Chest Radiography Reading

7/29/2019 Chest Radiography Reading

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Chest RadiographyInterpretation:Reading Chest Films

Lisa Chen , M.D.

Assistant Clinical Professor

Pulmonary and Critical Care Division

Department of MedicineSan Francisco General Hospital

Michael Gotway, MD

Associate Clinical Professor, Radiology

University of California, San Francisco


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Approach to the CXR:

Technical Aspects

Inspiratory effort

9-10 posterior ribs

Penetration

thoracic intervertebral disc space just visible Positioning/rotation

medial clavicle heads equidistant to spinous

process


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Low Lung Volumes


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Over Exposure Proper Exposure


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10


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What to Evaluate

Lungs

Pleural surfaces Cardiomediastinal contours

Bones and soft tissues

Abdomen


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Where to Look

Apices

Retrocardiac areas (left and right)

Below diaphragm


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Apical TB


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Left Retrocardiac Opacity


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Normal Anatomy: Frontal CXR

Heart

Aorta Pulmonary arteries

Airways

Diaphragm/costophrenic sulci

Junction lines


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Normal Anatomy: Lateral

Heart

Aorta

Pulmonary arteries

Airways

Spine


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AA

RV

LV


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Chest Radiography:

Basic Principles

X-ray photon fates:

completely absorbed in patient

transmitted through patient; strike film

scattered within patient; strike film

X-ray absorption depends on: beam energy (constant)

tissue density


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Maximum x-rayTransmission

(least dense tissue)

Maximum xrayAbsorption

(densest tissue)

Blackest

air

fat

soft tissue

calcium

bone

x-ray contrast

metal

Whitest


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All cardiothoracic pathology andnormal anatomy is visualized (or not)

by 7 different densities

How is this accomplished? differential x-ray absorption

Chest Radiography:

Basic Principles


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A structure is rendered visible on a

radiograph by the juxtaposition of two

different densities

Differential X-Ray Absorption


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Silhouette Sign

Loss of the expected interface

normally created by juxtaposition oftwo structures of different density

No boundary can be seen betweentwo structures of similar density


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Right Lower Lobe Pneumonia


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Differential X-Ray Absorption

The absence of a normal interface

may indicate disease;

The presence of an unexpected

interface may also indicate disease The presence of interfaces can be

used to localize abnormalities


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Chest RadiographicPatterns of Disease

Air space opacity

Interstitial opacity

Nodules and masses

Lymphadenopathy

Cysts and cavities

Lung volumes

Pleural diseases


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Cardiomediastinal contour abnormalities

Bone and soft tissue abnormalities

Below the diaphragm: abdominal and

retroperitoneal disease

Chest RadiographicPatterns of Disease


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Air Space Opacity

Components:

air bronchogram: air-filled bronchus

surrounded by airless lung

confluent opacity extending to pleural

surfaces

segmental distribution


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Air Space Opacity: DDX

Blood (hemorrhage)

Pus (pneumonia)

Water (edema)

hydrostatic or non-cardiogenic

Cells (tumor) Protein/fat: alveolar proteinosis and

lipoid pneumonia


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LUL Pneumonia


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Interstitial Opacity

Hallmarks:

small, well-defined nodules lines

interlobular septal thickening

fibrosis

reticulation

I i i l O i S ll N d l


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Interstitial Opacity: Small Nodules

I t titi l O it


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Interstitial Opacity:Lines

I t titi l O it Li & R ti l ti


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Interstitial Opacity: Lines & Reticulation


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Interstitial Opacity: DDX

Idiopathic interstitial pneumonias

Infections (TB, viruses) Edema

Hemorrhage

Noninfectious inflammatory lesions

sarcoidosis

Tumor


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Nodules and Masses

Nodule: any pulmonary lesion

represented in a radiograph by a sharplydefined, discrete, nearly circular opacity

2-30 mm in diameter

Mass: larger than 3 cm


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Nodules and Masses

Qualifiers:

single or multiple size

border definition

presence or absence of calcification

location

Well Defined


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Mass

Calcification

Well-Defined

Ill-Defined


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Lymphadenopathy

Non-specific presentations:

mediastinal widening

hilar prominence

Specific patterns:

particular station enlargement


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Right Paratracheal


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Right ParatrachealLymphadenopathy

Right Hilar LAN


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Right Hilar LAN

Right Hilar LAN


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Right Hilar LAN

Left Hilar LAN


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Left Hilar LAN

Subcarinal LAN


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Subcarinal LAN

Subcarinal LAN


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Subcarinal LAN

*

AP Window LAN


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AP Window LAN


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Cysts & Cavities

Cyst: abnormal pulmonary

parenchymal space, not containinglung but filled with air and/or fluid,

congenital or acquired, with a wall

thickness greater than 1 mm epithelial lining often present


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Cysts & Cavities

Cavity: abnormal pulmonary

parenchymal space, not containing

lung but filled with air and/or fluid,

caused by tissue necrosis, with a

definitive wall greater than 1 mm in

thickness and comprised of

inflammatory and/or neoplastic

elements


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Cysts & Cavities

Characterize:

wall thickness at thickest portion

inner lining

presence/absence of air/fluid level

number and location

Benign Lung Cyst : PCP Pneumatocele


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Benign Lung Cyst : PCPPneumatocele

Uniform wall thickness

1 mm Smooth inner lining

Benign Cavities :


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Benign Cavities :Cryptococcus

max wall thickness 4 mm minimally irregular inner lining

Indeterminate Cavities


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Indeterminate Cavities

max wall thickness 5-15 mm

mildly irregular inner lining


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Malignant Cavities: Squamous Cell Ca

max wall thickness 16 mm Irregular inner lining


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Pleural Disease: Basic Patterns

Effusion

angle blunting to massive

mobility Thickening

distortion, no mobility

Mass Air

Calcification

Pleural Effusion


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Pleural Effusion

Pleural Effusion


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Pleural Effusion

Subpulmonic Effusion


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Subpulmonic Effusion

Pleural Calcification


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Pleural Calcification

Chest Radiography Reading

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