiac defibrillator.
    References
    1. Martin GS, Ely EW, Carroll FE, Bernard GR. Findings on the portable chest radiograph correlate with fluid balance in critically ill patients. Chest. 2002;122: 2087–2095. 2. Marik PE, Janower MJ. The impact of routine chest radiography on ICU management decisions: an observational study. Am J Crit Care. 1997;6:95–98. 3. Brainsky A, Fletcher RH, Click HA, Lanken PN, Williams SV, Kundel HL. Routine portable chest radiographs in the medical intensive care unit: effects and costs. Crit Care Med. 1997;25:801–805. 4. Mettler FA Jr. Essentials of Radiology. 2nd ed. Philadelphia, PA: Elsevier Saunders; 2005. 5. Hendrikse KA, Gratama JWC, Hove WM, Rommes JH, Schultz MJ, Spronk PE. Low value of routine chest radiographs in a mixed medical-surgical ICU. Chest. 2007; 132:823–828. 6. Houghton D, Cohn S, Schell V, Cohn K, Varon A. Routine daily chest radiography in patients with pulmonary artery catheters. Am J Crit Care. 2002;11:262–265. 7. Krivopal M, Shlobin OA, Schwartzstein RM. Utility of daily routine portable chest radiographs in mechanically ventilated patients in the medical ICU. Chest. 2003;123: 1607–1614.
    8. Chahine-Malus N, Stewart T, Lapinsky SE, et al. Utility of routine chest radiographs in a medical-surgical intensive care unit: a quality assurance survey. Crit Care. 2001;5:271–275. 9. Graat ME, Stoker J, Vroom MB, Schultz MJ. Can we abandon daily routine chest radiography in intensive care patients? J Intensive Care Med. 2005;20:238–246. 10. Herring W. Learning Radiology: Recognizing the Basics. Philadelphia, PA: Mosby Elsevier; 2007. 11. Novelline R. Squire’s Fundamentals of Radiology. 6th ed. Cambridge, MA: Harvard University Press; 2004. 12. Goodman LR. Felson’s Principles of Chest Roentgenology. 3rd ed. Philadelphia, PA: WB Saunders Co; 2007. 13. Ketai L, Lofgren R, Meholic A. Fundamentals of Chest Radiology. 2nd ed. Philadelphia, PA: Elsevier Saunders; 2006. 14. Connolly MA. Black, white, and shades of gray: common abnormalities in chest radiographs. AACN Clin Issues. 2001;12(2):259–269. 15. Siela D. Using chest radiography in the intensive care unit. Crit Care Nurse. 2002;22(4):18–27. 16. West JB. Pulmonary Pathophysiology: The Essentials. 7th ed. Philadelphia, PA: Wolters Kluwer Health | Lippincott Williams & Wilkins; 2008. 17. West IB. Respiratory Physiology: The Essentials. 8th ed. Philadelphia, PA: Wolters Kluwer Health | Lippincott Williams & Wilkins; 2008.
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    Keeping Urinary And Reproductive System HealthyUrology is a very important medical specialty practice and most people underestimate the importance of a healthy urinary tract and reproductive system. It is important to see an urologist when you are experiencing symptoms of a disturbed urinary tract.By: Nova Adipublished on March 20, 2013
    Brief Information About What Is Sinus Infection And What Is Pink EyeWe are prone to various kinds of diseases. Sinus infection and the pink eye are two common infections that are experienced by the people. Here, in this article there is brief information about What is sinus infection and what is pink eye.By: Horihor Horonpublished on February 21, 2013
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    The Most Common Urinary Tract Infection SymptomsUrinary tract infection is a fairly common ailment affecting women. It is important to identify the urinary tract infection symptoms in order to cure the disease effectively.By: Horihor Horonpublished on February 11, 2013
    Symptoms Of Bladder Cancer In Women - Act on Them Before Its Too Late!As a very common perception, men are more likely to get affected from bladder cancer. However, recent studies have shown that women are also under high risk of cancer in the bladder.By: Pete Jamesonpublished on February 02, 2013
    Vitality of Seeking Treatment For Kidney DisordersAny disease can be cured if a person fight against it willingly till the end.Treatment on chronic kidney disease is possible from the experienced physicians but you must be knowing a good physician located in you area.Symptoms of kidney diseases can give you an awareness.By: Evelyn Gloriapublished on January 25, 2013
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    The Effective Treatment For Polycystic Kidney DiseaseIt is widely believed that Polycystic Kidney Disease is a kind of hereditary disease. Most of patients with Polycystic Kidney Disease have family history of PKD. The diagnosis can be accurate if ultrasound image and CT is used. Different people may have different illness condition.By: Jo Parkerpublished on January 11, 2013
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    What Are Side Effects of Renal DialysisWhen kidney disease develops into a more serious stage, the creatinine level would rise higher in patients. In western countries, no effective treatment can be adopted to reduce the level of creatinine except for renal dialysis.By: Giusy Boscopublished on December 05, 2012
    Simple Yet Effective Measure To Alleviate UTIsOne can get easily cured with the aid of medications available in the market; but there are various simple and efficient approaches that work in a potent manner to alleviate your trouble and get back your life on the normal track.By: Wilson Decostapublished on November 08,canada goose jackets, 2012
    Urinary Tests And The New Quick Fix Synthetic Urine 5.7Currently, the United States department of transportation requires that for one to commute in and out of the States, one has to have passed a specified drug test. To many residents and non- residents, this rule has become a hindrance to their will and freedom to commute.By: Antonio Robertspublished on November 22, 2012
    How to Treat Multiple Kidney CystsMultiple kidney cysts may develop on small tubes in the kidneys. The simple kidney cyst is different from the cysts that develop when a person has polycystic kidney disease, which is a genetic disease. Although its cause is not fully understood, the simple cyst is not an inherited condition.By: Bin Wangpublished on November 18, 2012
    The Reality Of Curing Kidney DiseaseYour body has one massive goal, and that is to keep you in the best health it can. In order to help you accomplish everything that you want to achieve, your body will do whatever it can to help you stay fit and healthy. If you have any sort of health issues then your body will work really hard.By: Jeffrey Lucasapublished on November 15, 2012
    Gall Bladder Treatment On Your Gall StonesIf bile becomes solid and moves to a person's gallbladder, then gallstones would form. If left untouched the stones may cause complications, though they are not normally significant. The post has numerous gallbladder treatment options for patients who suffer with gallstone conditions.By: Patricia Fordpublished on November 09, 2012
    Crucial Facts About Kidney TransplantIn case you or your loved one is about to undergo the transplant surgery then it is wise on your part to know all about it. Firstly, the main aspect that you must know is that the transplant surgery is the last option that is taken to save the persons life.By: Wilson Greenpublished on November 06, 2012
    An Overview of Interstitial Cystitis and the TreatmentsInterstitial cystitis, as one number of cystitis families, it is an autoimmune disorder after an inflammatory infection on bladder. It is a chronic pelvic pain syndrome. There are approximately 750,000 Americans that have bladder infection known as Interstitial Cystitis.By: Linda Stuartpublished on November 02, 2012
    Symptoms of Bladder Infection in MenAlthough women are far more susceptible to bladder infection, men aren't totally immune to it. In fact, for men, a bladder infection is usually a form of urinary tract infection,canada goose norge nettbutikk, where the bladder also gets infected with the same germs that caused the urinary tract infection.By: Jeffrey Eadiepublished on October 12, 2012


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    [ILLUSTRATION OMITTED]When you're driving through Burnsville on Highway 72, youmight not notice the unassuming warehouse-style building that housesFurniture, Fabrics & More, but if you venture inside, you'll beglad you did. This simple facadefacade聽(f蓹s盲d`), exterior face or wall of a building. The term implies ordered placement of its openings and other features and thus seems inapplicable to a wall without design. 聽disguises one of the nation'slargest fabric dealers.Discard your preconceptions of a fabric store before you walkthrough the door. Instead of a small-to-midsize retail space with amoderate selection of fabrics, you'll find a cavernouscavernous聽/cav路er路nous/ (kav麓er-nus)1. pertaining to a hollow, or containing hollow spaces.2. having a hollow sound, such as certain abnormal breath sounds. 聽72,canada goose norge,000square feet filled with 600,000 yards of fabric in 6,000 varieties. Ifit is a bit overwhelming at first, don't worry. Owner Kary Petershas an encyclopedicen路cy路clo路pe路dic聽聽adj.1. Of, relating to, or characteristic of an encyclopedia.2. Embracing many subjects; comprehensive: "an ignorance almost as encyclopedic as his erudition"聽聽knowledge of his inventory (computers get in hisway) and a knack for finding just the right fabric for any need. Thebest part? The average price of a yard of fabric is just $3.99, and nofabric sells for more than $7.99 per yard. The store draws customersfrom a 300-mile radius and will see 200 walk-ins on a typical Saturday.Kristina Barnard drove five hours from Beaver Dam, KentuckyBeaver Dam is a city in Ohio County, Kentucky, United States. The population was 3,033 at the 2000 census. It is named for nearby Beaver Dam Creek. GeographyBeaver Dam is located at 聽(37.407143, -86. , toshop at Furniture, Fabrics & More after she had despaired of findingaffordable fabric in her own community. After she and her husband builta new house, she needed fabric for all her drapesdrape聽聽v. draped,canada goose norge nettbutikk, drap路ing, drapesv.tr.1. To cover,canada goose parka, dress, or hang with or as if with cloth in loose folds: draped the coffin with a flag; a robe that draped her figure. 聽and shower curtains."Around here [in Kentucky],canada goose jacket, upholsteryupholstery,聽general term for household fittings, hangings, curtains, cushions, and covers. It refers to stuffed, padded, and spring-cushioned furniture, such as chairs and sofas, or to the usually decorative materials and fabrics that cover them. 聽fabric is $22 to $29 peryard, so it was well worth my five-hour drive to Burnsville," shesays. Barnard estimates she saved $400 by purchasing her fabric atFurniture, Fabrics & More. She priced fabric she bought for Romanshades at a regular retail outletretail outlet聽n 鈫� punto de ventaretail outlet聽n 鈫� point m de venteretail outlet聽retail n 鈫� 聽for $25 a yard but paid only $2.99 peryard at the Burnsville store. "We have nothing like that here, soI'm just amazeda路maze聽聽v. a路mazed, a路maz路ing, a路maz路esv.tr.1. To affect with great wonder; astonish. See Synonyms at surprise.2. Obsolete To bewilder; perplex.v.intr. ," she says.In addition to its walk-in business, Furniture, Fabrics & Moresupplies fabric for 24 major retailers and handles upholstery needs forthe boating industry, hotels, and restaurants. A major and rapidlygrowing portion of its business also goes to in-house upholstery. Forexample, a customer can bring in a sofa, select the fabric, and have thepiece recovered in-house for a mere $350 plus the cost of fabric. Anaverage piece requires 17 yards of fabric, which usually comes to anadditional $68, a price well under what you would pay at other outlets.Peters is looking to expand the store with branches near Oxford andChicago, Illinois. His main focus is customer service. "As much asanything else, we want to do things right," he says.In addition to his extensive knowledge of fabric, he has recentlyhired an interior decorator to consult with customers who are interestedin the additional service."We're like a family here," Peters says, and hemeans it. His 11-person staff includes a cousin, a formerbrother-in-law, and his mother. He describes the store asChristian-based (no profanityIrreverence towards sacred things; particularly, an irreverent or blasphemous use of the name of God. Vulgar, irreverent, or coarse language.The use of certain profane or obscene language on the radio or television is a federal offense, but in other situations, profanity 聽allowed) and has employed as many as fivepreachers at one time.The seeds of Peters' current business were sownsown聽聽v.A past participle of sow1.Adj. 1. sown - sprinkled with seed; "a seeded lawn"seededplanted - set in the soil for growth 聽during anearlier enterprise in which he designed and produced children'sfurniture, which he could upholster using a single yard of fabric,obtained as remnants. He became so good at finding fabric that he becamea fabric buyer and then, in 2003,parajumpers parka, opened Furniture, Fabrics & More."We don't have competition," Peters says proudly ofhis store. "What we have is people screaming for our fabric."[ILLUSTRATION OMITTED]Furniture Fabrics & More338 Hwy. 72 EastBurnsville, MS 38837662-255-1592photography by joe mckewenCOPYRIGHT 2009 Downhome Publications,canada goose outlet, Inc.No portion of this article can be reproduced without the express written permission from the copyright holder.Copyright 2009 Gale, Cengage Learning. All rights reserved.

