M C AlraiesM C Alraies 11

Chest Chest Radiography Radiography InterpretationInterpretation

M Chadi Alraies, MDM Chadi Alraies, MDChief Medical ResidentChief Medical Resident

Case Western Reserve University Case Western Reserve University SVCHSVCH

Reading CXR’sReading CXR’s

Have a structured method!Have a structured method!Be consistent with that methodBe consistent with that methodDon’t take short cutsDon’t take short cutsLOOK AT ALL YOUR PATIENTS XRAYS LOOK AT ALL YOUR PATIENTS XRAYS

YOURSELF (and with your resident of YOURSELF (and with your resident of course!)course!)

PRACTICE…PRACTICE… PRACTICEPRACTICE…PRACTICE… PRACTICE

What is a Chest Radiograph?What is a Chest Radiograph?

SHADOWSHADOW

Start at the beginningStart at the beginning

Identification!Identification! Correct patient Correct patient Correct date and time Correct date and time Correct examination Correct examination

Are old films available?Are old films available? DO THIS EVERYTIME – It buys you time and is DO THIS EVERYTIME – It buys you time and is

vitally important.vitally important.

Approach to the CXR: Technical AspectsApproach to the CXR: Technical Aspects

Projection – PA or APProjection – PA or AP Position – Upright or Supine (Supine folks are Position – Upright or Supine (Supine folks are

sick)sick) Inspiratory effortInspiratory effort

9-10 posterior ribs9-10 posterior ribs

PenetrationPenetration thoracic intervertebral disc space just visiblethoracic intervertebral disc space just visible

Positioning/rotationPositioning/rotation medial clavicle heads equidistant to spinous processmedial clavicle heads equidistant to spinous process

ProjectionProjection

Portable (Portable (APAP or Antero- or Antero-posterior)posterior)

FILMFILM

PAPA (Postero-anterior) (Postero-anterior)

FILMFILM

ProjectionProjection

PA AP

Low Lung VolumesLow Lung Volumes

Over ExposureOver Exposure Proper ExposureProper Exposure

9999

Mental BreakMental Break

AnatomyAnatomy

RML

RUL

RUL (Right Upper Lung)RUL (Right Upper Lung)

RML (Right Middle Lung)RML (Right Middle Lung)

RLL (Right Lower Lung)RLL (Right Lower Lung)

Right Sided FissuresRight Sided Fissures

LUL (Left Upper Lung)LUL (Left Upper Lung)

LLL (Left Lower Lung)LLL (Left Lower Lung)

Left Side FissureLeft Side Fissure

LUL

LLL

What to EvaluateWhat to Evaluate

LungsLungsPleural surfacesPleural surfacesCardiomediastinal contoursCardiomediastinal contoursBones and soft tissuesBones and soft tissuesAbdomenAbdomen

Where to LookWhere to Look

ApicesApicesRetrocardiac areas (left and right)Retrocardiac areas (left and right)Below diaphragmBelow diaphragm

Apical TBApical TB

Left Retrocardiac OpacityLeft Retrocardiac Opacity

Normal Anatomy: Frontal CXRNormal Anatomy: Frontal CXR

HeartHeartAortaAortaPulmonary arteriesPulmonary arteriesAirwaysAirwaysDiaphragm/costophrenic sulciDiaphragm/costophrenic sulci

Normal Anatomy: LateralNormal Anatomy: Lateral

HeartHeartAortaAortaPulmonary arteriesPulmonary arteriesAirwaysAirwaysSpineSpine

Maximum x-rayMaximum x-rayTransmissionTransmission

(least dense tissue)(least dense tissue)

Maximum x–ray Maximum x–ray AbsorptionAbsorption

(densest tissue)(densest tissue)

BlackestBlackest

airair

fatfat

soft tissuesoft tissue

calciumcalcium

bonebone

x-ray contrastx-ray contrast

metalmetal

WhitestWhitest

A structure is rendered visible on a A structure is rendered visible on a radiograph by the juxtaposition of two radiograph by the juxtaposition of two different densitiesdifferent densities

