Post on 01-Aug-2019
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Chest X-Ray 判讀
高雄長庚醫院胸腔內科
方映棠
Position
P-A view
A-P view
A-P supine
Lateral (Lt’/Rt’)
Lateral decubitus (Lt’/Rt’)
Lordotic
Oblique(Rt’/Lt’; post/anterior)
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Frontal P-A view
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Lateral view
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Lateral decubitus view
Anterior oblique view
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Lordortic view
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Frontal chest radiography
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Lateral radiography of chest
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Technical quality
Ideal KV exposure
4 basic radiographic densities
Air
Fat
Water(soft tissue)
Bone(metal)
12Densities
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未詳細判讀前先看
• 姓名/病歷號是否和病人的資料符合
• Position: PA or AP view.
• Sex: Breast, Rib calcified (男凹女凸).
• Nutrition: Soft tissue.
• R/L: Heart, Stomach, Aortic, Bronchus.
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拿到一張CXR你要從哪裡看起?
•照像姿勢好不好
•相片品質好不好
•系統性的判讀
Minimal rotation
• It can be assessed by
comparing the medial
ends of the clavicles to
the margins of the
vertebral body at the
same level
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如何判斷曝光好不好?
1. Trachea 與carina隱約可見
2. 下段 vertebra 隱約可見
3. Heart 後面的lung markings 隱約可見
4. Rt sub-diaphragm lung markings 隱約可見
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Reading Steps-1
•由內往外 or 由外往內
•由上往下
soft tissue bone trachea
mediastinum heartdiaphragm and
pleural cavity hilium bronchus
trees and lung marking
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Reading Steps-2• Airway由喉嚨到carina與bil main bronchus air column是否完整, 有無 endobronchial lesions, Carina 的夾角(正常70度)
• Bone/ Breast有無骨骼陰影濃度的變化/ rib, vertebra (fracture, osteoblastic or osteoclastic lesions), bone 與breast shadow是否完整,兩邊thorax是否對稱
• Cardiac/Catheter心臟腔室是否變大, 有無 retrocardiac mass, retrocardiac lung markings 有無變化; 管路位置
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Reading Steps-2• Diaphragm高度是否正常, CP angle 是否sharp
• Esophagus有無air-fluid level / Pneumomediastinum
• soFt tissues (Fascia)看病人的nutrition, 有無皮下氣腫/mass
• Gastric/GasPA view 可見gastric bubble ( 與左肺下緣應小於2cm), 有無異常mass
• Hilum看濃淡, 大小, 形狀, 對稱
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Lobar Anatomy-1
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Lobar Anatomy-2
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Lobar Anatomy-3
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Lobar Anatomy-4
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Lobar Anatomy-5
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Normal Anatomy-1
1.Location: chamber, valve,
main vesseles.
2.Size
3.PA + Lat.
4.Associated signs
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Normal Anatomy-2
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LV
RV
RA
aorta
Pul. trunk
MV & TV
LA
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LA
LV
RV
Pul trunk
aortaM , A
valve
IVC
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A.CP angle B.Lt diaphragm C.Heart D.Aortic knob E.Trachea F.Hilum G.Carina H.Gastric air
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Mediastinum
1. Anterior
trachea ant. Margin,
heart post. Margin.
2. Middle.
3. Posterior
vertebral body 後1cm連線.