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    P. 1Body ShapeBody ShapeRatings: 0|Reads: 760|Likes: 3Published by marlenedonnellychoose jewelry to compliment the shape of your facechoose jewelry to compliment the shape of your faceMore info:Categories:Topics, Art & DesignPublished by: marlenedonnellyover 2 years agoCopyright:Attribution Non-commercialAvailability:Read on Scribd mobile: iPhone, iPadand Android.Free download as PDF, DOC, TXT or read online for free from ScribdFlag for inappropriate content|Add to collectionApple body shapeNovember 1, 2007
    An Apple Body Shape is also referred to as an Oval Shape, O-Shape or a Round Shape. With a prominent tummy and an undefined waist, your upper body is often larger than your lower body. *NOTE: Image provided by IGIGI - Browse here to find plus size clothing designed for the Apple or Oval Body Shape. Characteristics of women with an apple body type:
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    A Pear Body Shape, also known as a Triangle Shape or an A-shape, is one of the more common plus size body types. The general outline of your body looks like a triangle which is smaller at the top and larger at the bottom. *NOTE: Illustration provided by IGIGI Browse here to find plus size clothing designed for the Pear or Triangle Body Shape.
    Characteristics of the woman with a pear body shape:
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    Your face and neck are usually smaller in proportion to the rest of your body Your shoulders are narrow to average in size Your bust is smaller than the lower torso Your waist is well defined and curvy Your hips are often much wider in comparison to the rest of your body Your buttocks are full, round and fleshly Your full thighs are considered voluptuous Your lower legs are usually proportionately heavier Use soft shoulder pads or wear a cowl or square neckline to broaden the look of your Don’t forget your accessories; chunky, colorful jewelry looks great on your body type Wear dark colors on the lower body and lighter colors above to draw the eye upward Blouses and jackets should be either long or short, avoiding the hips Choose A-line or empire style cuts to make the most of your curves up top and soften Wear pants and jeans with a flared bottom to create a more balanced look
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    Rectangle body shape
    November 2, 2007 | Leave a Comment
    The Rectangle Body Shape has a columnar, boxy silhouette. With a medium bust and moderately sized hips, you have no clearly defined waist. The rectangle’s fullness is evenly disbursed throughout the overall body. *NOTE: Image provided by IGIGI - Browse here to see plus size clothing designed for the Rectangle Body Shape. Characteristics of the woman with a rectangle body type:
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    Your face is fleshy and tends to have full jaw You usually have a shorter neck with fullness at the nape Your shoulders are in line with your hips You have a broad back with a large ribcage Your bust is moderate in comparison to the overall body You have an undefined waist and are often short-waisted Your high and low hips are evenly sized Your thighs are average sized and your buttocks are flat
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    Your legs are slender and are one of your best assets Your jackets should hit at your waist to create the appearance of a waistline Wear princess seams to make your silhouette look more curvy Garments with an empire waist will create the illusion of a high, thin waist Wear straight-leg pants and jeans to elongate your overall appearance Select pants with large, round pockets to create the illusion of curves at your hips Your hemlines should hit just above or below your knees to emphasize your legs
    Strategies to enhance and balance your body shape:
    Inverted triangle body shape
    November 1, 2007 | Leave a Comment
    The Inverted Triangle Body Shape is the opposite of the Pear or Triangle Body Shape. Athletic women often have this body type. With broad shoulders and bust in comparison to your waist and hips, your frame is often referred to as top heavy. *NOTE: Image provided by IGIGI - Browse here to shop for plus size clothing designed for the Inverted Triangle Body Shape. Characteristics of women with the inverted triangle body shape:
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    Your face tends to be fleshly Your neck is shorter with fullness at the nape and shoulders Your shoulders appear to be broad You are considered busty with your ample bust Your waist is slightly indented with some of the weight in the front midsection Your hips are usually proportionally slender Your buttocks are flat or meduim Your thighs are relatively thinner Your legs are very shapely Choose styles that have details below the waist, such as pockets, pleats, or a dropped Wear tops with V-necks, raglan sleeves or diagonal designs that pull the eye Wear dark colors on the upper body with lighter colors on the lower body Blouses and jackets should be either long or short, avoiding the hips Choose A-line or empire style cuts to make the most of your curves up top and soften Wear pants and jeans with a flared bottom to create a more balanced look
    Strategies to enhance and balance the inverted triangle body shape: waist. downward.
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    November 1, 2007 | Leave a Comment
    The Hourglass Body Shape is the most ideal body shape because of its evenly distributed propotions. Plus size women with this body type are often referred to as curvy or voluptuous. Your shoulders, bust, and hips are about the same width with the hips usually no more than 4” larger than your bust. Your waist could be 6”- 9” narrower than the smaller of the above two. *NOTE: Image provided by IGIGI - Browse here to find plus size clothing designed for the Hourglass Body Shape. Characteristics for women with an hourglass body shape:
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    You may have an oval, round, rectangular or heart shape face along with a well Your neck is proportionate in length with a tendency toward fullness at the nape and Your upper arms are average size but tend to be fleshy Your bust is medium to large, shapely and full; usually narrower or equal to your hips Your well-defined waist gently curves in and out to the high hip Your buttocks are round and full Your hips are usually soft, round and curvy; the lower hip is the widest part of your Your thighs are full but proportionate; you may have innner and outer thigh bulging Your shapely legs are proportionate to the rest of your body
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    Strategies to show off your smaller waist without overemphasizing your hips and
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    Every woman who wears plus sizes can look stylish and fashionable if she knows how to dress to flatter her figure. Women’s bodies come in a variety of shapes and sizes,canada goose norge nettbutikk, and they are as unique as their owners. Just remember, there are no body shapes better or worse than others. Your body type will not make you look more or less beautiful. However, it is important to know your shape so that you can accentuate your great features — no more hiding your curves! Most fashion experts agree that there are five basic body shapes — the Apple, the Hourglass, the Inverted Triangle, the Pear and the Rectangle. You can find general descriptions of these body types in this posting, but look for future posts for more detailed information about all the different body shapes and how to dress to flatter each one. APPLE BODY SHAPE:
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    Bust is narrower than your waist. Waist is fuller than your hips. Hips are narrower than your bust. Bust is fuller than my waist. Waist is narrower than my hips,canada goose outlet. Hips are equal to (up to 3″ difference) my bust. Bust is fuller than my waist,canada goose jackets. Waist is fuller than my hips. Hips are narrower than my bust. Bust is equal to (up to 3″ diff.) my waist. Waist is narrower than my hips. Hips are fuller than my bust. Bust is equal to (up to 3″ difference) my waist. Waist is equal to (up to 3″ difference) my hips. Hips are equal to (up to 3″ difference) my bust.
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    Activity (4)FiltersReviewAdd noteLikeEmbedShowingAllMost RecentReviewsAll NotesLikesRating 0/5Post notePost reviewPost replyPost note and like1 hundred reads|over 2 years agollanyi_254253833liked this|4 months agowindualiked this|over 2 years agowindualiked this|over 2 years agoLoad moreRecommendedPURCHASE ONLYSAMPLETejfalussy tanulmanyTotos-Ferenczi LauraPURCHASE ONLYSAMPLEElixír magazin 2010 - 11.beakodakPURCHASE ONLYSAMPLESONY KV-A3411Df17439PURCHASE ONLYSAMPLEA Harom Szellemi AramlatAlfa24PURCHASE ONLYSAMPLEBag StyleInterweavePURCHASE ONLYSAMPLEA%20chronological%20revolution%20made%20by%20historical%2...aleks3PURCHASE ONLYSAMPLEHandwoven 2000 TocInterweavePURCHASE ONLYSAMPLEKoppány kupájaRaRozsiPURCHASE ONLYSAMPLETale of two ecovillagesPeter CsontosPURCHASE ONLYSAMPLEPhotographyMozart Fialho JrMore From This UserPURCHASE ONLYSAMPLECaring for and Cleaning Your JewelrymarlenedonnellyDownload and print this documentRead and print without adsDownload to keep your versionEdit, email or read offlineChoose a format:.PDF.DOC.TXTDownloadRecommendedTejfalussy tanulmanyTotos-Ferenczi Laura
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    P. 1Body ShapeBody ShapeRatings: 0|Reads: 760|Likes: 3Published by marlenedonnellychoose jewelry to compliment the shape of your facechoose jewelry to compliment the shape of your faceMore info:Categories:Topics, Art & DesignPublished by: marlenedonnellyover 2 years agoCopyright:Attribution Non-commercialAvailability:Read on Scribd mobile: iPhone, iPadand Android.Free download as PDF, DOC, TXT or read online for free from ScribdFlag for inappropriate content|Add to collectionApple body shapeNovember 1, 2007
    An Apple Body Shape is also referred to as an Oval Shape, O-Shape or a Round Shape. With a prominent tummy and an undefined waist, your upper body is often larger than your lower body. *NOTE: Image provided by IGIGI - Browse here to find plus size clothing designed for the Apple or Oval Body Shape. Characteristics of women with an apple body type:
                  
    You have a proportionate face with slight fullness in the jaw and cheek area Your neck is shorter with a tendency to be full at the nape and shoulders Your shoulders are average sized with a slightly forward slope Your have a broad back with full upper arms You have medium to large breasts,canada goose norge, so wear a supportive bra Your tummy is large, and you tend to gain weight in this area Your undefined waist may measure equal to or larger than your hips Your buttocks are flat although you have generous thighs You have shapely or slender lower legs, one of your best assets Wear vertical patterns or stripes so the viewer’s eye will move up and down, making Monochromatic colors are also perfect for you because they create a smooth, sleek V-necklines slenderize your neck and frame your beautiful face Additional options for apples include tunics, A-line dresses and bootcut jeans Look for anything that provides midsection definition Avoid materials that clings, instead choose cottons and light linens
    Main strategies to enchance your body shape: your figure appear taller and slimmer line which softens and flatters your curves
    Pear body shape
    A Pear Body Shape, also known as a Triangle Shape or an A-shape, is one of the more common plus size body types. The general outline of your body looks like a triangle which is smaller at the top and larger at the bottom. *NOTE: Illustration provided by IGIGI Browse here to find plus size clothing designed for the Pear or Triangle Body Shape.
    Characteristics of the woman with a pear body shape:
                 
