Chest Radiography Interpretation: Reading Chest Films
Chest Radiography Chest Radiography Interpretation: Interpretation: Reading Chest FilmsReading Chest Films
Lisa Chen , M.D.Assistant Clinical Professor
Pulmonary and Critical Care DivisionDepartment of Medicine
San Francisco General Hospital
Michael Gotway, MDAssociate Clinical Professor, RadiologyUniversity of California, San Francisco
Approach to the CXR:Technical Aspects
Approach to the CXR:Approach to the CXR:Technical AspectsTechnical Aspects
Inspiratory effort 9-10 posterior ribs
Penetration thoracic intervertebral disc space just visible
Positioning/rotationmedial clavicle heads equidistant to spinous
process
Inspiratory effort 99--10 posterior ribs10 posterior ribs
Penetration thoracic intervertebral disc space just visiblethoracic intervertebral disc space just visible
Positioning/rotation medial clavicle heads equidistant to spinous medial clavicle heads equidistant to spinous
processprocess
Low Lung VolumesLow Lung Volumes
Over ExposureOver Exposure Proper ExposureProper Exposure
101010
What to EvaluateWhat to EvaluateWhat to Evaluate
Lungs Pleural surfaces Cardiomediastinal contours Bones and soft tissues Abdomen
Lungs Pleural surfaces Cardiomediastinal contours Bones and soft tissues Abdomen
Where to LookWhere to LookWhere to Look
Apices Retrocardiac areas (left and right) Below diaphragm
Apices Retrocardiac areas (left and right) Below diaphragm
Apical TBApical TB
Left Left RetrocardiacRetrocardiac OpacityOpacity
Normal Anatomy: Frontal CXRNormal Anatomy: Frontal CXRNormal Anatomy: Frontal CXR
Heart Aorta Pulmonary arteries Airways Diaphragm/costophrenic sulci Junction lines
Heart Aorta Pulmonary arteries Airways Diaphragm/costophrenic sulci Junction lines
Normal Anatomy: LateralNormal Anatomy: LateralNormal Anatomy: Lateral
Heart Aorta Pulmonary arteries Airways Spine
Heart Aorta Pulmonary arteries Airways Spine
AAAA
RVRV
LVLV
Chest Radiography: Basic Principles
Chest Radiography: Chest Radiography: Basic PrinciplesBasic 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
X-ray photon fates: completely absorbed in patientcompletely absorbed in patient transmitted through patient; strike filmtransmitted through patient; strike film scattered within patient; strike filmscattered within patient; strike film
X-ray absorption depends on: beam energy (constant)beam energy (constant) tissue densitytissue density
Maximum xMaximum x--rayrayTransmissionTransmission
(least dense tissue)(least dense tissue)
Maximum xMaximum xray ray AbsorptionAbsorption
(densest tissue)(densest tissue)
BlackestBlackest
airair
fatfat
soft tissuesoft tissue
calciumcalcium
bonebone
xx--ray contrastray contrast
metalmetal
WhitestWhitest
All cardiothoracic pathology and normal anatomy is visualized (or not) by 7 different densities
How is this accomplished? differential x-ray absorption
All cardiothoracic pathology and normal anatomy is visualized (or not) by 7 different densities
How is this accomplished? differential xdifferential x--ray absorptionray absorption
Chest Radiography: Basic Principles
Chest Radiography: Chest Radiography: Basic PrinciplesBasic Principles
A structure is rendered visible on a radiograph by the juxtaposition of two different densities
A structure is rendered visible on a radiograph by the juxtaposition of two different densities
Differential X-Ray AbsorptionDifferential XDifferential X--Ray AbsorptionRay Absorption
Silhouette SignSilhouette SignSilhouette Sign
Loss of the expected interface normally created by juxtaposition of two structures of different density
No boundary can be seen between two structures of similar density
Loss of the expected interface normally created by juxtaposition of two structures of different density
No boundary can be seen between two structures of similar density
Right Lower Lobe PneumoniaRight Lower Lobe Pneumonia
Differential X-Ray AbsorptionDifferential XDifferential X--Ray AbsorptionRay 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
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
Chest Radiographic Patterns of DiseaseChest Radiographic Chest Radiographic Patterns of DiseasePatterns of Disease
Air space opacity Interstitial opacity Nodules and masses Lymphadenopathy Cysts and cavities Lung volumes Pleural diseases
Air space opacity Interstitial opacity Nodules and masses Lymphadenopathy Cysts and cavities Lung volumes Pleural diseases
Cardiomediastinal contour abnormalities Bone and soft tissue abnormalities Below the diaphragm: abdominal and
retroperitoneal disease
Cardiomediastinal contour abnormalities Bone and soft tissue abnormalities Below the diaphragm: abdominal and
retroperitoneal disease
Chest Radiographic Patterns of DiseaseChest Radiographic Chest Radiographic Patterns of DiseasePatterns of Disease
Air Space OpacityAir Space OpacityAir Space Opacity
Components: air bronchogram: air-filled bronchus
surrounded by airless lung confluent opacity extending to pleural
surfaces segmental distribution
Components: air air bronchogrambronchogram: air: air--filled bronchus filled bronchus
surrounded by airless lungsurrounded by airless lung confluent opacity extending to pleural confluent opacity extending to pleural
