1. Interpretation of Chest Radio Graph
Transcript of 1. Interpretation of Chest Radio Graph
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Dr. Anindita Mishra, MD
Associate Professor
Department of Radiodiagnosis
GSL Medical College
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Introduction
Routinely obtained
Pulmonary specialist consultation
Inherent physical exam limitations
Chest x-ray limitations
Physical exam and chest x-ray provide
compliment
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Essentials Before Getting Started
Exposure
– Overexposure
– Underexposure
Sex of Patient
– Male
– Female
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Path of x-ray beam
– PA
– AP
Patient Position – Upright
– Supine
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Breath
– Inspiration
– Expiration
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Systematic Approach
Bony Framework
Soft Tissues
Lung Fields and Hila
Diaphragm and Pleural Spaces
Mediastinum and Heart
Abdomen and Neck
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Bony Fragments
– Ribs
– Sternum
– Spine
– Shoulder girdle
– Clavicles
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Soft Tissues
– Breast shadows
– Supraclavicular areas
– Axillae
– Tissues along side of
breasts
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Lung Fields and Hila
– Hilum
Pulmonary arteries
Pulmonary veins
– Lungs
Linear and fine nodular
shadows of pulmonary vessels
– Blood vessels
– 40% obscured by other tissue
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Diaphragm and
Pleural Surfaces
– Diaphragm
Dome-shaped
Costophrenic angles
– Normal pleural is not
visible
– Interlobar fissures
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Mediastinum and Heart
Heart size on PA
Right sideInferior vena cava
Right atrium
Ascending aorta
Superior vena cava
Left side
Left ventricle
Left atrium
Pulmonary arteryAortic arch
Subclavian artery and vein
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Abdomen and Neck
– Abdomen
Gastric bubble Air under diaphragm
–
Neck Soft tissue mass
Air bronchogram
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Air
Water
Bone
Tissue
Tissue
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Pitfalls to Chest X-ray
Interpretation
Poor inspiration
Over or under penetration
Rotation
Forgetting the path of the x-ray beam
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Lung Anatomy Trachea
Carina
Right and Left
Pulmonary Bronchi
Secondary Bronchi
Tertiary Bronchi
Bronchioles
Alveolar Duct
Alveoli
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Lung Anatomy
Right Lung
– Superior lobe
– Middle lobe
– Inferior lobe
Left Lung
– Superior lobe
– Inferior lobe
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Lung Anatomy on Chest X-ray
PA View: – Extensive overlap
– Lower lobes extend high
Lateral View:
– Extent of lower lobes
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Lung Anatomy on Chest X-ray
The right upper lobe(RUL) occupies the
upper 1/3 of the right
lung.
Posteriorly, the RUL is
adjacent to the first
three to five ribs.
Anteriorly, the RUL
extends inferiorly as far
as the 4th right anterior
rib
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Lung Anatomy on Chest X-ray
The right middle lobe
is typically the smallest
of the three, andappears triangular in
shape, being narrowest
near the hilum
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Lung Anatomy on Chest X-ray The right lower lobe is the
largest of all three lobes,
separated from the others
by the major fissure.
Posteriorly, the RLL extend
as far superiorly as the 6th
thoracic vertebral body,
and extends inferiorly to
the diaphragm.
Review of the lateral plain
film surprisingly shows the
superior extent of the RLL.
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Lung Anatomy on Chest X-ray These lobes can be separated
from one another by twofissures.
The minor fissure separates
the RUL from the RML, andthus represents the visceral
pleural surfaces of both of
these lobes.
Oriented obliquely, the major
fissure extends posteriorly
and superiorly approximately
to the level of the fourth
vertebral body.
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Lung Anatomy on Chest X-ray
The lobar architectureof the left lung is
slightly different than
the right.
Because there is no
defined left minor
fissure, there are only
two lobes on the left;
the left upper
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Lung Anatomy on Chest X-ray
Left lower lobes
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Lung Anatomy on Chest X-ray
These two lobes are
separated by a major fissure,
identical to that seen on the
right side, although often
slightly more inferior in
location.
The portion of the left lung
that corresponds
anatomically to the rightmiddle lobe is incorporated
into the left upper lobe.