    Your face and neck are usually smaller in proportion to the rest of your body Your shoulders are narrow to average in size Your bust is smaller than the lower torso Your waist is well defined and curvy Your hips are often much wider in comparison to the rest of your body Your buttocks are full, round and fleshly Your full thighs are considered voluptuous Your lower legs are usually proportionately heavier Use soft shoulder pads or wear a cowl or square neckline to broaden the look of your Don’t forget your accessories; chunky, colorful jewelry looks great on your body type Wear dark colors on the lower body and lighter colors above to draw the eye upward Blouses and jackets should be either long or short, avoiding the hips Choose A-line or empire style cuts to make the most of your curves up top and soften Wear pants and jeans with a flared bottom to create a more balanced look
    Strategies to help you balance your upper and lower body portions: shoulders
    the ones on the bottom
    Posted by Rene | Filed Under Blog, Pear body shape, Plus size body shapes,canada goose outlet, Plus size special occasion
    Rectangle body shape
    November 2, 2007 | Leave a Comment
    The Rectangle Body Shape has a columnar, boxy silhouette. With a medium bust and moderately sized hips, you have no clearly defined waist. The rectangle’s fullness is evenly disbursed throughout the overall body. *NOTE: Image provided by IGIGI - Browse here to see plus size clothing designed for the Rectangle Body Shape. Characteristics of the woman with a rectangle body type:
           
    Your face is fleshy and tends to have full jaw You usually have a shorter neck with fullness at the nape Your shoulders are in line with your hips You have a broad back with a large ribcage Your bust is moderate in comparison to the overall body You have an undefined waist and are often short-waisted Your high and low hips are evenly sized Your thighs are average sized and your buttocks are flat
          
    Your legs are slender and are one of your best assets Your jackets should hit at your waist to create the appearance of a waistline Wear princess seams to make your silhouette look more curvy Garments with an empire waist will create the illusion of a high, thin waist Wear straight-leg pants and jeans to elongate your overall appearance Select pants with large, round pockets to create the illusion of curves at your hips Your hemlines should hit just above or below your knees to emphasize your legs
    Strategies to enhance and balance your body shape:
    Inverted triangle body shape
    November 1, 2007 | Leave a Comment
    The Inverted Triangle Body Shape is the opposite of the Pear or Triangle Body Shape. Athletic women often have this body type. With broad shoulders and bust in comparison to your waist and hips, your frame is often referred to as top heavy. *NOTE: Image provided by IGIGI - Browse here to shop for plus size clothing designed for the Inverted Triangle Body Shape. Characteristics of women with the inverted triangle body shape:
                  
    Your face tends to be fleshly Your neck is shorter with fullness at the nape and shoulders Your shoulders appear to be broad You are considered busty with your ample bust Your waist is slightly indented with some of the weight in the front midsection Your hips are usually proportionally slender Your buttocks are flat or meduim Your thighs are relatively thinner Your legs are very shapely Choose styles that have details below the waist, such as pockets, pleats, or a dropped Wear tops with V-necks, raglan sleeves or diagonal designs that pull the eye Wear dark colors on the upper body with lighter colors on the lower body Blouses and jackets should be either long or short, avoiding the hips Choose A-line or empire style cuts to make the most of your curves up top and soften Wear pants and jeans with a flared bottom to create a more balanced look
    Strategies to enhance and balance the inverted triangle body shape: waist. downward.
    the ones on the bottom
    Hourglass body shape
    November 1, 2007 | Leave a Comment
    The Hourglass Body Shape is the most ideal body shape because of its evenly distributed propotions. Plus size women with this body type are often referred to as curvy or voluptuous. Your shoulders, bust, and hips are about the same width with the hips usually no more than 4” larger than your bust. Your waist could be 6”- 9” narrower than the smaller of the above two. *NOTE: Image provided by IGIGI - Browse here to find plus size clothing designed for the Hourglass Body Shape. Characteristics for women with an hourglass body shape:
            
    bust:
    You may have an oval, round, rectangular or heart shape face along with a well Your neck is proportionate in length with a tendency toward fullness at the nape and Your upper arms are average size but tend to be fleshy Your bust is medium to large, shapely and full; usually narrower or equal to your hips Your well-defined waist gently curves in and out to the high hip Your buttocks are round and full Your hips are usually soft, round and curvy; the lower hip is the widest part of your Your thighs are full but proportionate; you may have innner and outer thigh bulging Your shapely legs are proportionate to the rest of your body
    defined chin and possibly a double chin shoulders
    body
    Strategies to show off your smaller waist without overemphasizing your hips and
          
    Wear contrasting colors to show off your shape; details should be equally interesting Select vertical lines to give an appearance of length to your silhouette Accentuate your face, neck and décolleté area with open collars and V-necklines Wear a wrap dress to show off your curvy shape Opt for boot cut or straight-leg pants, which add volume on your lower leg to balance Choose tops with three-quarter sleeves to reveal the thinnest part of your arms Wear skirt and dress hemlines around your knees to show off your pretty legs
    on the top and bottom
    your hips
    How to dress to flatter your figure
    Every woman who wears plus sizes can look stylish and fashionable if she knows how to dress to flatter her figure. Women’s bodies come in a variety of shapes and sizes,canada goose norge nettbutikk, and they are as unique as their owners. Just remember, there are no body shapes better or worse than others. Your body type will not make you look more or less beautiful. However, it is important to know your shape so that you can accentuate your great features — no more hiding your curves! Most fashion experts agree that there are five basic body shapes — the Apple, the Hourglass, the Inverted Triangle, the Pear and the Rectangle. You can find general descriptions of these body types in this posting, but look for future posts for more detailed information about all the different body shapes and how to dress to flatter each one. APPLE BODY SHAPE:
                  
    Bust is narrower than your waist. Waist is fuller than your hips. Hips are narrower than your bust. Bust is fuller than my waist. Waist is narrower than my hips,canada goose outlet. Hips are equal to (up to 3″ difference) my bust. Bust is fuller than my waist,canada goose jackets. Waist is fuller than my hips. Hips are narrower than my bust. Bust is equal to (up to 3″ diff.) my waist. Waist is narrower than my hips. Hips are fuller than my bust. Bust is equal to (up to 3″ difference) my waist. Waist is equal to (up to 3″ difference) my hips. Hips are equal to (up to 3″ difference) my bust.
    HOURGLASS BODY SHAPE:
    INVERTED TRIANGLE BODY SHAPE:
    PEAR BODY SHAPE:
    RECTANGLE BODY SHAPE:
    Find the perfect little black dress to fit you and your budget
    Did you know that Coco Chanel is credited with creating the very first little black dress (LBD) in 1926? Although that makes the LBD over 80 years old, you will never look outdated if you wear one to the upcoming holiday festivities. The secret is to invest in a dress that works best for your body. Then you won’t need a new outfit for each holiday party — just swap your accessories. Apple shaped women have a rounded body. You should look for dress styles that will elongate your figure and not cut it in half. Look for dresses with wide necklines, empire waists,canada goose outlet, princess seams and A-line shapes.
    Hourglass shaped women have a curvy shape. Consider dress styles that will reveal your balanced curves. Look for A-line dresses or wrap dresses that cinch at the waist and then taper out. Women with inverted triangle shapes appear to be top heavy. You should wear wrap dresses or surplices with little or no detailing at the shoulders. Consider drop-waist dresses that flare out below your hips, making you look curvier on the bottom. Pear shaped women appear to be bottom heavy. Wearing dresses with off-the shoulder necklines will widen your shoulders to balance your hips. Consider empire dresses with details at the bustline to create more volume on the top half. Women with rectangle shapes have an undefined waist, so you want to create a waistline where you have none. Wear V-neck dresses, wrap dresses or surplice dresses that tie or pull in at the waist. Wearing an empire dress will make it look as if you have a thin, high waistline
    Activity (4)FiltersReviewAdd noteLikeEmbedShowingAllMost RecentReviewsAll NotesLikesRating 0/5Post notePost reviewPost replyPost note and like1 hundred reads|over 2 years agollanyi_254253833liked this|4 months agowindualiked this|over 2 years agowindualiked this|over 2 years agoLoad moreRecommendedPURCHASE ONLYSAMPLETejfalussy tanulmanyTotos-Ferenczi LauraPURCHASE ONLYSAMPLEElixír magazin 2010 - 11.beakodakPURCHASE ONLYSAMPLESONY KV-A3411Df17439PURCHASE ONLYSAMPLEA Harom Szellemi AramlatAlfa24PURCHASE ONLYSAMPLEBag StyleInterweavePURCHASE ONLYSAMPLEA%20chronological%20revolution%20made%20by%20historical%2...aleks3PURCHASE ONLYSAMPLEHandwoven 2000 TocInterweavePURCHASE ONLYSAMPLEKoppány kupájaRaRozsiPURCHASE ONLYSAMPLETale of two ecovillagesPeter CsontosPURCHASE ONLYSAMPLEPhotographyMozart Fialho JrMore From This UserPURCHASE ONLYSAMPLECaring for and Cleaning Your JewelrymarlenedonnellyDownload and print this documentRead and print without adsDownload to keep your versionEdit, email or read offlineChoose a format:.PDF.DOC.TXTDownloadRecommendedTejfalussy tanulmanyTotos-Ferenczi Laura
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    Tale of two ecovillagesPeter Csontosby J. DawsonDamanhur & FindhornItaly/ScotlandNovember/December 2004.
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    En EspañolTeachers - Looking for Health Lessons? Visit KidsHealth in the ClassroomWhat Other Parents Are ReadingAll About AllergiesScary News Report? What to SaySafety Tips: BaseballEasy Meal: Confetti QuinoaConnect With Us: Social MediaPregnant? Your Baby's Growth
    Cord-Blood BankingKidsHealth>Parents>Cancer Center>Treatment & Prevention>Cord-Blood BankingPrintAAA
    Text SizeWhat's in this article? (click to view)About Cord-Blood BankingWhy Cord Blood Is ImportantHow Banking WorksPrivate Banking Not Widely RecommendedIs Banking Right for You?Deciding to Donate 

    When you're expecting, you have many decisions to make. So if you've heard about banking umbilical cord blood, you might be wondering what it involves — and whether it's right for you and your family.
    About Cord-Blood BankingCord-blood banking basically means collecting and storing the blood from within the umbilical cord (the part of the placenta that delivers nutrients to a fetus) after a baby is born.
    Cord blood contains blood-forming stem cells,canada goose montebello parka, which are potentially useful for treating diseases that require stem cell transplants(also called bone marrow transplants), such as certain kinds of leukemiaor lymphoma, aplastic anemia, severe sickle cell disease, and severe combined immunodeficiency.


    There are two types of banks that store cord blood:
    Public banks collect donated cord blood for research or for use by anyone who may need it. There is usually no charge associated with this service. After birth, blood is collected, anonymously marked,parajumpers Kodiak herr, and sent to a public bank to potentially save the life of another child one day.

    If you choose this option and your child or a family member later develops a disease that requires a stem cell transplant for treatment, you won't be able to obtain the donation you made to the bank.Private banks store cord blood for personal use by the family. There is a fee associated with this service. People who have a family history of disease that can be treated with stem cell transplants sometimes consider this option.

