Overview of Thoracic Radiography - Squarespace · PDF fileOverview of Thoracic Radiology Paul...
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Overview of Thoracic Radiology
Paul M. Rist, DVM, Dipl. ACVR
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Common Indications
Coughing
Dyspnea/ tachypnea
Suspect heart disease
Cancer staging (met check)
Trauma
Exercise intolerance
Weight loss
Collapse
Chest wall abnormality
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Radiographic Technique
High kilovoltage peak (kVp)
– Lungs have inherent high contrast
– Goal is to spread out grayscale latitude
Low mAs
– Highest mA possible
– Allows shortest (fastest) time
Minimize respiratory motion
<1/30 second
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Radiographic Technique
Technique chart
Sedate – Severely dyspneic/ debilitated patients are
exceptions
– DO NOT do chest rads under anesthesia unless that is the only way possible
Maximize non-manual restraint – Tape the feet
– Sandbags
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Standard Projections
Two orthogonal views standard
– L or R lateral projection
Views named by recumbent side
– VD or DV projection
Views named by beam entry-exit direction
– All views taken at peak inspiration
– Be consistent in your “standard 2-view” choices
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Standard Projections
Three views as needed
– Both laterals and VD/DV
– Metastasis, pneumonia
– Anytime a mass, nodule or infiltrate is suspected!
– If in doubt, do three views
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Importance of Both Lateral Views
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Determining Proper Positioning
Lateral
– Legs pulled forward
– Center on heart or caudal edge of scapula
– Include thoracic inlet to last rib
– Rib heads superimposed
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Determining Proper Positioning
VD or DV
– Legs pulled forward
– Center on heart
– Thoracic inlet to last rib
– Spine superimposed on sternum
Teardrop-shaped dorsal spinous processes
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Determining the Phase of Respiration
Always expose at peak inspiration – Maximizes lung contrast
– Reduces one variable
– Inspiratory lateral view Caudodorsal aspect of lung caudal to T12
Increased aeration of accessory lung lobe
Separation of heart silhouette and diaphragm
– Inspiratory VD/DV view Diaphragmatic cupola cd to mid T8
Lung tips caudal to T10
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Inspiratory vs. Expiratory Lateral
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Inspiratory vs. Expiratory VD
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Determining Proper Exposure
Is it dark enough?
– Should be able to see individual vertebrae
Is it too dark?
– Should be able to see peripheral pulmonary vessels with naked eye
Correcting a bad exposure
– Minor-- change kVp +/- 10% (usu. 5-8 kVp)
– Major– double or half mAs
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Quality Control
Redo rads for the following reasons – Under or over exposure
– Not at peak inspiration
– Poor positioning
– Part of thorax omitted
– Motion
The likelihood of a diagnosis is strongly dependent on quality (even if you send them to a radiologist)
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Right Lateral Projection
Right lateral recumbency
– Heart more egg-shaped
– Diaphragmatic crura parallel
Right crus always cranial
Cd vena cava silhouettes with right crus
– Overlap of L and R cranial lobar vessels
– Air in fundus
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Left Lateral Projection
Left lateral recumbency
– Heart more circular
Apex lifts dorsally
– Crura diverge dorsally
Left crus usually cranial
Right crus is caudal but still silhouettes with cava
– Less overlap of L and R cranial lobar vessels
– Air in pylorus
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The Effects of Lateral Recumbency
Lung lesions (mass, nodule, infiltrate) may only be seen on 1 view!!!
Only the non-dependent (up) lung can be critically evaluated
– Dependent lung loses aeration (atelectasis)
Increases in opacity
Silhouettes with lesions
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Ventrodorsal Projection
Dorsal recumbency – Positioned in trough
More consistent results
Tough on dyspneic patients
– Heart more elongated
– Diaphragm appears flatter Crura superimposed on
cupola – “Mickey mouse” ears
– Aortic/ MPA enlargement more apparent
– Accessory lung lobe better aerated
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Dorsoventral Projection
Sternal recumbency
– Positioned directly on table
Tough to get straight
Better for dyspneic/ difficult patients
– Heart more oval due to upright position
– Diaphragm more elongated
– Caudal pulmonary vessels better visualized
Magnification (increased distance from cassette)
Increased aeration of caudal lung lobes
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Comparison of VD and DV Views
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Special Views
Oblique VD – Evaluate rib/
chest wall masses
Horizontal beam – Position patient
to move pleural fluid away from area of interest Cranial
mediastinal mass
Lung mass
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Interpretation of Thoracic Radiographs
Develop your own routine
Systematically evaluate everything on every view
Evaluate a specific structure simultaneously on both views (i.e. assess heart on lat and VD before moving on to cranial mediastinum)
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Interpretation of Thoracic Radiographs
My “from the inside out” routine (in this order)
– Heart and great vessels (middle mediastinum)
– Cranial and caudal mediastinum
– Lungs including pulmonary vessels and pleura
– Extrathoracic structures
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Heart and Great Vessels
Middle mediastinum
– Heart, Aortic arch, Ascending aorta, MPA, Tracheobronchial LN’s
Dogs
– Breed (and hence chest) conformation influences apparent size
– Deep chested (Dobes)
Heart appears small on LAT compared to chest size
Upright and therefore rounded on VD
– Barrel chested (Dachshunds)
Heart appears large on LAT compared to chest size