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The Normal Chest X-ray
PA View:1. Aortic arch
2. Pulmonary trunk
3. Left atrial appendage
4. Left ventricle
5. Right ventricle
6. Superior vena cava
7. Right hemidiaphragm
8. Left hemidiaphragm
9. Horizontal fissure
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The Normal Chest X-ray
Lateral View:
1. Oblique fissure
2. Horizontal fissure
3. Thoracic spine and
retrocardiac space
4. Retrosternal space
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The Silhouette Sign
An intra-thoracic radio-
opacity, if in anatomic
contact with a border of
heart or aorta, will obscure
that border. An intra-
thoracic lesion not
anatomically contiguous
with a border or a normal
structure will not obliterate
that border.
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Putting It All Together
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Understanding Pathological Changes
Most disease states replace air with a
pathological process
Each tissue reacts to injury in a predictable
fashion
Lung injury or pathological states can be
either a generalized or localized process
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Liquid Density
Liquid density Increased airdensityGeneralized Localized
Diffusealveolar
Diffuse
interstitialMixed
Vascular
InfiltrateConsolidation
Cavitation
MassCongestion
Atelectasis
Localized airwayobstruction
Diffuse airway
obstructionEmphysema
Bulla
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Consolidation
Lobar consolidation:
– Alveolar space filledwith inflammatoryexudate
– Interstitium and
architecture remainintact
– The airway is patent
– Radiologically:
A density correspondingto a segment or lobe
Airbronchogram, and
No significant loss of lung
volume
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Atelectasis
Loss of air
Obstructive atelectasis:
– No ventilation to the lobe
beyond obstruction
– Radiologically:
Density corresponding to a
segment or lobe
Significant loss of volume
Compensatory
hyperinflation of normal
lungs
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Stages of Evaluating an Abnormality
1. Identification of abnormal shadows2. Localization of lesion
3. Identification of pathological process
4. Identification of etiology5. Confirmation of clinical suspension
Complex problems
Introduction of contrast medium
CT chest
MRI scan
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Putting It Into Practice
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Case 1
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A single, 3cm relatively thin-walled cavity is noted in the left mid lung. This
finding is most typical of squamous cell carcinoma (SCC). One-third of SCC
masses show cavitation
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Case 2
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LUL Atelectasis: Loss of heart borders/silhouetting. Notice
over inflation on unaffected lung
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Case 3
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Right Middle and Left Upper Lobe Pneumonia
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Case 4
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Cavitation:cystic changes in the area of consolidation due to the
bacterial destruction of lung tissue. Notice air fluid level.
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Cavitation
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Case 5
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Tuberculosis
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Case 6
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COPD: increase in heart diameter, flattening of the
diaphragm, and increase in the size of the retrosternal air
space. In addition the upper lobes will become hyperlucent due
to destruction of the lung tissue.
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Chronic emphysema effect on the lungs
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Case 7
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Pseudotumor: fluid has filled the minor fissure creating a density
that resembles a tumor (arrow). Recall that fluid and soft tissue
are indistinguishable on plain film. Further analysis, however,
reveals a classic pleural effusion in the right pleura. Note the right
lateral gutter is blunted and the right diaphram is obscurred.
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Case 8
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Pneumonia:a large pneumonia consolidation in the right lower
lobe. Knowledge of lobar and segmental anatomy is important
in identifying the location of the infection
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Case 9
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CHF:a great deal of accentuated interstitial markings, Curly
lines, and an enlarged heart. Normally indistinct upper lobe
vessels are prominent but are also masked by interstitial edema.
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24 hours after diuretic therapy
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Case 10
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Chest wall lesion: arising off the chest wall and not the lung
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Case 11
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Pleural effusion: Note loss of left hemidiaphragm. Fluid drained
via thoracentesis
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Case 12
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Lung Mass
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Case 13
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Small Pneumothorax: LUL
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Case 15
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Right Middle Lobe Pneumothorax: complete lobar collapse
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Post chest tube insertion and re-expansion
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Case 16
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Metastatic Lung Cancer: multiple nodules seen
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Case 17
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Right upper lower lobe pulmonary nodule
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Case 18
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Tuberculosis
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Case 19
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Perihilar mass: Hodgkin’s disease
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Case 20
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Widened Mediastinum: Aortic Dissection
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Case 21
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Pulmonary artery stenosis with cardiomegally likely secondary
to stenosis.
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Questions?
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Acknowledgement
ARNP Bucky Boaz – Chest X-Ray
radiography
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Thank You