    Less commonly, people choose to privately bank their newborn's cord blood on the off chance that someday their child or a sick family member could be treated with it. This practice isn't recommended, however, since the costs associated with it are high and the chances of a family member ever using the cord blood are slim.Like community or hospital blood banks, cord-blood banks are regulated by the U.S. Food and Drug Administration (FDA), which has developed standards regulating future cord-blood collection and storage.
    Continue
    Why Cord Blood Is ImportantUp until the 1970s, the placenta and umbilical cord were discarded after birth without a second thought. But around this time, researchers discovered that umbilical cord blood could supply the same kinds of blood-forming (hematopoietic) stem cells as a bone marrow donor. They started collecting and storing umbilical cord blood.
    What are blood-forming stem cells? These are primitive (early) cells found primarily in the bone marrow that are capable of developing into the three types of mature blood cells present in our blood — red blood cells, white blood cells, and platelets. cord-blood stem cells may also have the potential to give rise to other cell types in the body.
    Some serious illnesses (such as certain childhood cancers, blooddiseases, and immune systemdisorders) require radiationand chemotherapytreatments to kill diseased cells in the body. Unfortunately, these treatments also kill many "good" cells along with the bad, including healthy stem cells that live in the bone marrow.
    When this happens, some kids can benefit from a stem cell transplant, from a donor whose cells closely match their own. Blood-forming stem cells from the donor are transplanted into the child who is ill, and those cells go on to manufacture new, healthy blood cells and enhance the child's blood-producing and immune system capability.
    BackContinue
    How Banking WorksCollectionCord-blood banking isn't routine in hospital or home deliveries. It's a procedure you have to choose and plan for beforehand.
    Collection of the cord blood takes place shortly after birth in both vaginal and cesarean (C-section)deliveries. It's done using a specific kit that parents usually order ahead of time from their chosen cord-blood bank.
    Blood is collected immediately after delivery by an obstetrician, nurse, or technician. After birth, the umbilical cord is cut and clamped on one side. To collect blood, a small needle is passed into the umbilical vein and a syringe is used to draw blood.
    Blood also can be collected by hanging a bag below the mother and letting gravity draw the blood down through a tube and into the bag. Blood collection can occur either before or after the placenta is delivered.
    StoringAfter collection, the cord blood is taken by courier to the cord-blood bank. Once there, the sample is given an identifying number. Then the stem cells are separated from the rest of the blood and are stored cryogenically (frozen in liquid nitrogen).
    How long can blood-forming stem cells last when properly stored? In theory, stem cells should last forever, but cord-blood research only began in the 1970s, so the maximum time for storage and potential usage are still being determined. Blood-forming stem cells that have been stored for more than a decade have been used successfully in transplants.
    There is no cost involved when donating cord blood to a public bank, though some doctors or midwivesmay charge a small fee to collect the blood. The cost for storing cord blood privately is approximately $1,000-$2,000, in addition to a yearly maintenance fee (usually around $100). You also might pay an additional fee of several hundred dollars for the cord-blood collection kit,canada goose outlet, courier service to the cord-blood bank, and initial processing.
    TransplantationCryogenic blood-forming stem cells can be thawed and used in either autologous procedures (when someone receives his or her own umbilical cord blood in a transplant) or allogeneic procedures (when a person receives umbilical cord blood donated from someone else — a sibling, close relative, or anonymous donor).
    In most cases, these transplants are done only with children or young adults. That's because the volume of a cord-blood donation usually isn't enough for an adult's transplant. The larger a person is, the more blood-forming stem cells he or she needs for a successful transplant.
    BackContinue
    Private Banking Not Widely RecommendedMost medical organizations, including the American Academy of Pediatrics (AAP),paraiumpers jacket on sale, recommend public donation of cord blood whenever possible.
    Currently, they do not recommend privately banking your newborn's cord blood unless you have a child or family member with a current or potential need for a stem cell transplant. The reason? The likelihood of a healthy person ever needing stem cells is rare, and research has never confirmed that self-donated cells (rather than cells from a relative or stranger) make transplantations safer or more effective.
    Stem cells from cord blood from both related and unrelated donors have been successful in many transplants. That's because blood-forming stem cells taken from cord blood are naive (a medical term for early cells that are still highly adaptable and are less likely to be rejected by the recipient's immune system). Therefore, donor cord-blood stem cells do not need to be a perfect match to create a successful stem cell transplant.
    There has been little experience with transplanting self-donated cells. Some experts are concerned that an ill baby who receives his or her own stem cells during a transplant would be prone to a repeat of the same disease. Most of the stem cell transplants that use blood-forming stem cells have been performed on relatives of the donating child, not on the donating child.
    Finally, there are a few cautions to keep in mind when it comes to private banking. Some doctors and organizations express concern that private cord-blood banks may capitalize on the fears of vulnerable new parents by providing misleading information about the statistics of stem cell transplants. Parents of children of ethnic or racial minorities, adopted children, or children conceived through in vitro fertilization may be especially encouraged to bank cord blood because it's statistically harder to find a match in these cases.
    BackContinue
    Is Banking Right for You?If you are considering banking your newborn's cord blood, be sure to discuss your options with your obstetrician.
    Here are a few questions to consider before choosing a cord-blood bank:
    What are the pros and cons of public versus private banking?If you consider public:Does the hospital where I will deliver work with a public cord-blood bank? If not, how can I get information about public banks that have a mail-in donation program?If you consider private:How financially stable is the cord-blood bank? (Financial stability means a reduced chance that you will have to transfer your sample if the facility closes.)How many samples are processed in the facility? (A larger number of samples usually means that there are more collection and handling procedures in place.)Do I have the option of switching to another facility if I choose?What happens to my sample if the facility goes out of business?
    What are the yearly fees and maintenance costs involved? Will these fees increase,parajumper kodiak women, or are they fixed?Answers to all of your questions might not be readily available. Cord-blood banking is still a relatively new medical practice. Many hospitals do not yet offer this service (or are not affiliated with a public or private bank that offers it), and some medical professionals are still not fully aware of how cord-blood banking works.
    But other resources are available to help you make an informed decision, including:
    The Parent's Guide to Cord Blood Foundation (www.parentsguidecordblood.org), which lists both public and private blood banks by geographic locationThe National Marrow Donor Program (www.bethematch.org), with information on registered cord-blood facilities that accept donationsYou also can contact your local chapter of the American Red Cross (www.redcross.org/find-your-local-chapter) or a local university hospital.
    Deciding to DonateMany doctors and researchers support saving umbilical cord blood mainly because of the promise that stem cell research holds for the future. Most of us would have little use for stem cells now, but research into using them to treat diseases is ongoing — and the future looks promising.
    If you'd like to donate your child's umbilical cord blood, talk to your obstetrician or midwife or contact the hospital or birthing center where your baby will be born. It's best to start this process early in your second trimester to give yourself plenty of time to register for this service.
    Reviewed by: Elana Pearl Ben-Joseph, MD
    Date reviewed: November 2012
    Back1• 2• 3• 4• 5For TeensFor KidsFor ParentsMORE ON THIS TOPICSevere Combined ImmunodeficiencyGenetic TestingGenetic CounselingA Guide for First-Time ParentsBloodFemale Reproductive SystemBirthing Centers and Hospital Maternity ServicesContact UsPrintAdditional resourcesSend to a friendReprint guidelinesBookmark this pageShare this page using:What are these?
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    [imagine REQUEST] someone tries to break you upHARRY:  “What do you mean we have to break up?” you ask, biting back your tears.  Harry places his hands on your upper arms.  “I said that management wants us to break up - I didn’t say that we are going to,” he explains softly.  “But why?  Did I do something wrong?”  He shakes his head frantically.  “No,parajumpers sverige, no, of course not.  They just have this stupid idea that if I were single our fan base would grow.  But I’m not buying it.”  “Harry…  I don’t want to get in the way of your career and ruin this for you.”  “Stop it.  We’re not breaking up.  I’ve done a lot for them that they thought would help the band, but I’m putting my foot down on this one.”  You nod, not knowing what else to say.  “I promise, we’re not breaking up over something this stupid.  We’ll get through this, together,” he soothes, taking you in his arms, knowing it’ll be a long uphill battle to fight management on this, but also knowing that there’s no way he’s going to back down and give in.
    LOUIS:  “I just really don’t think he’s the best fit for you…” your mom explains softly.  “What do you mean?” you ask, completely offended and surprised by this.  “He just seems a little immature.  I mean, do you seriously think he will be the one you settle down with?”  “Mom, you met him, you said you thought he was great!  Where is all this coming from?”  “I’ve just been thinking that you might be better off with someone who takes things a little bit more seriously, is all.”  “Mom, have you ever stopped to think that maybe that’s exactly why I fell for him?  Because he’s not so caught up in being stuffy and mature all the time?  He knows how to have fun and we have fun together…”  Your mom just shakes her head lightly.  You get up and leave the house, driving over to Louis’.  You tell him the conversation of just a few minutes ago.  “Well, I’m not gonna become the wedge in you and your mom’s relationship, so-“  “Shh, no, no.  That’s not why I’m telling you this.  She doesn’t know what she’s talking about.  I just wanted to tell you so that we can work together at showing her that she’s wrong about you and about us.”  Louis smiles, “I’ll do whatever it takes to keep you, baby.”  You smile and place a light kiss on his cheek.
    LIAM:  “I really think it’s best if you and my sister break up.  This whole dating a guy in a band thing just isn’t good for her.  You aren’t even here 98% of the time.  She just mopes around all depressed when she has to go days without hearing from you,” your older brother is telling Liam one afternoon while you listen in from the hallway.  “I understand this is hard on her, but you have to know this is hard on me too.  It’s no easier being away from her all the time than it is to be away from my family,” Liam explains rationally.  “Look,canada goose ?terf?rs?ljare, you’re a nice guy.  You’re one of the few boyfriends that she’s brought home and I’ve actually liked.  It’s nothing personal, I mean it.  I just have my sister’s best interests in mind.”  “Did you ever think that maybe I am best for her?” Liam questions.  At this point, you butt in.  Stepping into the room and taking a stand next to Liam, you grab his hand and say, “I really appreciate your concern, but in all honesty I couldn’t imagine my life any other way.  Yes, it sucks that he’s gone so much, but at the end of the day it’s all worth it.  If he were in the military and had to be gone on duty for long periods of time, would you want me to break up with him for that?” you interrogate your brother.  Stumped, he doesn’t answer you.  You’d brought up a valid point that he just doesn’t have a rebuttal for.  “Come on, let’s go,” you say to Liam, pulling him out of the room behind you.
    NIALL:  “Why would she say something like that?” you ask in disbelief.  Niall shakes his head.  “I have no idea.  It just kinda came out of nowhere.  It took me completely by surprise.”  “Well what did you say to her in reply?”  “I tried to be nice about it - I didn’t wanna give her any other reason to say you’re a bad influence - so I just said that I appreciated her advice but I was capable of making my own decisions.  She wasn’t happy about it,canada goose sverige, I could tell,parajumper outlet, but whatever.”  “I just don’t understand why she thinks I’m a bad influence?  What did I do wrong?”  “Nothing, baby!  I think she was just using that as an excuse for her to tell me to break up with you.”  “This sucks…”  “I know it does,” Niall agrees, taking you into his embrace.  “So what do we do now?” you ask.  “We keep going on like we have been.  She’ll come around eventually.  And if she doesn’t…  Well, we’ll deal with that if we have to.”  “Are you sure?”  “Of course!  I’m not gonna let her make this kind of choice for me.  Frankly, this is none of her business.”  “I love you, Niall.”  He kisses your forehead before murmuring against your skin, “I love you too.”
    ZAYN: “Have you seen what your trashy girlfriend is up to this week?” Zayn’s sister asks, coming into the living room and showing him a picture of you that she’d printed offline.  “Would you stop calling her that?” Zayn asks exasperatedly.  “What?  It’s true.  Look at that outfit she’s wearing!”  Zayn doesn’t even look at the picture, he just grabs it and crumples it up in his hand.  “Why do you always make those comments?  What’s the issue?”  “I just think you can do better, that’s all.  You could find a girl with a little more class.”  “For your information, she has plenty of class.  And I’d really appreciate it if you kept those kinds of comments to yourself.”  “Not until you dump her…” she says, turning to leave the room.  Angered, Zayn picks up his phone to call you.  You can tell something is eating at him, but when you ask about it, he gets defensive.  “Nothing, my sister is just being stupid and saying we should break up.  She’s so full of bull…”  “Uh…ok…” you stutter out, not sure to begin the conversation with why his sister would say that, or accuse him of actually being bothered by it despite his trying to play it off.  “She just thinks I can do better, but I disagree completely.  You’re the best thing that’s ever happend to me, [Y/N].”  You smile into the phone.  “Well,Canada Goose Expedition Parka, I guess I’ll just have to work extra hard at winning her over then, won’t I?”  Zayn chuckles,billiga canada goose jackor, “Yeah, I guess so.”


