Lecture 7- CXR Lecture Slides
-
Upload
ubcradadmin -
Category
Documents
-
view
260 -
download
0
Transcript of Lecture 7- CXR Lecture Slides
-
7/31/2019 Lecture 7- CXR Lecture Slides
1/72
Thoracic Imaging - Basic
pproac o es
-
7/31/2019 Lecture 7- CXR Lecture Slides
2/72
De artment of Radiolo
Vancouver General Hospital
Dr. Savvas NicolaouDirector of ER/Trauma Radiology
-
7/31/2019 Lecture 7- CXR Lecture Slides
3/72
Learning Objectives
Be able to evaluate technical factors required for an adequate interpretation ofa chest x-ray with respect to
Penetration Inspiration Magnification
Angulation
-
7/31/2019 Lecture 7- CXR Lecture Slides
4/72
Learning Objectives Continued
Be able to identify the following structures on a PA chest x-ray:
Lungs & Airways Trachea Hila Right and left mainstem bronchi Right Lobe: upper, middle, lower lobes Left Lobe: upper & lower lobes
Mediastinum Heart borders Transverse thoracic aorta Pulmonary trunk Atrial appendage Aorto- ulmonar window
-
7/31/2019 Lecture 7- CXR Lecture Slides
5/72
Learning Objectives Continued
Be able to identify the following structures on a PA chest x-ray:
Costodiaphragmatic recesses
Clavicles
Spine
Humerus Sternum
-
7/31/2019 Lecture 7- CXR Lecture Slides
6/72
Learning Objectives Cont d
Be able to identify the following structures on a PA chest x-ray:
Sternum Right ventricle Vertebral bodies
-
7/31/2019 Lecture 7- CXR Lecture Slides
7/72
-
7/31/2019 Lecture 7- CXR Lecture Slides
8/72
-
7/31/2019 Lecture 7- CXR Lecture Slides
9/72
Chest Radiography
Very Inexpensive
os common reques e exam
Easily obtained
representat on o aanatomic structure
Usually first line imaging of thechest
Excellent for emergency, lineplacement, post surgical imaging
and query abnormality
-
7/31/2019 Lecture 7- CXR Lecture Slides
10/72
Arrow indicatesArrow indicatesmalpositionedmalpositionedtube.tube.
Normally, the ETNormally, the ETtube should betube should beat least overat least over
of carina.of carina.
-
7/31/2019 Lecture 7- CXR Lecture Slides
11/72
PLAIN RADIOGRAPHY PLAIN RADIOGRAPHY
Involve passing x-rays through patient s body to expose a
Computed / Digital display
unit
X-ray Unit
-
7/31/2019 Lecture 7- CXR Lecture Slides
12/72
INTRODUCTION TO THE CHEST XINTRODUCTION TO THE CHEST X- -RAYRAY
Posteroanterior (PA) ViewPosteroanterior (PA) View
--
Standard view, taken on full inspirationPatient stands with anterior chest wall against the film cassette
-
Anteroposterior (AP) View Anteroposterior (AP) ViewMagnifies the cardiac and mediastinal shadows (approx. 20%)
-
7/31/2019 Lecture 7- CXR Lecture Slides
13/72
Basic Information
metal
fat
5 Radiographic Densitiesyou should be aware of
bone
air
Water,soft tissue metal Water, air
so ssue
-
7/31/2019 Lecture 7- CXR Lecture Slides
14/72
Chest xray CT
-
7/31/2019 Lecture 7- CXR Lecture Slides
15/72
Introduction to the Chest X-RayHow the radiograph is taken - Technique
Posteroanterior (PA) View
Standard view, taken on full inspiration Patient stands with anterior chest wall against the film cassette
X-ray beam enters from behind
Anteroposterior (AP) View
Magnifies the cardiac and mediastinal shadows (approx. 20%)
-
7/31/2019 Lecture 7- CXR Lecture Slides
16/72
Chest X-ray Technique
PA AP
-
7/31/2019 Lecture 7- CXR Lecture Slides
17/72
