2013

Chest X-Ray Interpretation: A Simplified Approach

Eugene Orientale, Jr, MD

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National Conference of Family Medicine Residents and Medical Students August 1-3, 2013 Kansas City, MO

Chest X-Ray Interpretation: A Simplified Approach

Workshop Agenda:

1. Pretest 10 Minutes

2. CXR Basics 10 Minutes 3. CXR Algorithm with 60 Minutes

Clinical Vignettes 4. Pretest Revisited 10 Minutes

Eugene Orientale, Jr., MD Program Director

Professor, Family Medicine UCONN / St. Francis Family Medicine

Hartford, Connecticut

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PRETEST

CXR (Chest X-Ray Workshop) Eugene Orientale, Jr., M.D.

Instructions: Please circle the appropriate response(s). Note: More than one answer may be correct.

1. This 60 year old male presents with dyspnea, orthopnea, and pedal edema. He is a non-smoker. Findings observed on this PA/Lat CXR include:

a. bilateral infiltrates b. cardiomegaly c. pleural effusion(s) d. Kerleys B-lines e. cephalization of pulmonary flow f. evidence of restrictive lung disease

2. This 63 year old male requires nasal cannula home O2 therapy to enable ambulation. He has a >60 pack/year smoking history. Findings observed on this PA/Lat CXR include:

a. hyperinflation b. increased AP diameter c. cardiomegaly d. flattening of diaphragms e. evidence of air trapping f. COPD

3. This 36 year old male complained of 3 days of progressive fever, cough productive of yellowish-green sputum, nocturnal chills, and rigors. The films on the right were taken 3 weeks after this acute illness. True statement(s) regarding this patients CXR include:

There is a: a. Left Lower Lobe infiltrate which subsequently cleared. b. Left Lingular infiltrate which subsequently cleared. c. Left Upper Lobe infiltrate which subsequently cleared. d. Silhouetting of the left heart border is present. e. Silhouetting: of the left heart border is absent.

4. Which clinic setting(s) is/are consistent with this CXR? a. aspiration pneumonia b. pneumonia c. tension pneumothorax d. total pneumonectomy e. lobar consolidation f. hemothorax

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5. This 34 year old medical student presented with two weeks of nonproductive cough following his medicine rotation at the VA. Two days prior to being evaluated, he noted the onset of fever and cough, productive of yellowish white sputum. On further review of history, he notes recent exposure to patients with Legionella and Mycoplasma. This CXR illustrates:

a. bilateral infiltrates b. over-penetration c. under-penetration d. increased pulmonary markings secondary to over-penetration e. increased pulmonary markings secondary under-penetration f. normal lung markings.

6. A chest x-ray film that is unexposed to x-ray radiation, if developed, appears: a. white b. black

7. In a normal CXR, pulmonary (lung) markings represent: a. bronchioles b. acini c. pulmonary arteries d. pulmonary veins e. pulmonary lymphatics

8. Choose the best three landmarks utilized in the normal, well-positioned and exposed CXR that yield the most information about mediastinal shift:

a. corina b. left hilum c. right hilum d. trachea e. aortic knob f. left heart border g. right heart border

9. Causes of mediastinal shift include: a. pleural/pulmonary effusions b. air trapping c. tension pneumothorax d. pneumonectomy e. atelectasis f. fibrosis

10. Which of the following must one assess before establishing the validity of a CXR? a. adequacy of inspiration (i.e., 9-10 ribs present) b. degree of penetration (exposure) c. rotation, judged with respect to the clavicles d. rotation, judged with respect to the humerus and scapula e. name and date on film

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I. Clinical Contest 1. Who is the patient? 2. Why was the test ordered? 3. Any relevant history? 4. Check name, date on film. . . 5. Determine projection (AP vs. PA lateral)

II. Validity: RIP R = Rotation judged with respect to clavicles

I = Inspiration adequate equals 9 to 10 ribs bilaterally

P = Penetration (=Exposure) assess with respect to vertebral spine should see intervertebral spaces to mid-thorax