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Usually, socks and other hosiery are worn between the feet and the footwear,parajumpers china, except for sandals and flip flops (thongs).  market.Using the most current point-of-salepoint of salen. pl. points of saleA business or place where a product or service can be purchased. Also called point of purchase.point  data compiled from thenation's leading sporting goods retailers, department storesThis is a list of department stores. In the case of department store groups the location of the flagship store is given. This list does not include large specialist stores, which sometimes resemble department stores.  andspecialty storesNoun 1. specialty store - a store that sells only one kind of merchandiseshop, store - a mercantile establishment for the retail sale of goods or services; "he bought it at a shop on Cape Cod" , SportsTrend.Info each week tracks exactly whatproducts consumers are purchasing, as well as where and when.The top-selling footwear manufacturers, first quarter of 2000compared with the first quarter of 1999 based on market share dollars,are as follows:Manufacturer 2000 Manufacturer 19991. Nike 39.2% Nike 48.9%2. Adidas 15.1% Adidas 16.9%3. Reebok 10.9% Reebok 10.9%4. New Balance 9.4% New Balance 3.7%5. K-Swiss 3.6% K-Swiss 3.1%6. Timberland 2.9% Timberland 2.1%7. Asics 2.1% Asics 1.5%8. Saucony 1.4% Lugz 1.4%9. Skechers 1.4% And 1 0.9%10. And 1 1.2% Saucony 0.9%After the first quarter of 2000,canada goose jacka dam, Nike products comprised more than39% of the footwear market, including an astoundinga·stound  tr.v. a·stound·ed, a·stound·ing, a·stoundsTo astonish and bewilder. See Synonyms at surprise.[From Middle English astoned, past participle of astonen,  65.5% of thebasketball shoe market. Although down from last year's numbers(48.9% of the overall market and 73.6% of the basketball shoe market),Nike continues to dominate the footwear industry.In addition to its stronghold on the basketball shoe market,parajumper long bear,Nike's market share ranks first for cleated shoes (56.6%), secondfor aerobicaerobic /aer·o·bic/ (ar-o´bik)1. having molecular oxygen present.2. growing, living,Canada Goose Ontario Parka, or occurring in the presence of molecular oxygen.3. requiring oxygen for respiration.4.  shoes (22.7%) and casual shoes (12.0%) and third amongcourt/fitness shoes (16.3%).Second among overall footwear is Adidas with a market share of15.1%. After one quarter last year, Adidas was in the same position,holding the second highest overall market share (16.9%). In 2000, Adidashas closed the gap on Nike overall and ranks second in basketball shoesand cleated shoes.Remaining consistent from 1999-2000 is ReebokRee´bok`   n. 1. (Zool.) The peele.  who's marketshare is 10.9% compared with last year's 10.9%. While remainingthird in overall market share, Reebok continues to dominate the aerobicshoe market with a 61.4% market share, up from last year's firstquarter share of 56.4%.Making a considerable jump from 1999 to 2000 is New Balancewho's market share went from a 1999 first quarter percentage of 3.7to a 2000 percentage of 9.4.K-Swiss raised its first quarter overall market share from 3.1% in1999 to 3.6% this year and leads all manufacturers in 2000 with a marketshare of 28.5% in the casual shoe category. Timberland is number six forthe first quarter of 2000 with a 2.9% market share, up from its 1999first quarter share of 2.2%,parajumper jackets, while Asics raised its market share from1.5% to 2.1% in 2000.With an increase from 0.91% in 1999 to 1.42% in 2000, Skechers madea significant overall increase and is very strong in the casual shoemarket with an 11.9% market share, trailing only K-Swiss and Nike.Rounding out the first quarter's top 10 are Saucony and And 1.Both manufacturers increased their market share from the first quarterof 1999 with Saucony going from 0.9% to 1.4% and And 1 from 0.9% to1.2%. Among basketball shoes, And 1 increased its share from 3.6% in1999 to 6.5% in this year's first quarter.SportsTrend.Info is designed to provide weekly, point-of-sale datawith the highest possible degree of accuracy and integrity. Functioningas a central clearinghouseclearinghouseInstitution established by firms engaged in similar activities to enable them to offset transactions with one another in order to limit payment settlements to net balances.  for sports industry data, SportsTrend.Infoenables its subscribers to access comprehensive reports from a widevariety of perspectives.All of the nation's major retailers are included in surveys.Mass merchandisers, smaller chains and independent retail outletsretail outlet n → punto de ventaretail outlet n → point m de venteretail outlet retail n →  areincluded in order to provide a comprehensive basis for the generatedreports.NOTE TO EDITORS: Jeff AtkinsonJeff Atkinson might be: A Canadian politician, see New Democratic Party candidates, 2003 Ontario provincial election Jeff Atkinson (athlete) , vice president, Sales and Marketingfor SportsTrend.Info is available for commentary and analysis of trendsand developments within the sporting goods industry,canada goose sverige online, and the athleticfootwear market in particular.COPYRIGHT 2000 Business WireNo portion of this article can be reproduced without the express written permission from the copyright holder.Copyright 2000, Gale Group. All rights reserved. Gale Group is a Thomson Corporation Company.

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    Contents1 Winners and nominees2 Multiple wins/nominations3 Age superlatives4 See also5 Notes6 References7 Bibliography8 External linksWinners and nominees[edit source| edit]In the following tables,paraiumpers jacket on sale, the years are listed as per Academy convention, and generally correspond to the year of film release in Los Angeles County; the ceremonies are always held the following year.[6][7]For the first five ceremonies, the eligibility period spanned twelve months from August 1 to July 31.[8]For the 6th ceremony held in 1934, the eligibility period lasted from August 1,parajumpers vest, 1932 to December 31, 1933.[8]Since the 7th ceremony held in 1935, the period of eligibility became the full previous calendar year from January 1 to December 31.[8]