Chest Radiography: Basic PrinciplesChest Radiography: Basic Principles

Silhouette SignSilhouette Sign

Loss of the expected interface normally Loss of the expected interface normally created by juxtaposition of two structures created by juxtaposition of two structures of different densityof different density

No boundary can be seen between two No boundary can be seen between two structures of similar densitystructures of similar density

Right Lower Lobe PneumoniaRight Lower Lobe Pneumonia

Differential X-Ray AbsorptionDifferential X-Ray Absorption

The absence of a normal interface may The absence of a normal interface may indicate disease; indicate disease;

The presence of an unexpected The presence of an unexpected interface may also indicate diseaseinterface may also indicate disease

The presence of interfaces can be used The presence of interfaces can be used to localize abnormalitiesto localize abnormalities

Chest Radiographic Chest Radiographic Patterns of DiseasePatterns of Disease

Air space opacityAir space opacity Interstitial opacityInterstitial opacityNodules and massesNodules and massesLymphadenopathyLymphadenopathyCysts and cavitiesCysts and cavitiesLung volumesLung volumesPleural diseasesPleural diseases

LUL PneumoniaLUL Pneumonia

Air Space OpacityAir Space Opacity

Components:Components:air bronchogram: air-filled bronchus air bronchogram: air-filled bronchus

surrounded by airless lungsurrounded by airless lungconfluent opacity extending to pleural confluent opacity extending to pleural

surfacessurfacessegmental distributionsegmental distribution

Air Space Opacity: DDXAir Space Opacity: DDX

Blood (hemorrhage)Blood (hemorrhage)Pus (pneumonia)Pus (pneumonia)Water (edema)Water (edema)

hydrostatic or non-cardiogenichydrostatic or non-cardiogenicCells (tumor)Cells (tumor)Protein/fat: alveolar proteinosis and Protein/fat: alveolar proteinosis and

lipoid pneumonia lipoid pneumonia

Interstitial Opacity: Small NodulesInterstitial Opacity: Small Nodules

Interstitial Opacity: Interstitial Opacity: LinesLines

Interstitial Opacity: Lines & ReticulationInterstitial Opacity: Lines & Reticulation

Interstitial OpacityInterstitial Opacity

Hallmarks:Hallmarks:small, well-defined nodulessmall, well-defined nodules lines lines

interlobular septal thickeninginterlobular septal thickening fibrosisfibrosis

reticulationreticulation

Interstitial Opacity: DDXInterstitial Opacity: DDX

Idiopathic interstitial pneumoniasIdiopathic interstitial pneumonias Infections (TB, viruses)Infections (TB, viruses)EdemaEdemaHemorrhageHemorrhageNon–infectious inflammatory lesionsNon–infectious inflammatory lesions

sarcoidosissarcoidosisTumorTumor

MassMass

CalcificationCalcification

Well-DefinedWell-Defined

Ill-DefinedIll-Defined

Nodules and MassesNodules and Masses

Nodule: any pulmonary lesion represented in Nodule: any pulmonary lesion represented in a radiograph by a sharply defined, discrete, a radiograph by a sharply defined, discrete, nearly circular opacity 2-30 mm in diameternearly circular opacity 2-30 mm in diameter

Mass: Mass: larger than 3 cmlarger than 3 cm

Nodules and MassesNodules and Masses

Qualifiers:Qualifiers:single or multiplesingle or multiplesizesizeborder definitionborder definitionpresence or absence of calcificationpresence or absence of calcification locationlocation

Right Paratracheal Right Paratracheal LymphadenopathyLymphadenopathy

Right Hilar LANRight Hilar LAN

Right Hilar LANRight Hilar LAN

Left Hilar LANLeft Hilar LAN

Subcarinal LANSubcarinal LAN

*

AP Window LANAP Window LAN

LymphadenopathyLymphadenopathy

Non-specific presentations:Non-specific presentations:mediastinal wideningmediastinal wideninghilar prominencehilar prominence

Specific patterns:Specific patterns:particular station enlargementparticular station enlargement