III. Systematic Approach Must cover all major structures Consider Eccentric Circles approach Preffered approach

1. Clinical Context 2. Validity 3. Bones & Soft Tissues 4. Diaphragms 5. Cardiac Silhouette 6. Mediastinum 7. Lungs

a. Hilum b. Parenchyma c. Pleura

8. Interpretation

IV. Bones & Soft Tissue Relatively low yield unless clinical history indicates otherwise Inspect bones for lucency, old/new fractures Beware of costochondral calcifications Consider extra-pulmonic soft tissue densities

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Osteoblastic Osteolytic Mixed Other Cause Osteoblastic

Prostate Ca Multiple Myeloma Breast Ca OA Hodgkins Renal Ca GI Malignancies TB Lymphoma Thyroid Ca Pagets Disease Bone Sarcomas

V. Diaphragms Observe for relative symmetry Right is one rib-breadth higher than left Follow contour carefully, especially to costophrenic angels Observe lateral x-ray carefully for posterior costophrenic sulcus Look for silhouette sign

VI. Heart Primarily focus on enlargement using both views Cardiomegaly: cardiac diameter > widest thoracic diameter Beware of silhouetting Left Side (of CXR) Right Side of (CXR)

Azygos Vein (SVC) Aortic Knob Ascending Aorta Left Hilum Right Hilum Left Atrium Right Atrium Left Ventricle Cardiac Fat Pad Cardiac Fat Pad

VII. Mediastinum Beware of widening or asymmetry Lateral view is very helpful in assessing fullness in the retrosternal clear-space Look for shifting of the mediastinum due to either mass effect or volume loss

VIII. Lungs A. Hilum

complex tangle of veins, arteries, and bronchi left hilum is higher than the right look for calcifications note non-calcified adenopathy

B. Parenchyma normal lung parenchymal markings consist only of vasculature look for tapering of vasculature look at redistribution of vasculature infiltrate is a very nonspecific but nevertheless useful term localize infiltrate (look for silhouetting) describe infiltrate as appropriately as possible

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air bronchograms? Kerley B lines? Examples: Airspace (lobar) pneumonia interstitial Bronchopneumonia Pneumococcus Mycoplasma Aspiration Klebsiella

C. Pleura look for visceral/parietal separation and clear demarcation of visceral pleura in a

pneumothorax look for pleural thickening or scarring

IX. Interpretation summarize findings in general terms generate a differential diagnosis based upon findings and clinical history formulate further diagnostic or therapeutic plan

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Clinical Case Addendum

I. Interstitial Lung Disease findings: inflammation and/or fibrosis reticulonodular pattern

reticular = fine linear densities nodular = rounded densities (nodules) honeycombing = coarse reticular pattern, with airspaces >5mm diameter

Examples:

nodular reticular reticulonodular military TB asbestosis sarcoidosis silicosis drug-induced (e.g. bleomycin)

II. Obstructive Lung Disease findings: vary depending upon airway obstruction (bronchitis, asthma) vs. destruction

(emphysema). best defined by pulmonary function testing

typical findings; gyperlucent lungs, flattened diaphragms, chest enlargement, pruning of pulmonary vessels (I.e. pulmonary hypertension).

Examples:

Emphysema COPD Zebras: Alpha 1 antirypsin deficiency (early age) Cystic Fibrosis (early age, pseudomonas) Kartegeners Syndrome (triad: situs inversus, chronic sinusitis, infertility)

III. Pneumonias Immunocompetent Host:

A. lobar or airspace pneumonia (little airway inflammation, alveoli fill with inflammatory cells) 1. pneumococcal 2. klebsiella chronic alcoholic, currant jelly sputum 3. staphylococcal B. bronchopneumonia (usually no air bronchograms) 1. staph. Aureus pneumatoceles 2. aspiration pneumonia can lead to necrotizing lung abscess empyema

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C. interstitial Pneumonia 1. mycoplasma 2. legionella

Immunocompormised Host: Examples: A. aspergillosis (nodular, cavitary) B. pneumocystis (diffuse) C. CMV (diffuse) D. Drug-induced (diffuse)

Caveat: dont forget CHF as a cause of pneumonia in the immunocompromised patient

IV. Hemoptysis

Findings: Normal CXR most common. Clinical history is paramount. Blood initially looks like fluid; resorption in 2-3 days results in a reticular pattern with RBCs degraded by macrophages in the interstitium and lymphatics. Within 2 weeks, CXR may return to normal.