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    P. 1Analysis of Love in LAAnalysis of Love in LARatings: 0|Reads: 10,126|Likes: 5Published by Keefe LiuMore info:Published by: Keefe Liuabout 1 year agoCopyright:Attribution Non-commercialAvailability:Read on Scribd mobile: iPhone, iPadand Android.Free download as PDF, DOCX, TXT or read online for free from ScribdFlag for inappropriate content|Add to collectionAnalysis of Love in L.A. The most intriguing aspect of Dagoberto Gilb’s story Love in L.A. is how realistic it really is.Generally, love stories follow the traditional pattern of two strangers meeting, falling in love and living happily ever after. Love in L.A by no means follows this pattern. Many real life romantic relations do not follow this pattern either. Not following the pattern, however, does not disqualify Love in L.A. from being a love story. The essay is still very much a love story only with a twist. Most of the story’s realism stems from its stereotypical characters. Very rarely does one actually come across a handsome, well-mannered man on a white horse. Instead, one often finds a dishonest, self-absorbed, unemployed playboy. A prime example of this type of man is the main character in the story, Jake. Gilb provides numerous examples throughout the story to illustrate Jake’s character. The first image of Jake is given by the description of his dream car. The following description exemplifies his playboy characteristics. He needed an FM stereo in something better than this ’58 Buick he drove. It would have crushed velvet interior with electric controls for the L.A. summer, a nice warm heater and defroster for the winter drives at the beach, a cruise control for those long trips,canada goose jacka pris, mellow speakers front and rear of course, windows that hum closed, snuffing out that nasty exterior noise of freeways. The fact was that he’d probably have to change his whole style. Exotic colognes, plush, dark nightclubs, maitais and daiquiris, necklaced ladies in satin gowns, misty and sexy like in a tequila ad. It is very clear that he has selected these features in the hopes to attract and impress women. The audience is given further insight into the character of Jake upon his rearending of a young woman, Mariana. He hopes that this unexpected encounter will increase the chance of fulfilling his sexual needs. This is displayed through the sexual imagery used by Gilb. In paragraph 12, Gilb describes Jake as “fondling the wide dimple” in the car and includes Jake’s thoughts about cars being “so soft they might replace waterbeds.” The words bed and fondle definitely imply sex. These choice words draw on sexual images and reveal Jake’s sexual drive. Aside from these sexual images, Jake also shows his true womanizing character when he immediately uses this opportunity to try to pick Mariana up. The first words out of his mouth were obvious pickup lines. “So how you doin? Any damage to the car? I was kinda hoping so, just so it takes a little more time and we can talk. Or else you can give me your phone number now and I won’t have to lay my regular b.s. on you to get it later.” These lines are pick up lines in the sense that Jake not only hopes to be rewarded with her phone number but also with the pleasure of getting to know her on a personal level. In his efforts to do so, he tries to win her over with his wit and charm. This incident also gives the audience an understanding of how deceitful and suave Jake really is. Upon the request of his license, he quickly concocts the following spiel; “I didn’t bring it. I just forgot it this morning. I’m a musician, and well, I dunno, I
    . Her innocence is portrayed when she is described as shaking his hand “like she she’d never done it before in her life. a love story. His dream car too holds an enormous piece of his heart.A. It adds to the affect of the brief. Mariana too is very stereotypical. meaningless relationship between Jake and Mariana. Although he is obviously attracted to Mariana. He then proceeded to give her a fake last name as well as address.” Her inexperience was also apparent in her “timid Call me” upon her departure. Gilb does a very good job making Mariana fit this description. This is significant because L. he shows no hesitation or fear of rejection in trying to pick up on Mariana. the infatuation lies not with the woman but with himself. Thinking that this dream is even feasible gives insight as to how full of himself he really is. She has been married more times than even she can count. she is not described nearly as elaborately as his dream car. were obviously invalid. Take the Hollywood star Elizabeth Taylor for example. is a very fast paced and unfeeling city,shoppa online kl?der.A. Also. They too had a very tumultuous relationship with repeated abuse and adultery.” In this small speech.A,parajumpers light long bear. It seems as if many women are portrayed as naïve damsels in distress with limited knowledge. can make for quite a culture shock,canada goose jacka trillium parka dam. An example of this is found in her response to his statement that not only is he a musician but he is also an actor and has stared in a few movies.” This is also supported by the fact that she eats up all of the lies that Jake feeds her. is the setting. he managed to not only convince her that he was a musician but also that he had simply forgotten his wallet. Furthermore. It is for this reason that we see hostility. In this case. Jake is not the only object of Jake’s affection. road rage. Any man lacking self-confidence could not have pulled off that attempt as well as he did. Upon hearing this “She smiled like a fan. His dream is to ride around in a car with crushed velvet interior wearing expensive cologne on his neck and a necklaced lady on his arm. It is implied throughout the text that Jake sees himself as God’s gift to the female gender. Another example is the former couple Tommy Lee and Pamela Anderson. the time of day and the location of the accident play a large role in the story. most of which.A. He even gave the insurance information of his previous girlfriend. but instead they shifted back to the crushed velvet interior lining the seats of his dream car. The city itself is as shallow as those that reside in it. as he drove away his thoughts were not with Mariana. Entering a city as large as L,parajumpers rea. in drivers. At his time of day people are in a hurry to reach their destination and disregard the feelings and well being of others. It is for this reason that the setting is more than just a setting. It has the reputation for producing a number of scandalous relationships. It may be that she simply seen Jake as a nice guy being hospitable. In addition. noncommittal. Another very important aspect of Love in L. It is especially hard coming from a culture in which woman are placed on a pedestal to a culture where women are simply a piece of meat. This idea of moving at a fast pace and the lack of sensitively correlates with many romantic relationships. It is the infatuation or love that Jake has for himself and even for his car that make Love in L. A portion of her innocence may have a great deal to do with the fact that she is not native to the United States. It even describes the type relationship that is desired by many men including Jake.left my wallet in the pants I was wearing last night. It is set during rush hour on a busy freeway.
    The theme of the story has allowed love to be seen for what it can be.Gilb has truly created a love story fitting to modern times. shallow and insincere. He touched on several stereotypes evident in today’s society and has altered the traditional view of love to be more realistic..
    Activity (10)FiltersReviewAdd noteLikeEmbedShowingAllMost RecentReviewsAll NotesLikesRating 0/5Post notePost reviewPost replyPost note and like1 hundred reads|about 1 year ago1 thousand reads|about 1 year agoEmily Mirosliked this|3 months agoFina Leeliked this|4 months agoJulian Angelesliked this|8 months agoSara Villacisliked this|10 months agoSara Villacisliked this|10 months agoKyle Jimenezliked this|10 months agoKyle Jimenezliked this|10 months agoMiriam Ariasliked this|10 months agoLoad moreRecommendedPURCHASE ONLYSAMPLEEating Betel Nuthaicctlc4887PURCHASE ONLYSAMPLEFamine_Fiesta AnalysisGabby MondelliPURCHASE ONLYSAMPLEThe House on Mango Street: Shmoop Literature GuideShmoopPURCHASE ONLYSAMPLEExam 6 With AnswersCourseNotesPURCHASE ONLYSAMPLECAE Result Teacher's BookFictivityPURCHASE ONLYSAMPLEAssn2PR1Shauna SinyardPURCHASE ONLYSAMPLEBosanski jezikNejla DemirPURCHASE ONLYSAMPLE01. the Story of an Hour by Kate Chopinholo_2010PURCHASE ONLYSAMPLEMiss Brill (Katherine Mansfield 1922)WolfstationMore From This UserPURCHASE ONLYSAMPLEEscapeKeefe LiuPURCHASE ONLYSAMPLEEscape scriptKeefe LiuPURCHASE ONLYSAMPLESharrett Fairy Tales for the ApocalypeKeefe LiuDownload and print this documentRead and print without adsDownload to keep your versionEdit, email or read offlineChoose a format:.PDF.DOCX.TXTDownloadRecommendedEating Betel Nuthaicctlc4887
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    HistoryEditAsuras are entities that take on varying roles in the Asian religions.
    In the old Vedic religion, they were simply gods of moral/social phenomenon who regularly competed with the Devas, who were gods of natural phenomenon.
    In Hinduism, they are fanatical, demon-like entities associated with carnal and materialistic pleasures, and often thirsted for violence, opposed to the more peace-inclined Devas. There are many kings and rulers of the Asura, but the Megami Tensei series' Asura Lord is based on Virocana, the king of the asuras who, alongside Indra, searched for the secret of enlightenment.
    In Buddhism,Parajumpers New Alaska Jackor, they are the lowest rank of deities and are jealous gods addicted to various malign passions, while said to be one of the four unhappy births, being representative of a human being incapable of peace and always angered with the world, while also seeking strife and violence. In Japanese Buddhism, they are demigods, or semi-blessed beings. Powerful protectors of Buddhism, yet fierce and quarrelsome, they are partly good and partly evil, like humans. Their realm is believed to be a world of strife said to be located on the ocean floor. Some say Ashura was an Indian royal who converted to Buddhism. In other traditions, Ashura was a sun goddess who was feared for bringing droughts. The leaders of the Asuras were called Asurinda or Asurendra ("Asura Lord"). The principal leaders are Vemacritin (also called Vepacitti), Rahu(also called Veroca, Verocana, or Virocana),canada goose baby, and Paharada. The appearance of the Megami Tensei series' Asura is most likely based on the Japanese Buddhist depiction of the Asuras.
    However, in Zoroastrianism, Asura is known as Ahura, and are depicted as the forces of good,parajumper outlet, led by Ahura Mazda. In fact, the Indo-Iranians, the term asura (or in this case ahura) originally referred to divine beings on par with the gods. After the Aryans went their separate ways from the Iranians,canada goose snow mantra, the asuras came to be seen as rival gods, eventually even demonic. The struggle between the devas and the asuras possibly reflects the conflict between the tribes who worshiped a pantheon led by the god Indra and the tribes who worshipped the gods called the asuras.
    AppearancesEditMegami Tensei: Jashin ClanMegami Tensei II: Jashin ClanKyuuyaku Megami Tensei: Jashin ClanShin Megami Tensei: Tenma Clan, Final boss (LAW and NEUTRAL paths)Shin Megami Tensei: Strange Journey: Tyrant RaceShin Megami Tensei IV: Fury RaceLast BibleMajin Tensei: Majin ClanDevil Summoner: Raidou Kuzunoha vs. King Abaddon: Pyro OrderPersona 3: Sun ArcanaPersona 3 FES: Sun ArcanaPersona 4: Sun ArcanaPersona 3 Portable: Sun ArcanaPersona 4 Golden: Sun ArcanaDigital Devil Saga: Demon class titleDigital Devil Saga 2: Demon class titleDevil Survivor: Deity RaceDevil Survivor Overclocked: Deity RaceDevil Survivor 2: Deity RaceProfileEditNote: Significant plot details follow.Megami Tensei IIEditNear the end of the final dungeon, the heroand his party encounter Asura. If the hero recruited Lucifer, Asura is turned back into Ahura Mazda, his true form and joins the party. Otherwise, he will fight the hero.
    Shin Megami TenseiEditAs the one responsible in leading the forces of the Gaian Churchin order to intervene in God'ssummoning on the Great Cathedraland bringing forth a world of freedom under the demons (and, for some, a world of survival of the fittest), Asura stands in his chambers located on the heart of the last floor basement of the Messian cathedral as the last enemy and final boss fight the protagonistmust face on Law and Neutral alignments; while serving as a non-playable ally if he is Chaos aligned, providing aid in the attainment of the "Devil Ring"--a valuable item needed for the final showdown against Michaelto become available. In contrast to this, Asura's own throne room is inaccessible unless the player have the "Angel Ring" in his possession, but only if he follows the Law route. No item is required in the Neutral path.
    He poses as the leader of the Gaian army that have taken control of the inferior part of the Cathedral, and serves as the most powerful servant of Lucifer on Earth, guiding his demon generals on the complete obliteration of the Messian factionalongside the Chaos Heroand his female partner Rie.
    After encountering the hero, Asura mocks him. Stating that "to have betrayed one who cared about [him] (referring to the Chaos Hero) in order to follow the orders of one who has done nothing for [him]", he is truly a "shining example of a servant of God". With that said,parajumpers adirondack, Asura proceeds to engage the heroes in the final battle, where he is slain and the balance of the world finally restored.
    It is interesting to note that, according to him, he is actually Ahura Mazda, cursed by God to be the demon Asura.
    Shin Megami Tensei: Strange JourneyEdit"A violent group of demons in Hindu lore. They were very powerful and caused the gods great trouble. They are a strict group and attack anyone who runs counter to their ideals. They were originally gods of light who were worshipped in Persia. The Zoroastrian god Ahura Mazdawas one of them."—Shin Megami Tensei: Strange Journey CompendiumAsura appears as the violent demon lord of Sector Delphinus, initially as a mass of Formless demons scattered through Delphinus. These could possess crew members and manifest a form of violent insanity until Zeleninand the Protagonist intervened using special energy guns to drive the demons away. The fleeting demons began coalescing in giant hives around Delphinus' higher levels. When a sizable number of them had been destroyed, they gathered in a giant stone statue of Asura, recreating their massive form.
    Asura is a violent demon who seeks to "polish" the human spirit by having it devolve into a state of savage barbarism. Fittingly, his signature attack is Asura Roga, an attack that leads the targets to develop the Rage ailment, which causes them to mindlessly attack any target in the battlefield: themselves, the enemy, or their own allies. After being destroyed, he leaves behind his rare forma and Delphinus' Rosetta.
    Asura later returns in Sector Fornax, in which he appears as an invisible demon which can hurt the Protagonist with impunity unless he has the upgraded Enemy Search program. Upon being discovered, he manifests a Formless demon to attack while he hurries to Fornax' basements to shed his shape and assume his true form - Asherah.
    Shin Megami Tensei IVEditAsura appears in the Challenge Quest, Samurai and Hunters United. He has been attacking humans in the region and this has lead Nozomito make a Quest for aid to fight him in the Jouhoku region. He appears as a red foe on the map. Arrogant and prideful, he tells Flynn to know his place as a human and that he'll send him to the land of the dead. As his body starts to crumble at the end of the battle, he expresses his surprise at being defeated by a human.
    Devil Summoner: Raidou Kuzunoha Vs King AbaddonEditAsura appears as an optional boss in Raidou Kuzunoha Vs King Abaddon. Provided that the player has completed all other quests by the Yatagarasu and provided that Raidou's alignment is Lawful, the case file "A critical request" shall open up for the player in Chapter 7.
    The player must go through the Akarana Corridor to find Asura. Asura will explain that he wishes to leave to go to an alternate space-time where the forces of Chaos have waged war upon God. He explains that his current form as Dainichi Nyoraiis not his true form and that he is Ahura Mazda. Raidou must choose if he dares to challenge Asura and then after the fight he must decide Asura's fate. As the player, you can choose to allow Asura to go join the armies of Chaos so that he may pursue his desire in once again becoming Ahura Mazda or to have him return to being Dainichi Nyorai.
    Gouto will comment about the potential ramifications Raidou's decision could have on their world.
    Persona 3Edit"The king of Asura in Hindu myth. His name is Maha Vairocana (One Who Shines On All). In Buddhism, he is known as Dainichi Nyorai."—Persona 3 CompendiumAsura is the ultimate Personaof the Sun Arcana. He can only be summoned after completing the Akinari KamikiSocial Link. A hexagon spread with the Personas Yatagarasu, Quetzalcoatl, Jatayu, Horus, Suparnaand Vishnuis required to obtain him. He is the only Persona that learns the passive skill Unshaken Will, which grants the user immunity to all ailments except poison. The skill itself can be passed on to other Personas and is available as a skill card in Persona 3 Portable.
    Persona 3: FESEdit"Divine weapon made from a holy bone."—Vajra DescriptionAsura can be fused with any kind of Nihil weapon to obtain Vajra, a Knife-type weapon with an attack value of 450 and a hit rate of 100. It boosts all stats by +10.
    Persona 4EditAsura is the ultimate persona of the Sun Arcana. He is only available after completing either the Ayane Matsunaga Social Linkand receiving the Handmade Ticket from her or completing the Yumi Ozawa Social Linkand receiving the Annotated Script depending on whether you chose the Drama Club or Music club for your cultural activity. Much like in Persona 3he is the only persona that learns Unshaken Will, which nullifies all mental ailments (doesn't cover Sielence, Poison, Dizzy or Exhustion). Like the majority of skills exclusive to certain Personas Unshaken Will cannot be passed on to other Personas, making Asura the only Persona that can possibly nullify all ailmentsif the appropriate nulls are fused onto him.
    Digital Devil Saga seriesEditAsura does not actually appear in both games, but as a demon title given to the demons initially "tuned" in the virtual battlefield, Junkyard, because the digital world is constructed under the "Asura Project" for selecting battle AI. In the second game, another group of demons which initially tuned in the "real world" is classified as "Yaksa" in contrast to the Asura demons. Even though many demons exit the Junkyard to the "upper realms", they still retain the Asura title during boss battles, such as Agniand Hayagriva.
    Devil Survivor 2Edit"A violent group of demons in Hindu lore. They are very powerful and caused the gods much grief.
    They are a strict group who attacks anyone that runs counter to their ideals. They were originally gods of light who were worshipped in Persia. The Zoroastrian god Ahura Mazdawas one of them."—Devil Survivor 2 CompendiumAsura is unlocked by reaching Faterank 3 with the Anguished One. It is also the strongest member of the Deityrace,parajumpers ?terf?rs?ljare.
    StatsEditMegami Tensei IIEdit

