1 Principles of Chest X-Ray Interpretation Dr Rod Taylor Consultant Respiratory Physician Dr Rod...
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1 Principles Principles of of Chest X-Ray Chest X-Ray Interpretati Interpretati on on Dr Rod Taylor Dr Rod Taylor Consultant Respiratory Consultant Respiratory Physician Physician
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Transcript of 1 Principles of Chest X-Ray Interpretation Dr Rod Taylor Consultant Respiratory Physician Dr Rod...
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Principles ofPrinciples ofChest X-Ray Chest X-Ray
InterpretationInterpretation
Principles ofPrinciples ofChest X-Ray Chest X-Ray
InterpretationInterpretation
Dr Rod TaylorDr Rod TaylorConsultant Respiratory PhysicianConsultant Respiratory Physician
Dr Rod TaylorDr Rod TaylorConsultant Respiratory PhysicianConsultant Respiratory Physician
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Different from us….Different from us….
3
Only Two ChoicesOnly Two Choices
Hmmn!There are
far too many white
bits!
That’s funny - this one’s got too many black bits!
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5
Chest X-ray Chest X-ray
PP= important radiological
principle
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The Normal CXRThe Normal CXRVertebral spines
equidistant
Horizontalfissure
Costophrenic
angle
Cardiophrenicangle
Lefthilum
Descending
aorta
Rightdiaphrag
m
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It’s All Relative… 1It’s All Relative… 1
Stupid humans
…PPPP
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Why Does It Show Up?Why Does It Show Up?
Because there is something of a different radiological
density next to it.
Four main densities:
Because there is something of a different radiological
density next to it.
Four main densities: PP
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Étienne de SilhouetteÉtienne de Silhouette
The silhouette signIf a structure shows up,
there must be adjacent to itsomething of a different
radiological density.
If a structure does not showup, there must be adjacentto it something of a similar
radiological density.
The silhouette signIf a structure shows up,
there must be adjacent to itsomething of a different
radiological density.
If a structure does not showup, there must be adjacentto it something of a similar
radiological density. Controller-General of Finances during the Seven Years War
(1754 – 63)
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Silhouetted HillsSilhouetted Hills
This hill shows up
This hill shows up
This one
doesn’t
This one
doesn’t
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RotationRotationPA
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The LobesThe Lobes
FrontFront BackBack
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Lateral View (Right)Lateral View (Right)
Horizontalfissure
UpperLobe
Lower Lobe
Oblique
fissure
Apical segment of lower
lobe
Vertebral bodies
appear to darken
MiddleLobe
Heart
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Lateral View (Left)Lateral View (Left)
Oblique
fissure
UpperLobe
LowerLobe
Lingula
No fissure(normally)
Heart
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Naming of SegmentsNaming of SegmentsApicalApical
AnteriorAnterior
Posterior Posterior
Medial Medial
Lateral Lateral
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Don’t Forget….Don’t Forget….
The bonesThe bones
Gas under the diaphragmGas under the diaphragm
Has this patient had a chest x-ray?
Oh, good, then I can
start!
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It’s All Relative… 2It’s All Relative… 2
Normal CXRNormal CXR
Too White?
Too White?
TooBlack?
TooBlack?
PPLook for
collateral evidenceLook for
collateral evidence
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What Do You See?What Do You See?
The most obvious abnormality is
likely to be the primary event.
Other, more subtle, changes are
likely to be secondary to this.
The most obvious abnormality is
likely to be the primary event.
Other, more subtle, changes are
likely to be secondary to this.
PP
19
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The Man in the StreetThe Man in the Street
Dryclough Lane
Er, there’s a white bit on the right… at the
top… um… which comes… ooh, about halfway down… with a sharp, um, line, at
the bottom…
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Right Upper Lobe ConsolidationRight Upper Lobe Consolidation
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The ‘Pair of Scissors Sign’The ‘Pair of Scissors Sign’
If you could cut along a line seen ona CXR with a pair of scissors
- think of a pleural boundary or fissure.
If you could cut along a line seen ona CXR with a pair of scissors
- think of a pleural boundary or fissure.
PP
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Interlobar EffusionInterlobar Effusion
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Right Upper Lobe Right Upper Lobe CollapseCollapse
Horizontal fissure ispulled up, producing
a sharply-defined RUZ opacity.
Trachea is pulled tothe right.
Right hilum is pulled upwards.
Right hemidiaphragmmay be pulled up.
Horizontal fissure ispulled up, producing
a sharply-defined RUZ opacity.
Trachea is pulled tothe right.
Right hilum is pulled upwards.
Right hemidiaphragmmay be pulled up.