TECHNICAL FACTORSTECHNICAL FACTORS QAULITY QAULITY
RotationRotationSpinous processes shouldSpinous processes shouldproject midway betweenproject midway betweenmedial heads of claviclesmedial heads of clavicles
InspirationInspiration
Dome of rightDome of rightover the anterior 6over the anterior 6 ththinterspace and posteriorinterspace and posteriorri ht 10ri ht 10 thth inters aceinters ace
ExposureExposureThe lower thoracic discThe lower thoracic disc
through the cardiacthrough the cardiacsilhouettesilhouette
-
7/31/2019 Lecture 7- CXR Lecture Slides
18/72
Determining Adequacy of the Film
Penetration:
Disk spaces of the thoracicspine can be seen behind the
ear , u no ony e a s othe spine
-
7/31/2019 Lecture 7- CXR Lecture Slides
19/72
Determining Adequacy of the Film
Inspiration:
Diaphragm is below ribs 8-10;9-10 ribs can be seenpos er or y
10
9
-
7/31/2019 Lecture 7- CXR Lecture Slides
20/72
Determining Adequacy of the Film
Rotation:
Clavicles are equidistant fromthe spinous processes
-
7/31/2019 Lecture 7- CXR Lecture Slides
21/72
Determining Adequacy of the Film
Magnification:
The heart appears larger onan AP film than on a PA film
ue o e ear e ng ur erfrom the film and casting alarger shadow
Standard chest x-rays are PA
- most often AP
PA film shown here
-
7/31/2019 Lecture 7- CXR Lecture Slides
22/72
Determining Adequacy of the Film
Angulation3
Clavicle is over the 3 rd rib If the beam is angled towards
the head due to patientposture, the clavicle would
appear higher and structures,. ,distorted
-
7/31/2019 Lecture 7- CXR Lecture Slides
23/72
BASIC ANATOMYBASIC ANATOMY
TracheaTrachea
SVC Az osSVC Az os
TransversethoracicTransversethoracic
confluence
confluence Left hilumLeft hilum
Right hilumRight hilum
appendage
appendage
ventricle
ventricle
RighthemidiaphragmRighthemidiaphragm
Costophrenic
angle
Costophrenic
angle
-
7/31/2019 Lecture 7- CXR Lecture Slides
24/72
SternumSternum
bodiesbodies
abuttingabuttingretrosternal spaceretrosternal space
Left AtriumLeft Atrium
Posterior margin ofPosterior margin ofLT ventricleLT ventricle
Normal Lateral Chest
-
7/31/2019 Lecture 7- CXR Lecture Slides
25/72
MAJOR AIR WAYS
-
7/31/2019 Lecture 7- CXR Lecture Slides
26/72
TRANSVERSE PORTION OF THE THORACIC AORTA
-
7/31/2019 Lecture 7- CXR Lecture Slides
27/72
Heart Chambers
-
7/31/2019 Lecture 7- CXR Lecture Slides
28/72
Coronal mediastinal structures:Gross vs CXR
1
3
13
22
1. Right atrium2. Ri ht ventricle3. Left ventricle
-
7/31/2019 Lecture 7- CXR Lecture Slides
29/72
Coronal mediastinal structures:CXR vs CT
3
2 3
5
4
7
4
5
6
887
1. Trachea2. Superior Vena Cava
5. Right atrium6. Left ventricle
. ort c rc4. Pulmonary Trunk
. g t em ap ragm8. Costophrenic angle
-
7/31/2019 Lecture 7- CXR Lecture Slides
30/72
1
Coronal mediastinal structures:Gross vs CXR
1
32
3
4
5
6
42
56
1. Trachea 1. Pulmonary Trunk.
3. Aortic Arch.
3. Left Ventricle
-
7/31/2019 Lecture 7- CXR Lecture Slides
31/72
Coronal mediastinal structures:Gross vs CXR
1
3
1
24
3
4
55
1. Trachea 4. Aortopulmonary Window.
3. Aortic Arch.
-
7/31/2019 Lecture 7- CXR Lecture Slides
32/72
Looking at Chest Wall / Soft Tissues
Check each rib individually
Check clavicles Check for the presence or
absences of breasts
Check for presence of soft tissue
masses
Vertebra
o ec o y, pe c es, sp nous
process, disc space.