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Usual location of Mediastinal Mass• Anterior Mediastinum
– Thymic tumors/Masses
– Germ cell tumors (teratoma)
– Thyroid/Parathyroid masses
– Lymphoma
– Mesenchymal tumors• Middle Mediastinum
– Benign LN
– Lymphoma
– Metastasis to LNs
– Bronchogenic cysts
– Pleuropericardial cysts
– Vascular masses
– Morgagni’s hernia
• Posterior Mediastinum
– Neurogenic tumors
– Hiatal hernia
– Meningoceles
– Gastroenteric cysts
– Thoracic duct cysts
– Bochdalek’s hernia
– Thoracic spine
neoplasm
•肺門是指左右主支氣管及肺動脈進人肺臟之部位,X光片上所顯示出來的是肺動脈的陰影,左方肺門比右方高(高出0-3公分)
•Pulmonary arteries, veins, bronchial
•需注意兩側上下,位置,大小及形狀
肺門地區的檢視
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Localization
• Lobar distribution
• Air bronchogram
• Silhouette sign
• Extra pleural sign
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Silhouette sign•Silhouette : 就是<輪廓、側影>的意思
•在X光片上的兩個連接的影像,如果兩個影像在前後
的層面是同一層的,則界限不清楚
空氣支氣管像徵(Air bronchogram sign)
•正常胸部X光像中,支氣管因管壁很薄且支氣管壁內外兩側都是空氣,故支氣管的影像無法顯現。而當包圍支氣管的肺泡產生實變化(consolidation),此時支氣管內仍充滿空氣,故一條條分支的支氣管影像會被實變化的肺襯托出來。
•看到air brondogram sign表示病變在肺內。
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Air bronchogram
肋膜外病灶徵(Extrapleural sign)
指肋膜外的病灶往肺內突入,但因其外圍有兩層肋膜包被,故有下列三個特徵:
(1)病灶外緣界限清晰
(2)影像的基底部較寬,與胸廓或橫隔或縱
膈之交角為鈍角。
(3)convex border朝向肺
不完全邊緣徵(Incomplete border sign)
肋膜外病灶只有在突入肺內的部分與肺內空氣產生對比,故可見該突入部分的邊緣,而病灶位於縱膈或橫膈或胸壁內的部分則因positive silhouette sign的緣故,因此看不到該部分的border
Neurogenic Tumor
肺炎
肺炎就是以肺泡為主的肺實質炎症,肺泡
內佈滿著發炎細胞和物質,造成肺泡的含
氣量減少,故照片上呈白色。
右上肺葉肺炎Pneumonia
肺膿瘍
肺膿瘍(lung abscess):
呈現薄壁的空洞性腫瘤,裏面
常見有air-fluid level
肺腫瘤Lung
mass
轉移性肺癌〈結腸癌〉:在兩側下肺野散佈
著大小不一的多發性結節狀陰影
肺腫瘤Lung
mass
中央支氣管(central)的原發性肺癌:
以肺門為主,和吸煙有關,男性居多
Squamous cell carcinoma
肋膜積水
Pleuraleffusion
肺癌引起的右側大量肋膜積水:
注意縱膈腔,氣管,心臟位移至健側
弦月徵(meniscus sign)
肋膜腔積液時,由於毛細現象,積液沿著兩層肋膜間向上延伸,因而形成半月狀之空氣一水介面,稱為弦月徵。此外,在一個空洞內產生徽菌球(mycetoma),空洞內未被mycetoma填滿之空氣呈半月狀,亦稱為meniscus sign
肋膜積水
Pleuraleffusion
左側肋膜積水:左下肺野呈現往下凸出的弧狀陰影,左側肋膈角鈍化,左橫膈膜陰影和心臟輪廓都消失不見
Mycetoma
有關惡性腫瘤之徵候
反轉S 徵 reverse S sign
Golden's S sign
尾巴徵(tail sign)
肺膨脹不全
Collapse
右上肺葉肺癌(Squamous cell carcinoma)
(Golden’s sign)
肺膨脹不全可因阻塞性、壓迫性、收縮性
而造成肺泡的含氣量減少。
肺膨脹不全
Collapse 右全肺葉膨脹不全〈右主支氣管肺癌〉
肺膨脹不全
Collapse左上肺葉肺癌
1. 左上肺葉膨脹不全 (LUL collapse)
呈現特別的影像2. 正面影像:左上肺野透亮度減少,
和下部的界限非常不明顯3. 側面影像:major fissure向前位移,
呈現似“雨傘開花”的不透明陰影
肺結核TB
肺結核在胸部X光上呈現多采多變的
影像,常見好發於上葉、多發性、
邊界不明顯的淡斑狀陰影
肺結核TB
結核瘤(tuberculoma):呈現邊界明顯
的腫瘤般病灶,常見鈣化發生
肺結核TB
空洞形成(cavity) :呈現空洞,
邊界不明顯的不透亮陰影
中膈腔病變
AORTIC ANEURYSM
食道鬆弛症,此時所
看到之食道擴大所形
成之陰影較長,可後
下縱膈延伸至上縱膈
,有時也可看到水平
面
結節狀病灶
多發性肺結節
惡性疾病轉移膠原血管疾病Wegener granulomatosis
類風濕性結節感染肺膿瘍Histoplasmosis
肺結核
癌性淋巴管炎:此種線條與正常肺紋不同,其鑑別重點如下:
(1)正常肺紋很少延伸到肺野外側1/3處。
(2)肺紋是肺動脈之陰影,其條紋是「柔軟」性,由內向
外逐漸變細,且呈二分法之分叉。
(3)癌之蔓延線條是細而「硬」.直線或略彎曲,分叉
不明顯。
(4)癌之蔓延線條常可出現在肺末稍
處呈1-2公分長與胸壁垂直之線
條。若是兩肺瀰漫性分布,則此
癌以胃癌、大腸癌轉移者為多。
胸廓異常
..胸骨凹陷
氣胸(pneumothorax)
氣胸
臟側肋膜
肋膜腔內存有空氣的狀態─氣胸;X光片上呈現透亮性增加,肺紋理消失,可見一條明顯的臟側肋膜輪廓線
氣胸(pneumothorax)
嚴重氣胸時,一側的整個肺會完全萎縮
在肺門形成腫瘤狀陰影
診斷氣胸之徵候
深溝徵(deep sulcus sign)