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    by Ellen_C,parajumpers sale
    100 FollowersCoach Coupons, Factory Store locationsGet official Coach Sales and CouponsI have listed a few reliable ways to find real coach discounts at retail stores and online. The sales are out there, you just have to know where to look!
    Tip: Sign up online at the official Coach.com site for e-mails so you get alerts to sales,parajumpers. This month's coupon valid Feb 16-27th is for 30% off your purchase at the outlet.

    Don't forget to register at the Coach Factory Offer link below, this is how you get on the mailing list for Coach Outlet coupons. This is the best way to get official coupons from Coach for a Factory Store near you.

    I stumbled upon a Coach outlet store in my area of Texas where I found purse sales for 75% off original price. Ever since, I can't bring myself to pay the original retail ticket of the item. You can find the signature collection purses, seasonal handbags,parajumpers dk, coach sneakers,parajumpers, belts and more at the Coach Outlet stores. In the regular mall Coach store locations I have made a purchase and later was mailed a coupon for the Coach store so repeat shoppers get great discounts.
    On a Satruday when I have a coupon, I can expect to wait in line at one particular location in Allen, TX for 25-45 minutes, but for the 80% savings I end up getting - it is worth the wait! The Allen Outlet Mall Coach Factory Store has some of the best deals on designer goods and has the largest selection in the whole region.
    When I get a coupon in the mail for the Allen, TX Coach outlet location,parajumper long bear, the store will still just prints them out and hand them to customers in store the day of the sale. So if you don't get a coupon in the mail but know it is a coupon weekend, just show up and you will get a discount anyway.



    Retail Store & Factory Store LocationsCOACH FACTORY OFFER - SIGN UP YOUR E-MAIL!
    Enter your information in this official Coach Factory Offer link to get on the mailing list, have official coupons mailed to you, 10-30% off already reduced prices at Coach outlets.Coach :: Coach Factory Stores
    Coach Factory Outlet Store LocationsCoach Outlet Stores
    There are about 100 Coach outlet stores and this link provides a list of their locations. Coach sends all product categories to these stores. The one near me in Allen, TX devotes the back half of the store to 50% off reduced clearance. Savings 75%!!Coach.com Store Locator
    Find retailers who carry coach and they usually have end-of-season sales like Macy's at prices like 25-30% off.Shop OnlineMany 3rd party sellers at places like Amazon and eBay do buy a lot of items from the Coach outlets and pass the savings along to you. It is possible to find authentic Coach handbags online. Read seller reviews and customer comments first and don't every buy if you are suspicious.
    Second-HandeBay and other online sites are a good place to find gently worn Coach items at a discount. If you don't mind buying second-hand items, you can save a lot of money. Stores like Plato's closet and Buffalo Exchange get in good product, but you have to hunt for it. Buffalo Exchange and the better GoodWill Boutique can be the unexpected place to find your next deal. The GoodWill boutique stores are located in the more affluent area where donations for name brand merchandise can be sent and the market demand for brand names is greater.

    My Other Articles on Saving MoneyCoach Sale: Discount Coach Sneakers and Shoes
    Tips to finding Coach shoes on sale and Coach shoe disounts in stores and online. Find Coach sneakers, books, and sandals without paying full price. Check out Coach Outlet Factory stores I have a link to the locations.Coupon Guide: Maximum Coupon Savings Tips
    Tips on coupons you can still save a lot of money! Maximize your coupon savings and double/triple grogery store coupons.Coach Lux A7760 Women's Rubber Rain Boots Brown Size 9Amazon Price: $114.99
    List Price: $150.00 Last updated on March 31, 2011
    You can help the HubPages community highlight top quality content by ranking this article up or down,ned frakker.
    Useful  • Funny  • Awesome  • Beautiful  • Interesting {3}previousJCPenney Discounts and Coupons jcp.comnextCoach Sale: Discount Coach Shoes and SneakersDiscover More HubsHow to Get the Best Price on a Coach PurseCoach Outlet Coupons - How to Get Discounts at the Coach Factory OutletHow to tell differences between regular Coach store bag and factory outlet bagCoach Factory Outlet StoreDiscount Coach Handbags at the Coach Factory Outlet StoreCostco.ca: Costco CanadaExtreme couponing? Sales and coupons for food are 99% GMO brands!Coach Purses and Bags On Sale Follow (2)Comments 3 commentsjohny five 11 months ago
    I found all Coach outlet stores and directions here http://www.outlet-stores-malls.com/brands/648-coac
    Elise Scott 20 months ago from Chicagp
    Thanks! I have my eye on the madison lindsey bag, but to pay the full price makes me cringe. I will definitely use your tips as I shop around for it :)
    klw5200 4 years ago from Pennsauken,NJ
    great hub,
    As soon as I saw the title, I sent it to my wife!
    Sign inor sign upand post using a HubPages account.
    8192 characters left.Post CommentNo HTML is allowed in comments, but URLs will be hyperlinked. Comments are not for promoting your Hubs or other sites.
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    May 27,parajumpers, 2013By Laura Heinbuch
    The hunt is on for Canadians' prized possessions,http://www.stemmer.dk/parajumpersforhandler.html
    Looking to hawk a rare collectible or family heirloom? How about a Tiffany lamp,parajumpers, or a vintage movie poster,parajumpers outlet, or even that oil painting that's been hanging in the living room for decades? 
    If your answer is "yes", then CBC's new reality show Four Roomswants to make a deal with you!
    Now is your chance to sell those treasures to four of Canada's top art, antiques and memorabilia dealers. And there's big cash to be had. 
    Here's how it works: The buyers wait in four rooms, ready to make an offer on the perfect item. Sellers can take the deal or move on to the next room. But once a bid has been refused,parajumper long bear, the offer is off the table for good. Think Antiques Roadshow meets Dragons' Den. 
    Apply onlinetoday to audition in a city near you.
    FOUR ROOMS AUDITION SCHEDULE:June 8 - TorontoJune 16 - MontrealJune 22 - WinnipegJune 24 - VancouverJune 26 - VictoriaJune 29 - CalgaryJuly 3 - HalifaxJuly 6 - Toronto,ned frakker, North Hatley
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    Many people don't know who Ras Tafari was, but certainly most of the world knows who Jesus Christwas reputed to be. For back ground, Ras Tafari was crowned the 354th king in a line of Kings extending from the son of King Solomonof Israel and Queen Makeda of Sheba. Their son,http://www.tobi.se/parajumpersjacka.html, Bayna Lehkem, was crowned King David of Ethiopia by Solomon. History knows him as Menyelek I.
    Ras Tafari was crowned as H.I.M. (His Imperial Majesty) Haile Selassie I, Emperor of Ethiopia, King of Kings, Conquering Lion of Judah. By the time he arrived in Jamaican on April 12, 1966, the Rastafarians' believed he was the Messiah promised to rule over Israel as King, foretold of in the Old Testament. Rastafarians and Christians both believe in the same Messiah, but recognize different persons as the physical manifestation of him. Both of these religions draw from the same Hebrew Scriptures for proof of their beliefs. Both of them believe the Israelite prophecies have been fulfilled. Obviously, both the Jesus Christians and the Rastafarians believe themselves to be right.
    The major difference between these two religions is the why of their beliefs. Christians believe Jesus because of the New Testament. Rastafarians believe in Haile Selassie I because of the Old. Apart from this amazing detail,http://www.stemmer.dk/parajumpersforhandler.html, both believe essentially' the same thing. Essentially, because there are a few distinctions between the two that should be addressed. These distinctions detail how' both these religions can believe in the same messiah' but have different representations of that messiah.
    This curious detail about both the Rastafarians and Christians is merely one of many similarities that, when compared, reveal why neither of them can be true. The fact that these two religions can believe the same scripture, draw almost identical conclusions,parajumpers sale, yet differ in such a distinct manner speaks volumes.
    The focus here will be exclusively on the Hebrew Scriptures both these religions use to establish their beliefs. Though Christians do not use the Hebrew Scriptures to teach their religion, the Rastafarians do, which gives them a peculiar point of view of Christians,ned frakker, who are almost completely ignorant of Rastafarians,parajumpers frakke, their beliefs,parajumpers, and their almost identical faiths.
    Even though the similarities between these two religions are noteworthy, the differences add fuel to the fire. Rastafarians believe themselves to be descendants of Israel. Because Rastafarians keep the Law, and because of the varying degrees of focus on the Old Testament,
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    Farewell brewing,parajumpers forhandler. You’ve been amazing!I’m leaving the world of brewing.
    Hopefully not for too long though…
    It’s been a tough decision,parajumpers, but we’ve decided to move back to Taranaki to be closer to my family and my Dad who has got cancer. Jobs come and go but we all only have one family and it’s going to be great to be living around the corner from Mum,parajumpers forhandler, Dad and my brother and his family so we can spend loads of quality time together.
    Good George Brewing will continue on,ned frakker, with our great brewers Nate Ross and JB Martineau taking the reins and doing the Good things that they’re currently doing and I’m sure I’ll be keeping in close touch with them, especially as I want to see how our barrel aged and sour beers go over the coming months and years and taste my babies as they progress!
    Thanks for everyone in the brewing world’s support,parajumper long bear. It’s been an incredible 13 years since I began as an innocent trainee brewer,parajumpers jacka. I’ve made friends for life and will hopefully keep meeting all of the brilliant people that surround this industry.
    And if anyone wants to set up a brewery in New Plymouth and throw heaps of money at me… You know where to find me
    Rock on!!!!