surfacessurfaces segmental distributionsegmental distribution
Air Space Opacity: DDXAir Space Opacity: DDXAir Space Opacity: DDX
Blood (hemorrhage) Pus (pneumonia) Water (edema) hydrostatic or non-cardiogenic
Cells (tumor) Protein/fat: alveolar proteinosis and
lipoid pneumonia
Blood (hemorrhage) Pus (pneumonia) Water (edema) hydrostatic or nonhydrostatic or non--cardiogeniccardiogenic
Cells (tumor) Protein/fat: alveolar proteinosis and
lipoid pneumonia
LUL PneumoniaLUL Pneumonia
Interstitial OpacityInterstitial OpacityInterstitial Opacity
Hallmarks: small, well-defined nodules lines interlobular septal thickening fibrosis
reticulation
Hallmarks: small, wellsmall, well--defined nodulesdefined nodules lines lines interlobular septal thickeninginterlobular septal thickening fibrosisfibrosis
reticulationreticulation
Interstitial Opacity: Small NodulesInterstitial Opacity: Small Nodules
Interstitial Opacity: Interstitial Opacity: LinesLines
Interstitial Opacity: Lines & ReticulationInterstitial Opacity: Lines & Reticulation
Interstitial Opacity: DDXInterstitial Opacity: DDXInterstitial Opacity: DDX
Idiopathic interstitial pneumonias Infections (TB, viruses) Edema Hemorrhage Noninfectious inflammatory lesions sarcoidosis
Tumor
Idiopathic interstitial pneumonias Infections (TB, viruses) Edema Hemorrhage Noninfectious inflammatory lesions sarcoidosissarcoidosis
Tumor
Nodules and MassesNodules and MassesNodules and Masses
Nodule: any pulmonary lesion represented in a radiograph by a sharply defined, discrete, nearly circular opacity 2-30 mm in diameter
Mass: larger than 3 cm
Nodule: any pulmonary lesion represented in a radiograph by a sharply defined, discrete, nearly circular opacity 2-30 mm in diameter
Mass: larger than 3 cm
Nodules and MassesNodules and MassesNodules and Masses
Qualifiers: single or multiple size border definition presence or absence of calcification location
Qualifiers: single or multiplesingle or multiple sizesize border definitionborder definition presence or absence of calcificationpresence or absence of calcification locationlocation
MassMass
CalcificationCalcification
WellWell--DefinedDefined
IllIll--DefinedDefined
LymphadenopathyLymphadenopathyLymphadenopathy
Non-specific presentations:mediastinal widening hilar prominence
Specific patterns: particular station enlargement
Non-specific presentations: mediastinal wideningmediastinal widening hilar prominencehilar prominence
Specific patterns: particular station enlargementparticular station enlargement
Right Paratracheal Right Paratracheal LymphadenopathyLymphadenopathy
Right Hilar LANRight Hilar LAN
Right Hilar LANRight Hilar LAN
Left Hilar LANLeft Hilar LAN
Subcarinal LANSubcarinal LAN
Subcarinal LANSubcarinal LAN
*
AP Window LANAP Window LAN
Cysts & CavitiesCysts & CavitiesCysts & Cavities
Cyst: abnormal pulmonary parenchymal space, not containing lung but filled with air and/or fluid, congenital or acquired, with a wall thickness greater than 1 mm epithelial lining often present
Cyst: abnormal pulmonary parenchymal space, not containing lung but filled with air and/or fluid, congenital or acquired, with a wall thickness greater than 1 mm epithelial lining often presentepithelial lining often present
Cysts & CavitiesCysts & CavitiesCysts & 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
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
Cysts & CavitiesCysts & CavitiesCysts & Cavities
Characterize: wall thickness at thickest portion inner lining presence/absence of air/fluid level number and location
Characterize: wall thickness at thickest portionwall thickness at thickest portion inner lininginner lining presence/absence of air/fluid levelpresence/absence of air/fluid level number and locationnumber and location
Benign Lung Cyst : Benign Lung Cyst : PCPPCP PneumatocelePneumatocele 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 max wall thickness 55--15 mm15 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
Pleural Disease: Basic PatternsPleural Disease: Basic PatternsPleural Disease: Basic Patterns
Effusion angle blunting to massivemobility
Thickening distortion, no mobility
Mass Air Calcification
Effusion angle blunting to massiveangle blunting to massive mobilitymobility
Thickening distortion, no mobilitydistortion, no mobility
Mass Air Calcification
Pleural EffusionPleural Effusion
Pleural EffusionPleural Effusion
Subpulmonic EffusionSubpulmonic Effusion
Pleural CalcificationPleural Calcification
Chest Radiography Interpretation: Reading Chest FilmsApproach to the CXR:Technical AspectsWhat to EvaluateWhere to LookNormal Anatomy: Frontal CXRNormal Anatomy: LateralChest Radiography: Basic PrinciplesChest Radiography: Basic PrinciplesDifferential X-Ray AbsorptionSilhouette SignDifferential X-Ray AbsorptionChest Radiographic Patterns of DiseaseChest Radiographic Patterns of DiseaseAir Space OpacityAir Space Opacity: DDXInterstitial OpacityInterstitial Opacity: DDXNodules and MassesNodules and MassesLymphadenopathyCysts & CavitiesCysts & CavitiesCysts & CavitiesPleural Disease: Basic Patterns
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