空氣往上飄,故氣胸時,肋膜腔內之空氣往高處堆積。當病人平躺時,胸腔的最高處是位於subpulmonary area ,故空氣會積在Subpulmonary area,而將該側的costophrenic sulcus顯示得非常清晰,且能看得比正常時更深。
診斷縱隔氣腫之徵候
Continuous diaphragm sign
正常時,心臟緊貼著diaphragm ,左右兩側hemidiaphragm看似分離。當發生pneumomediastinum時,心臟底下的mediastinal space及兩側diaphragm的extrapleural space都可能充氣,因而可見mediastinal gas把兩側hemidiaphragm的superior surface顯示出來, mediastinal gas與diaphragm面的extrapleural gas因而連成一條線,稱為continuous diaphragm sign 。
Continuous diaphragm sign
Spontaneous: 縱膈氣腫通常出現於哮喘發作時肺泡破裂
Chest trauma: 車禍時支氣管裂傷(可能合併氣胸與皮下氣腫)
Perforation: esophagus, trachea, bronchus… etc
Secondary to pneumoperitoneum
Secondary to peumoretroperitoneum
判讀要點是由於空氣聚集於縱膈,使得肋膜陰影(細白線條)清晰可見。當此縱膈氣腫較厲害時,此空氣會上升到頸部之皮下以及前胸部,使得胸大肌之肌束清晰可見,是為皮下氣腫
Traumatic esophageal rupture
Rupture of the cervical esophagus typically produces local subcutaneous emphysema
Rupture of the thoracic portion mat also show subcutaneous emphysema as well as pneumomediastinum
Pleural effusion or pneumothorax, usually on the left side, is often noted
The finding of an exudate or serosangious fluid with a low pH and a high amylase level is confirmatory
Pericardial effusion
The diagnosis of pericardial effusion by radiograph and its differentiate from cardiomegaly can be difficult.
An increase in cardiac silhouette is typical.
The shape is usually decribed as globular in appearance
Cervicothoracic Sign
Used to determine location of mediastinal
lesion in the upper chest
Based on principle that an intrathoracic lesion
in direct contact with soft tissues of the neck
will not outlined by air
Uppermost border of the anterior mediastinum
ends at level of clavicles
Cervicothoracic Sign
Middle and posterior mediastinum extends
above the clavicles
Mediastinal mass projected superior the level
of clavicles must be located either within
middle or posterior mediastinum
More cephalad the mass extends the most
posterior the location
Intrathoracic goiter
肺門覆蓋徵 (Hilum overlay sign)
Ant. Mediastinum Tumor
有關肺萎縮(collapse)之徵候
上三角徵(upper triangle sign)
主動脈球被覆徵(top-of-the-knob sign)
平腰徵(flat waist sign)
Luftsichel sign
上三角徵(upper triangle sign)
主動脈球被覆徵(top-of-the-knob sign)
平腰徵(flat waist sign)
LLL collapse
Luftsichel sign
Thymic spinnaker-sail sign
Infant的pneumomediatinum,漏出至縱隔腔的氣體會將胸腺撐開而形成如大三角帆狀,稱為thymic spinnaker-sail sign
診斷肺栓塞、梗塞之徵候
Westermark's sign:
represents a focus of oligemia (vasoconstriction) seen distal to a pulmonary embolus
Hampton sign:
a shallow wedge-shaped opacity in the periphery of the lung with its base against the pleural surface
Knuckle sign:
abrupt tapering of an occluded vessel distally
Hampton Sign
Knuckle sign Westermark's sign
Bulging fissure sign
在nonsegmental air-space pneumonia時,常呈現大片的consolidation ,且常緊貼interlobar fissure,若其產生大量的炎性滲出液,則會導致該大片肺炎的volume
expansion ,因而將 interlobar fissure往外壓,
造成interlobar fissure往外膨出,稱為bulging
fissure sign。
Klebsiella Pneumonia
Thank You
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