Cysts & CavitiesCysts & Cavities

Cyst: abnormal pulmonary parenchymal Cyst: abnormal pulmonary parenchymal space, not containing lung but filled with air space, not containing lung but filled with air and/or fluid, congenital or acquired, with a and/or fluid, congenital or acquired, with a wall thickness greater than 1 mmwall thickness greater than 1 mm

epithelial lining often presentepithelial lining often present

Cysts & CavitiesCysts & Cavities

Cavity: abnormal pulmonary parenchymal Cavity: abnormal pulmonary parenchymal space, not containing lung but filled with air space, not containing lung but filled with air and/or fluid, caused by tissue necrosis, with and/or fluid, caused by tissue necrosis, with a definitive wall greater than 1 mm in a definitive wall greater than 1 mm in thickness and comprised of inflammatory thickness and comprised of inflammatory and/or neoplastic elementsand/or neoplastic elements

Benign Lung Cyst : Benign Lung Cyst : PCPPCP Pneumatocele Pneumatocele

• Uniform wall thicknessUniform wall thickness• 1 mm1 mm• Smooth inner liningSmooth inner lining

Benign Cavities :Benign Cavities :CryptococcusCryptococcus

• max wall thickness max wall thickness 4 mm4 mm• minimally irregular inner liningminimally irregular inner lining

Indeterminate CavitiesIndeterminate Cavities

• max wall thickness 5-15 mmmax wall thickness 5-15 mm• mildly irregular inner liningmildly irregular inner lining

Malignant Cavities: Squamous Cell CaMalignant Cavities: Squamous Cell Ca

• max wall thickness max wall thickness 16 mm16 mm• Irregular inner liningIrregular inner lining

Cysts & CavitiesCysts & Cavities

Characterize:Characterize:wall thickness at thickest portionwall thickness at thickest portion inner lininginner liningpresence/absence of air/fluid levelpresence/absence of air/fluid levelnumber and locationnumber and location

Pleural EffusionPleural Effusion

Pleural EffusionPleural Effusion

Pleural CalcificationPleural Calcification

Pleural Disease: Basic PatternsPleural Disease: Basic Patterns

EffusionEffusionangle blunting to massiveangle blunting to massivemobilitymobility

ThickeningThickening distortion, no mobilitydistortion, no mobility

MassMassAirAirCalcificationCalcification

Thoracic Aorta AneurysmThoracic Aorta Aneurysm

Chest breast implantsChest breast implants

Rib fx’s

Mediast. OK

Pulmonary contusion

Subcu air

Chest tube

NG tube

MVC victimMVC victim

Deep Right Mainstem IntubationDeep Right Mainstem Intubation

CarinaTip of ET tube

Tip of ET

Pneumomediastinum

wide wide mediastinummediastinum

obliteration of obliteration of aortic knobaortic knob

Rt mainstem Rt mainstem shift up and shift up and rightright

NG deviate NG deviate to rightto right

pleural cappleural cap

Major Vessel Injury

Potential X ray findings

PneumothoracesPneumothoraces

Expiration reduces lung volume, Expiration reduces lung volume, making a small pneumo easier to seemaking a small pneumo easier to see

Irregular linear opacities are present in both lungs, especially in the periphery and the bases of the lungs. The heart is slightly enlarged, but this is not related to the pulmonary abnormalities in this case.

Hodgkin’s Disease

Ao

SVC

Mediastinal Hematoma

Chest tube

NG shift to Rt.

Tracheal deviation to Rt.

ET tubeObliterated aortic knob First rib fx

ET

NG

Rt. Subclavian Art.Lt. Internal Carotid

Artery

Lt. Subclavian Artery

Aortic Rupture

Tension Pneumothorax on CTTension Pneumothorax on CT

Rt. Lt.Mediastinum

Ao

Tension Pneumo

HemothoracesHemothoraces

HemothoraxHemothorax

Supine Upright

Hemopneumothorax

Indistinct diaphragm

Elevated, irregular hemidiaphragm

Close-upClose-upRib fxs

Clavicle fx

Chest tube

Suspicious

Indistinct, elevated diaphragm

Crushed right chestCrushed right chest

After ventilated with PEEPAfter ventilated with PEEP