Examples: Disease Process CXR Finding(s) Bronchogenic carcinoma solitary lesions without calcifications

Tuberculosis apical infiltrates (especially RUL, scarring)

hemoptysis and renal disease: consolidation with hemorrhage, Goodpastures which evolves into chronic Wegeners Granulomatosis interstitial fibrosis SLE or other Collagem Vascular Disease

Pulmonary embolism Hamptons Hump: wedge shaped infiltrate With its base along the pleural surface Westermark: cut-off sign

V. Cardiovascular

Disease Process CXR Finding(s) pulmonary hypertension pruning of pulmonary vessels prominent RV, RA

mitral regurgitation prominent LA, LV: possible mitral valve calcification

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mitral stenosis LA enlarged: increased pulmonary vasculature

aortic regurgitation LV enlargement

aortic stenosis LV enlarge: calcified aortic valve: prominent aorta

hypertension LV hypertrophy: prominent tortuous aorta

congestive heart failure LV enlarged: pulmonary vessel engorgement: Kerley B lines: cephalization of pulmonary vasculature

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Bibliography

1. Chest X-Ray in Primary Care. A Multimedia CME Program and Resource. Appleton & Lange New Media. PO Box 120041. Stamford, CT 06912-0041. 1-800-423-1359. Order via www.medinfosource.com ($149 personal/institutional)

2. Squires L. Fundamentals of Radiology. Cambridge, MA: Harvard University Press, 1975.

3. Bates BA. Guide to Physical Examination. Philadelphia, PA: Lippincott, 1979.

4. Macklis RM, et al. Manual of Introductory Clinical Medicine. Boston/Toronto: Little, Brown and Company, 1984.

5. Felson B, et al. Principles of Chest Roentgenology. Philadelphia, PA: W.B. Saunders, 1965.

6. Friedman M. Clinical Imaging. New York, NY: Churchill Livingston, 1988.

7. Krone KD, Weiner SA. How to Read a Chest X-Ray. Hospital Medicine. May 1988:137-172.

8. Squire L, et al. Exercises in Diagnostic Radiology: The Chest. Philadelphia, PA. W.B. Saunders, 1970.

9. Fanta CH. Clinical Case Presentation: Chest X-Ray Refresher. Harvard medical School CME Conference, 1991.

1Chest X-Ray Interpretation: A Simplified Approach

Eugene Orientale, Jr. MD

Program Director; Professor in Family Medicine

University of Connecticut / St. Francis Hospital Family

Medicine Residency Program

2013 National Conference of Family Medicine

Residents and Medical Students

August 1-3, 2013

All images are the property of Eugene Orientale, Jr, MD

2Workshop Format

Pretest 10 minutes

CXR Basics 10 minutes

CXR Algorithm 60 minutes

With Clinical Vignettes

Pretest revisited 10 minutes

Pretest: Question 1

3Pretest: Question 2

Pretest: Question 3

Pre-Treatment

PA and Lateral

Post-Treatment

PA and Lateral

4Pretest: Question 4

Pretest: Question 5

5Pretest

Please complete multiple choice questions 6-10

1 minute per question

All answers will be given at workshop

conclusion

CXR Basics

Who is the patient?

Why was the test ordered?

Relevant clinical history?

Check name, date on CXR

Establish plane of projection (AP vs. PA)

Obtain old films

6CXR: Normal

Key Point:Density: Bone > [Tissue + Fluid] > Fat > Air

CXR Validity

What constitutes a good Chest X Ray?

7CXR Validity: RIP

Rotation

Are the clavicles oriented in midline?

Inspiration

9-10 posterior ribs

6 anterior ribs

Penetration

Synonymous with exposure

Assess with respect to vertebral spine

Can the vertebrae be seen to the mid-thorax?