Normal size on VD
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Heart and Great Vessels
Cardiac size (dogs) – Lateral
2.5-3.5 ICS wide – Measure at widest
point
Approximately 2/3 height of thorax
Trachea should diverge ventrally from spine
– VD/ DV ½ to 2/3 width of chest
More elongated on VD
Apex on L side
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Heart and Great Vessels
Cardiac size (cats)
– Lateral
2-3 ICS wide
Measure perpendicular to apex/ carina axis
– Heart tilts cranially with increasing age
– VD/ DV
½ to 2/3 width of thorax
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Location of Specific Cardiac Chambers--Dog
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Clock Face Analogy
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Location of Specific Cardiac Chambers--Cat
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Pitfalls of Cardiac Radiology
Radiographs are insensitive for assessing heart size – May be normal with severe cardiac disease
– Overlap of ST structures
– Wide variation in “normal”
– Chamber walls may severely thicken without visible change in cardiac silhouette size HCM in cats
Echocardiography if cardiac dz suspected
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Cranial Mediastinum
Space between pleural sacs – Trachea
– Multiple structures silhouette Esophagus
Brachiocephalic and L subclavian arteries
Cranial vena cava
Thymus
Sternal/ mediastinal lymph nodes
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Cranial Mediastinum
Structures sometimes visible
– Esophagus
Fluid or air filled
– Thymus
Young animals
“Sail sign” on VD
– Sternal/ mediastinal lymph nodes
Lymphadenopathy
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Caudal Mediastinum
Visible structures
– Caudal vena cava
– Descending aorta
– +/- Esophagus
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Lungs
Normal anatomy
– Left
Cranial (cranial subsegment)
Cranial (caudal subsegment)
Caudal
– Right
Cranial
Middle
Caudal
Accessory
– There is no dorsocaudal lung lobe!
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Lungs
Normal lung boundaries
– 4th to 5th ICS on VD
Fissure b/w L cranial lung subsegments
Fissure b/w R cranial and middle lung lobes
– 6th to 7th ICS on VD
Fissure b/w L cranial and caudal lobes
Fissure b/w R middle and caudal lobes
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Lungs
Regions of a specific lung lobe
– Perihilar (hilar)
– Midzone
– Periphery
Distribution of disease may lead to etiology
– Edema
– Pneumonia
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Pulmonary Patterns
Interstitial
– Structured or unstructured
Alveolar
Bronchial
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Pulmonary Patterns
Interstitial
– Structured (nodular)
Nodules (<3cm)
– Must be at least 5mm to be visible if soft tissue
– Smaller mineralized nodules may be visible
Masses (>3cm)
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Structured or Nodular Interstitial Pattern
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Pulmonary Patterns
Interstitial
– Unstructured
Fluid, cells, scarring in connective tissue
Lungs more opaque
Blurred but visible vascular margins
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Unstructured Interstitial Pattern
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Pulmonary Patterns
Alveolar – Consolidation
Alveoli filled with blood, pus, edema, or other infiltrate
– Atelectasis Collapse of alveoli
– Radiographs Silhouetting of soft tissue structures
+/- Air bronchograms – Bronchial lumen remains filled with air
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Alveolar Pattern
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Bronchial Pattern
Increased visualization of bronchial wall
– Bronchial wall thickening
– Peribronchial infiltrate
Increased soft tissue adj to bronchus
– Radiographs
“Tram tracks and donuts”
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Bronchial Pattern
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Pulmonary Vasculature
Disregard the use of “vascular pattern”
Artery-bronchus-vein relationship
– Veins are “ventral and central” to bronchus
– Arteries are dorsal and lateral to bronchus
Mild asymmetry OK
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Pulmonary Vasculature
Normal vascular sizes
– Deciding if they’re too big…
Cranial lobar arteries and veins
– Diameter < width of proximal 4th rib on LAT view
Caudal lobar arteries and veins
– Diameter < width of 9th rib where vessel crosses rib on VD view
– Deciding if they’re too small…
Vessels should be >=to half the rib width
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Normal Pulmonary Vessels
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Pulmonary Vasculature
Type of vascular changes may indicate etiology
– A few examples
Caudal lobar arteries may be dilated with HWD
Large veins may indicate LHF
Small vessels with dehydration
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Pleura
Two layers
– Parietal
Lines thoracic wall and diaphragm
– Visceral
Lines outer lung surface
– Pulmonary (pleural) fissure lines sometimes visible
Pleural thickening in older patients
Fluid or air in pleura space
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Extrathoracic Structures
Sternum
Vertebrae
Ribs
Adjacent soft tissues
Diaphragm
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Extrathoracic Structures
Extrathoracic changes may indicate cause of intrathoracic findings
– Examples
Pneumothorax
– Rib fractures may suggest secondary to trauma
Pleural effusion secondary to rib or chest wall mass
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The Limitations of Thoracic Radiography
Multiple soft tissue structures silhouetting
“Snapshot” in time
– Radiographic changes may lag behind disease
Poor assessment of cardiac enlargement
Pleural effusion may obscure normal or abnormal structures
– Repeat rads after thoracocentesis
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The Strengths of Thoracic Radiography
Cheap and easy
Good screening exam
– Lungs and extrathoracic tissues
– Determine if other procedures are necessary
Valuable for assessing cardiac failure
***Ultrasound cannot penetrate air, but X-rays can
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