-
7/31/2019 Lecture 7- CXR Lecture Slides
33/72
ANTERIOR
-
7/31/2019 Lecture 7- CXR Lecture Slides
34/72
POSTERIOR
-
7/31/2019 Lecture 7- CXR Lecture Slides
35/72
Chest Wall: Ribs
Posterior Ribs
More apparent on PA
Posterior Ribs
More apparent on PAfilm
Up to 10 visible on
film
Up to 10 visible onPPPP
PP
Anterior RibsAnterior RibsAA
PA film
PA film AA
AA
Ch t W ll C ti RibCh t W ll C ti Rib
-
7/31/2019 Lecture 7- CXR Lecture Slides
36/72
Chest Wall: Counting RibsChest Wall: Counting Ribs
Posterior Ribs
-more apparent on PA film
Posterior Ribs
-more apparent on PA film PP-up o v s e on uinspiration-up o v s e on uinspiration
Anterior Ribs Anterior Ribs-less visible on PA film-less visible on PA film
-
7/31/2019 Lecture 7- CXR Lecture Slides
37/72
Chest Wall: Counting Ribs
Posterior Ribs
-more a aren on PA
Posterior Ribs
-more a aren on PAfilm
-up to 10 visible on full
film
-up to 10 visible on full PPPP
inspirationinspiration PP
Anterior Ribs Anterior Ribs A A
- ess v s e on m- ess v s e on m A A A A
P t i Rib
-
7/31/2019 Lecture 7- CXR Lecture Slides
38/72
Posterior Ribs
22
33
44
55
66
77
88
99
1010
Diaphragm
-
7/31/2019 Lecture 7- CXR Lecture Slides
39/72
Diaphragm
,namely the lateral and posterior costophrenic angles (arrows).
Right hemidiaphragm normally about 2cm higher than left.
L
R
Coronal mediastinal structures:
-
7/31/2019 Lecture 7- CXR Lecture Slides
40/72
Coronal mediastinal structures:Gross vs CXR
211
2
1. Right hemidiaphragm.
-
7/31/2019 Lecture 7- CXR Lecture Slides
41/72
-
7/31/2019 Lecture 7- CXR Lecture Slides
42/72
Pleura
-
7/31/2019 Lecture 7- CXR Lecture Slides
43/72
Pleura
Pleura extends to the:
8th rib in themidclavicular line
10th rib in the midaxillaryline , and to the
12th rib posterior
Pneumothorax - Air in Pleural Space
-
7/31/2019 Lecture 7- CXR Lecture Slides
44/72
p
pleura
-
7/31/2019 Lecture 7- CXR Lecture Slides
45/72
Mediastinum
-
7/31/2019 Lecture 7- CXR Lecture Slides
46/72
The mediastinum is the space
between the spine at the back,
,
lungs at the sidesMiddle
It is divided into the anterior,
middle and posterior mediastinum
Anterior Posterior
Lateral film helpful but usually will
need a CT scan for furtherinvestigation
-
7/31/2019 Lecture 7- CXR Lecture Slides
47/72
-
7/31/2019 Lecture 7- CXR Lecture Slides
48/72
A
Thymic mass in anteriormediastinum
Hila
-
7/31/2019 Lecture 7- CXR Lecture Slides
49/72
Comprised of lobar bronchi,
central/lobar pulmonary arteries,
veins, lymph nodes
The left hilum is slightly higher
than the right in normal
,
masses or enlarged lymph
nodes
HILUM
-
7/31/2019 Lecture 7- CXR Lecture Slides
50/72
-
7/31/2019 Lecture 7- CXR Lecture Slides
51/72
Coronal mediastinal structures:CXR CT
-
7/31/2019 Lecture 7- CXR Lecture Slides
52/72
CXR vs CT
2
34
34
1. Trachea2. Aortic Arch
.4. Left hilum
Coronal mediastinal structures:CXR vs CT
-
7/31/2019 Lecture 7- CXR Lecture Slides
53/72
CXR vs CT
1 4
2 3
4
2
56
5 6
1. Trachea2. Right Main Bronchus
1. Aortic Arch2. Right Hilum
3. Left Main Bronchus 3. Left Hilum
Coronal mediastinal structures:Gross vs CXR
-
7/31/2019 Lecture 7- CXR Lecture Slides
54/72
Gross vs CXR
1
2
4
1
4
1. Trachea2. Aortic Arch
. g t um4. Left hilum
Coronal mediastinal structures:Gross vs CXR
-
7/31/2019 Lecture 7- CXR Lecture Slides
55/72
Gross vs CXR
1
4
2
6
31 4
2
35
6
1. Trachea2. Ri ht Main Bronchus
4. Aortic Arch5. Ri ht Hilum
3. Left Main Bronchus 6. Left Hilum
-
7/31/2019 Lecture 7- CXR Lecture Slides
56/72
u y y
Axial (transverse) mediastinal structures: Gross vs CT
-
7/31/2019 Lecture 7- CXR Lecture Slides
57/72
a (t a sve se) ed ast a st uctu es: G oss vs C
213
3
5
5
6
12
4 6
1. Right Major (oblique) fissure.
3. Right Upper Lobe4. Right Lower lobe
1 2
3 5
.6. Left lower lobe
Cross Sectional CT Imaging of Lungs
-
7/31/2019 Lecture 7- CXR Lecture Slides
58/72
3
4
57
3
4
5
7
1 2
6 8 68
1. Right Major (oblique) fissure. e t ma or o que ssure
3. Right minor (horizontal) fissure4. Right Upper Lobe
. g t ower o e7. Left Upper lobe8. Left lower lobe
5. g t e o e
-
7/31/2019 Lecture 7- CXR Lecture Slides
59/72
Coronal Saggital
Transverse
Coronal CT Imaging of Lungs
-
7/31/2019 Lecture 7- CXR Lecture Slides
60/72
g g g
23
4 7
12
3
7
8
6 8
1. Right Major (oblique) fissure2. Left major (oblique) fissure3. Ri ht minor horizontal fissure
5. Right Middle lobe6. Right Lower lobe7. Left U er lobe
4. Right Upper Lobe 8. Left lower lobe
The Right Lung
-
7/31/2019 Lecture 7- CXR Lecture Slides
61/72
The Right Lung
-
7/31/2019 Lecture 7- CXR Lecture Slides
62/72
Major fissure
The Right Lung
-
7/31/2019 Lecture 7- CXR Lecture Slides
63/72
Minor fissure
(Horizontal Fissure)
The Right Upper Lobe
-
7/31/2019 Lecture 7- CXR Lecture Slides
64/72
RUL
Right Middle Lobe
-
7/31/2019 Lecture 7- CXR Lecture Slides
65/72
RMLRML
Right Lower Lobe
-
7/31/2019 Lecture 7- CXR Lecture Slides
66/72
RLL
RLL
The Left Lung
-
7/31/2019 Lecture 7- CXR Lecture Slides
67/72
Left Lower and Upper Lobes
-
7/31/2019 Lecture 7- CXR Lecture Slides
68/72
LUL
LLL
LLL
Normal Lateral Chest
-
7/31/2019 Lecture 7- CXR Lecture Slides
69/72
Sagittal mediastinal structures:Gross vs CXR
-
7/31/2019 Lecture 7- CXR Lecture Slides
70/72
1
32
1
3
75
4
6
4
7
5
1. Sternum2. Right Pulmonary Artery
5. Right Ventricle6. Inferior Vena Cava
.4. Left Atrium
.
LOOKING AT THELOOKING AT THE LUNGSLUNGS
-
7/31/2019 Lecture 7- CXR Lecture Slides
71/72
RadiographicRadiographica earance isa earance iscomprised of gas filledcomprised of gas filledalveoli (black) andalveoli (black) and
(white)(white)
Bronchi dont normallyBronchi dont normallycontribute radiographiccontribute radiographicdensitydensity
by their tapering andby their tapering andbranching patternbranching pattern
NORMAL PULMONARY EDEMA
-
7/31/2019 Lecture 7- CXR Lecture Slides
72/72