CXR: Normal

8AP Chest X-Ray

Key Point:AP = Widened, dumb-belled shaped ends of clavicles; No accompanying lateral view

Approach to CXR Interpretation

Typical errors:

No clinical history

Validity disregarded

Type of film not assessed

Lungs looked at first

Common omissions

Soft tissues and bones

Diaphragm

Mediastinum

Pleura

9CXR Algorithm

Clinical context

Validity: RIP

Eccentric Circles Approach

Bones and soft tissues

Diaphragms

Cardiac silhouette

Mediastinum

Lungs (Hilum, Parenchyma, Pleura)

Interpretation

CXR: Normal

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Bones and Soft Tissues

Relatively low yield unless clinical history

indicates otherwise

Inspect bones for lucency, old/new fractures

Beware of costochondral calcifications

Consider extra-pulmonic soft tissue

densities

32 yo male s/p MVA, unrestrained driver, thrown from vehicle. Confused, intoxicated at scene. Brought in by paramedics, agitated and combative.

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35 y.o. female complaining of chest wall discomfort. Hx of GSW 10 years prior.

Hemi-Diaphragms

Observe for symmetry

Right is higher (one rib breadth)

Think of liver pushing up right while heart

weighs down left

Follow contour to costophrenic angles

Look at lateral, esp. posterior costophrenic

sulcus

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CXR: NormalNote diaphragmatic relationships

60 yo male s/p right pneumonectomy for lung cancer

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Cardiac Silhouette

Patients Right

Azygos to SVC

Ascending Aorta

Right Hilum

Right Atrium

Cardiac Fat Pad

Patients Left

Aortic Knob

Left Hilum

Left Atrium

Left Ventricle

Cardiac Fat Pad

CXR: Normal

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50 yo female smoker, 30 pack year history

Mediastinum

Beware of widening or asymmetry

Lateral view helpful in assessing fullness in the retrosternal clear space

Look for shifting due to

Mass effect

Volume loss

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Mediastinal widening in a 60 year old smoker due to a tortuous uncoiled aorta

75 yo German female s/p radiation therapy for lung cancer: RT received in Germany without a tissue diagnosis.

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Lungs

Hilum

Parenchyma

Pleura

Hilum

Complex tangle of

veins, arteries, and

nerves

Look for calcifications

Note non-calcified

adenopathy

Left hilum is higher than

the right

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Parenchyma

Normal lung markings

consist only of

vasculature

Tapering of vasculature:

think branches or roots

of a tree

Look at redistribution

of vasculature

Parenchyma

Infiltrate is a

nonspecific term

Describe features of

infiltrate

Localize infiltrate

Example of a right middle lobe infiltrate: Note Silhouetting of the right heart border.

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Important Radiologic Terms

Silhouetting

Absence or loss of an

interface when objects

of equal density are

adjacent to one

another.

Air Bronchograms

Air filled bronchiolar tree

becomes visible when

edema (or thickening) of

the bronchiolar walls

occurs.

Trachea is best example

of an air bronchogram in

a normal CXR.

55 yo female smoker needing CXR for employment physical. Diagnosis: Solitary pulmonary nodule

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Pleura

Look for visceral /

parietal separation and

clear demarcation of

visceral pleura in setting

of pneumothorax

Look for pleural

thickening or scarring

20 yo male smoker with acute onset dyspnea

Pretest: Question 1

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Pretest: Question 2

Pretest: Question 3

Pre-Treatment

PA and Lateral

Post-Treatment

PA and Lateral

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Pretest: Question 4

Pretest: Question 5

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Pretest Answers

6. A chest x-ray film that is unexposed to x-ray

radiation, if developed, appears:

a. white

7. In a normal CXR, pulmonary (lung) markings

represent

c. pulmonary arteries

d. pulmonary veins

Pretest Answers

8. Best three landmarks for mediastinal shift

a. trachea

b. aortic knob

c. right atrium

9. Causes of mediastinal shift

All are correct:

a-c. by mass effect

d-f. by volume loss

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Pretest Answers

10. Which must be assessed before establishing

the validity of a CXR?

a. adequacy of inspiration

b. degree of penetration (exposure)

c. rotation, judged with respect to the

clavicles

e. name and date on film

Contact Information

Eugene Orientale, Jr. MD

Program Director

University of Connecticut / St Francis

Family Medicine Residency Program

Hartford, CT

Work: 860-714-6738

FAX: 860-714-8079

Webpage: http://uconnfamilymedicine

Email: eorienta@stfranciscare.org

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