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    Accessibility links Skip to contentSkip to local navigationAccessibility HelpBBC iD BBC iDSettingsSign outbbc,parajumpers jacka.co.uk navigation NewsSportWeatherCapitalCultureAutosTVRadioMore…Search term: BBC OneEastEnders
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    You might also like…Around the BBC Similar programmes By genre: Drama > SoapsBBC OneWatch live
    01:15 Joins BBC NewsHomeScheduleProgrammesTV GuideYou're using the Internet Explorer 6 browser to view the BBC website. Our site will work much better if you change to a more modern browser. It's free,parajumper long bear, quick and easy. Find out more about upgrading your browser here…
    BBC links Mobile siteTerms of UseAbout the BBCAdvertise With UsPrivacyAccessibility HelpAd ChoicesCookiesContact the BBCParental GuidanceBBC © 2013 The BBC is not responsible for the content of external sites,ned frakker. Read more,http://www.eksakte.dk/parajumpersfrakke.html.
    This page is best viewed in an up-to-date web browser with style sheets (CSS) enabled. While you will be able to view the content of this page in your current browser,parajumpers forhandler, you will not be able to get the full visual experience. Please consider upgrading your browser software or enabling style sheets (CSS) if you are able to do so.


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    Současný stav[editovat]V současnosti mám dva studentské účty. Jeden u České Spořitelny a druhý u Komerční Banky. Jsou to běžné účty, u obou jsem si letos aktivoval e-banking. Neplatím poplatky za vedení účtu (u ČS asi letos už ano). Platím, 4 koruny za odchozí položky, asi nic za výběr z automatu. Používám účet ČS. Jinak jsem samostatně výdělečný student s málo času a nepravidelnými příjmy.
    Cíl[editovat]Jsem významně nespokojen s účtem a službami ČS. Vše se zkomplikovalo v momentu, kdy jsem začal mít velké množství plateb a začal používat internetové bankovnictví. Často se stávalo, že neodešla platba a také se často stávalo, že úředníci dělali své chyby. Letos jsem si u obou účtu zavedl internetové bankovnictví, abych ušetřil čas a peníze. U komerční banky mě to stálo jednu návštěvu na pobočce a asi hodinu nastavování a seznamování. Navíc hodnotím kladně funkci e-bankingu v tom, že se mi natahuje certifikát z počítače a nemusím si pamatovat žádné šílené kódy, nebo je mít při ruce. U ČS mě stálo nastavení 2 návštěvy na pobočce (protože se mezi tím něco změnilo a já a se ani neptám, kolik jsem za tu návštěvu zaplatil), jeden telefonát na klientskou linku a 3 týdny nastavování. Se systémem jsem nespokojený - systém nefunguje správně, banka není schopna včas aktualizovat nápovědu. Celá situace vyústila v to, že jsem se dostal do dluhů, díky neschopnosti změnit trvalé příkazy a dokonce jsem dostal i pokutu. Nakonec se mi podařilo účet zablokovat. Z lásky dostanu nové aktivační kódy za "pouhých" 100 korun.
    Cílem je najít vhodný běžný účet a vhodný spořivý účet. Od běžného účtu očekávám:
    jednoduchý fungováníco nejnižší náklady a poplatkyjednoduché internetové bankovnictví, nejlépe s možností vybrati si,parajumpers sale, jak budu ke svému účtu přistupovatelektronickou platební kartu, levné výběry, nebo výběry u cizích automatů zadarmozdarma vedení účtu, nebo odchozí položkymožnost vedení účtu ve více měnách výhodouembosovaná karta výhodouOd spořícího účtu pak očekávám:
    nemuset vkládat na začátku nějakou horentní sumuvýhodnou úrokovou sazbumožnost pravidelně jednou za měsíc vkládat penízeneplatit nic za příchozí, odchozí položky a vedení účtuMetodika[editovat]Pro tento výzkum jsem si zvolil cestu, osobní návštěvy pobočky. To proto, že letáky a internet bank chápu jako propagaci a ne vždy tyto média obsahují všechny potřebné údaje, které potřebuji vědět. Navíc návštěva pobočky je výhodou, že se můžete na vše zeptat a objasnit si to hned na místě. Na čem mi záleží? Záleží mi na tom, když o bance něco vím, tzn. není to "zázračná" banka, o které skoro nikdo nic neví a kolují o ni rozporuplné informace. Úředník nemusí být příjemný, ale musí mi být schopen vysvětlit to na co se ptám a ne se chovat jako robot.
    Navštívené banky[editovat]ČSOB[editovat]Do této banky jsem vyrazil jako první. Byl jsem obsloužen velmi rychle. Úřednice byla příjemná a vše mi vysvětlila - nabídla mi běžný účet a termínovaný vklad, nebo spořící účet. Dostal jsem kontakt a materiály, které jsou srozumitelné a mohu si je v klidu promyslet.
    Tak se ke mě doneslo, že ČSOB je ve skutečnosti součást mezinárodního koncernu a že má problémy, proto se to teď záplatuje. To je na zamyšlenou.--Juan de Vojníkov5. 11. 2008, 18:23 (UTC)Další informace přichází a krizi v této bance, ale já si tak říkám,ned frakker, že u běžného účtu by mě to nemuselo vadit.--Juan de Vojníkov7. 11. 2008, 09:50 (UTC)Raifka[editovat]Úřednice byla milá, nabídla mi a vysvětlila jak běžné, tak spořící účty. Tuto volbu jsem ale zamítl: a) mám nepravidelné příjmy - tím se dostávám s účtem do pohybu, tento pohyb mě zatěžuje, že stále musím sledovat v jakém jsem režimu a podobně, očividně takovýto účet pro mě nevýhodný b) složitost účtu - pořád se musí člověk o něco starat, necítím vnitřní pohodu c) úrokové sazby spořících účtů byly méně výhodné než u ČSOB
    Česká Spořitelna[editovat]Čekání na pobočce jsem asi po 20 minutách vzdal.
    Prý jsou tu dobré spořivé účty.--Juan de Vojníkov7. 11. 2008,parajumpers, 09:50 (UTC)Komerční Banka[editovat]Dlouhé čekání na pobočce - chtěl jsem se zeptat na spořící účty. Po té co úřednice zjistila, že patřím na jinou pobočku, tak se ke mě chovala jako "co tady pohledáváte", mluvila jako robot - těžce jsem věc chápal. V podstatě jsem byl rád, že jsem z pobočky mohl odejít, celý pohovor byl nepříjemný a nabyl, jsem dojmu, že úřednice nabízeným produktům nerozumí a není schopna používat vlastní hlavu. Nicméně ve výsledku jsem možnost také zamítl,http://www.tobi.se/parajumpersjacka.html, z důvodu: a) úrokové sazby termínovaných vkladů byly méně výhodné než u ČSOB
    ING[editovat]No tak jsem byl na pobočce,parajumpers jacka, ve velmi příjemném pomerančovém prostředí – uj, hned jsem na jeden dostal chuť. Dostal jsem nějaké papíry a ted se díval na internet a určitě to chci. Jen je třeba s tímto počkat až na konec, protože můžete zadat jen tři účty, na které můžete peníze převádět. Vše je zdarma, úrok 3,25 % a drží. Možná nevýhoda, je, že můžu mít pouze korunový účet, ale proč si ho pak nezaložit na Slovensku, že. Je to spořící účet a s těmi pěnězmi se moc nemanipuluje.
    Modrá Pyramida[editovat]Všichni víme jak jsou ty byty z dob totáče znehodnoceny a nastal čas do nich investovat peníze. Když dám sem ročně 20 000, tak dostanu značnou podporu, to se musí využít, alespoň bude na novou kuchyni:-)
    UniCredit Bank (dříve Živnostenská banka[1])[editovat]Na pobočce se mnou zacházeli na rovinu, zvýhodňovali mi termínované vklady před spořícím účtem - prý lepší úroková sazba. Žádné další papíry jsem neobdržel, k běžným účtům jsem si vzal propagační letáky. Pro mě neznámá banka, ještě budu muset prostudovat. Tak jsem se ještě koukal na internet na ty spořící účty a nic jsem nenašel, stránky jsou docela dost komplikované. Jako banka je to na úrovni služeb tak ČSOB, ale ještě si nevypracovala takové renomé a jednoduchý přístup k zákazníkovu.
    Byl jsem opět v této bance. Nějak mi paní sama tvrdila, že spoření v této bance je nevýhodné a nafásnul jsem přehled úrokových sazeb termínovaných vkladů - pravda nic moc, pouze u eur to vypadá zajímavě. Zajímavé ovšem bylo,parajumpers sale, že můžu mít studentský běžný účet zadarmo do 30 let, ale teď to nemám - houby zadarmo, za 19 korun. No a pak teda nějaký účet kde budu platit stovku (to je stéjné jak u ČSOB) a navolím si 9 položek co chci. No, pokud by mi to stálo tolik, tak bych to moc nepoužíva, když mám jiné zadarmo. Navíc ta otřesná krabičká, kterou aktivuju e-banking.

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    Basketball Wives star Jennifer Williams is busy with her business Lucid Cosmetics,parajumpers sale, as she is no longer filming the show. She recently had her white Bentley repossessed because her ex-husband Eric Williams hadn't been paying for it since she filed for divorce. In addition, she recently learned that he had been keeping a big secret from her; he had cheated back when they were married, which resulted in a love child. Now,parajumpers sale, he is being used for not paying child support.

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    June 13, 2011Atlanta Angelina Jolie and fans of designer Louis Vuitton will be interested to learn that Jolie poses barefoot on a boat for the luxury handbag and luggage designer!
    Angelina Jolie fans in Atlanta have seen her regularly toting Louis Vuitton’s designer bags and now the actress has become the new face of luxury Louis Vuitton label.
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    As it turns out, the bag in the picture Angelina is wearing her own years-old monogrammed Alto bag, a style which is no longer in production!
    Jolie had also adopted her eldest son nine-year-old Maddox as an infant, from Cambodia.
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    Sean Connery, Bono,parajumper long bear, Buzz Aldrin and Mikhail Gorbachev have all posed for the “Core Values” campaign in the past as well as Madonna, Jennifer Lopez and Scarlett Johansson being “faces” for other campaigns for the label.
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    This recipe really takes less than 30 minutes to prepare. Ideally you want the sauce to be done the same time the pasta is cooked.
    You need:
    400g  Penne
    Maldon salt to taste
    Freshly ground pepper to taste
    Couple lugs Olive oil
    4 chopped garlic cloves
    1 ½  ts dried oregano
    3 chopped birds eye chilies
    8 – 12 anchovies chopped
    Handful of chopped capers
    Handful chopped stoned olives
    Handful fresh basil, chopped
    2 x 420 g tins of quality whole peeled Italian tomatoes. Chop tomatoes yourself,parajumpers jacka.
    You do:
    Put the pasta water on, and try and time the sauce and pasta to be done simultaneously.
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    Posted in Resepte en kos goed,ned frakker.|Tagged Penne alla Puttanesca pasta easy recipes

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    Why should I stop stripping

    Why should My partner and i quit stripping?

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    You should probably consider using a backup career. Simply no offense, but your amazing stripping career probably will go down with age, not necessarily up like most occupations.

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    it sounds like you are doing a good work at making a living along with saving up for your potential! their is nothing wrong with stripping in my opinion, but being the practical girl u are most often, u need to think about the future. Strippers usually have a brief career. You have to start off thinking about what you will accomplish after you stop draining. maybe you should invest in college and start studying for a future profession. GL!

    1. A college education must enlighten you and help you to get a better paying job, not sell the soul and your body to get a little paper now and spoil your chances of a serious work opportunity later.

    3. The staff treats anyone with respect but the law enforcement officials won There is a 95% probability of getting raped AFTER you leave the club with a drunk customer whom enjoyed your boogie, by an unstable customer or by the team owner himself.

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    Those are the reasons will think of. In a way I'm a bit wrong with seedy old man featuring at me however that me. In any case keep your job if you want it.

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