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Fissure extends
medial to hilum
Fissure extends
medial to hilum
Diaphragm
disappears
Diaphragm
disappears
Vertebrae get
whiter
Vertebrae get
whiter
Diaphragm
indistinct
Diaphragm
indistinct
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Right Lower LobeRight Lower Lobe
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Right Lower Lobe Right Lower Lobe CollapseCollapse
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Horizontal fissure
Horizontal fissure
Oblique
fissure
Oblique
fissure
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31
32
Horizontal fissure
Horizontal fissure
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Middle Lobe CollapseMiddle Lobe Collapse
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35
36
Right M & LL CollapseRight M & LL Collapse
Oblique
fissure
Oblique
fissure
Horizontal fissure
Horizontal fissure
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Displaced
oblique fissure
Displaced
oblique fissure
Elevated left
diaphragm
Elevated left
diaphragm
Overinflatedlower lobe
Overinflatedlower lobe
Tongue of collapsed
upper lobe
Tongue of collapsed
upper lobe
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Left Upper Lobe CollapseLeft Upper Lobe Collapse
Overinflated left lower lobe
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Consolidation Collapse
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What is it?What is it?
42
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““Radiological Radiological Homeostasis”Homeostasis”
If a structure is displaced on a CXR,
then something else will happen
to compensate for that displacement.
Example: collapse of one lobe overinflation of another
If a structure is displaced on a CXR,
then something else will happen
to compensate for that displacement.
Example: collapse of one lobe overinflation of another
PP
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If a Structure is DisplacedIf a Structure is Displaced
Pushed out of placePushed out of place
Pulled out of placePulled out of place
Look for collateralevidence
Look for collateralevidence
PP
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Left heart border
indistinct
Left heart border
indistinct
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Left heart border visible
Left heart border visible
Oblique fissure
Oblique fissure
Diaphragmindistinct
Diaphragmindistinct
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Diaphragm
indistinct
Diaphragm
indistinct
Descending aorta
indistinct
Descending aorta
indistinct Triangular opacity
Triangular opacity
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Collapsed Left Lower LobeCollapsed Left Lower Lobe
Descending aorta
Descending aorta
Diaphragm visible
Diaphragm visible
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Left Lower Lobe CollapseLeft Lower Lobe Collapse
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Collapsed left lower
lobe
Collapsed left lower
lobeCollapsed right lower
lobe
Collapsed right lower
lobe
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Left main bronchus
endsabruptly
Left main bronchus
endsabruptly
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Total Lung CollapseTotal Lung Collapse
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Pleural EffusionPleural Effusion
Davis, Gardner & Qvist 1963, BMJ
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Basic PrinciplesBasic Principles
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INTERLUDEINTERLUDE
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Bronchial TreeBronchial Tree
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Bronchial TreeBronchial Tree
RULRULLULLUL
MLML
Apicallower
Apicallower
Apicallower
Apicallower
Basallower
Basallower
Basallowe
r
Basallowe
r
Upperdivisio
n
Upperdivisio
n
LingulaLingula
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Anaesthetist’s Eye Anaesthetist’s Eye ViewView
Middle
lobe
Middle
lobe
trachea RLBasallower
Basallower
Lingula
Lingula
Left upperdivision
Left upperdivision
Apical
lower
Apical
lower
Rightupper
Rightupper
Apical
lower
Apical
lower
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Use Your Imagination!Use Your Imagination!
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Aspiration and GravityAspiration and Gravity
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Apical SegmentApical Segment
Anterior
Posterior Apicalsegment
Apicalsegment
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Air BronchogramAir Bronchogram
Two requirements: 1. The bronchus must contain air.
2. The surrounding lung must not.
Two requirements: 1. The bronchus must contain air.
2. The surrounding lung must not.PP
Contrast bronchogram
Contrast bronchogram Air bronchogramAir bronchogram
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ResolutionResolutionNodules
Fibrosis
Ground glass
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Ground Glass Ground Glass ShadowingShadowing
Can still see the vessels and airways
Can still see the vessels and airways
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ConsolidationConsolidation
Ground glass
shadowing
Ground glass
shadowing
Consolidation
Consolidation
Obscures the vessels and airways
Obscures the vessels and airways
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Pixels and VoxelsPixels and Voxels
Pixel Voxel
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Volume AveragingVolume Averaging
When a pixel contains more than one type of tissue, it shows the average density of the voxel.
1. One big object, only partially within the voxel
2. Lots of small objects, all within the voxel
When a pixel contains more than one type of tissue, it shows the average density of the voxel.
1. One big object, only partially within the voxel
2. Lots of small objects, all within the voxel
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Partial VolumingPartial Voluming
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Partial VolumingPartial VolumingAortic arch
Aortic arch
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Partial Voluming (1)Partial Voluming (1)
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Partial VolumingPartial Voluming
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Partial Voluming (2)Partial Voluming (2)
Ground glassshadowing
Ground glassshadowing
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Volume-averagedmixture
Volume-averagedmixture
Individual ingredientsIndividual
ingredients
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Ground Glass ‘Micro-fibrosis’Ground Glass ‘Micro-fibrosis’
Normal Normal BronchiectaticBronchiectatic
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Traction BronchiectasisTraction Bronchiectasis
Dilatedbronchu
s
Dilatedbronchu
s
Fibrosis
Fibrosis
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Pulmonary FibrosisPulmonary Fibrosis
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Tree in Bud SignTree in Bud Sign
Plugging and thickeningof bronchioles
Plugging and thickeningof bronchioles
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Basic PrinciplesBasic Principles
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(Sigh)If only everything was as simple as interpreting chest
x-rays…
