Diagnostic Radiographs Basic CXR Interpretation
Marc Imhotep Cray, M.D.
Introduction Review of normal chest x-ray Administrative Initial survey
2
Review of normal chest x-ray A systematic approach to film review is most important skill to developďƒ major areas of should be viewed in a sequential order
3
Review of Normal CXR (2) Sequenced Checklist: 1. Check patient name, position, technical quality 2. Soft tissue including breast, chest wall, companion shadow 3. Review soft tissues and skeletal structures of shoulder girdles and chest wall 4. Review abdomen for bowel gas, organ size, abnormal calcifications, free air, etc. 5. Review soft tissues and spine of neck
4
Review of Normal CXR (3) Sequenced Checklist: 6. Review spine and rib cage: check alignment, disc space narrowing, lytic or blastic regions, etc. 7. Review mediastinum: a. overall size and shape b. trachea: position c. margins: SVC, ascending aorta, right atrium, left subclavian artery, aortic arch, main pulmonary artery, left ventricle d. lines and stripes: paratracheal, paraspinal, paraesophageal (azygoesophageal), paraaortic e. retrosternal clear space
5
Review of Normal CXR (4) Sequenced Checklist: 8. Review hila: a. normal relationships b. size
9. Review lungs and pleura: a. compare lung sizes b. evaluate pulmonary vascular pattern: compare upper to lower lobe, right to left, normal tapering to periphery c. pulmonary parenchyma d. pleural surfaces • • •
fissures - major and minor - if seen compare hemidiaphragms follow pleura around rib cage 6
Administrative Get in habit of always checking following items before anything elseďƒ takes a few seconds and is an important legal safe guard as well 1. Patient's name 2. Date exam done (very important if comparing prior exams) 3. Check for position markers right vs. left, upright 7
Administrative (2) Other items to check before commencing w clinical review of film include: 1.Type of film (practice noticing if it is a plain film, CT, angio, MRI, etc.) 2.Patients position - supine, upright, lateral, decubitus 3.Technical quality of exam - learn what are acceptable limits for examďƒ Ex. You can't find a subtle pneumothorax if there is patient motion or the film is overexposed.
8
Administrative (3) A basic principle to adopt going from general observations to specific details sometimes a change may be so major that old saying “missing the forest for the trees” comes true o For instance, an absent breast shadow on a film of a patient after a mastectomy
After completing your administrative housekeeping, get a general overview of film before zooming in on tiny detail
9
Administrative (4)  Notice following b/c may change baseline normals you use as reference points, and you may be sensitized to look for specific findings 1.General Body Size, Shape, and Symmetry 2.Male vs. Female 3.Is this an infant, child, young adult, elderly person? 4.Survey for foreign objects - tubes, IV lines, EKG leads, surgical drains, prosthesis, etc., as well as non-medical objects, bullets, shrapnel, glass, etc.
10
The Chest X-Ray
Following radiographic plates are scan-ins from: Felson, B., et al.: Principles of Chest Roentgenology. Philadelphia, W.B. Saunders Co., 1973. Fraser, R., et al.: Diagnosis of Diseases of the Chest, 3rd edition. Philadelphia, W.B. Saunders Co., 1988.
11
Discussion Outline •Densities •Techniques •Anatomy •CXR Interpretation •Common Pathologies
12
Densities The big two densities are: (1) WHITE - Bone (2) BLACK - Air The others are: (3) DARK GREY- Fat (4) GREY- Soft tissue/water And if anything Man-made is on film, it is: (5) BRIGHT WHITE – Man made 13
Techniques - Projection P-A (relation of x-ray beam to patient)
14
Techniques – Projection cont’d. Lateral
15
Techniques - Projection cont’d. Lateral Decubitus
16
“The A-B-C-D Sequence” Assessment Assess quality of film using mnemonic PIER: Position: Is this a supine AP film? PA? Lateral? Inspiration: Count posterior ribs. You should see 8–9 ribs with a good inspiratory effort Exposure: Well-exposed films have good lung detail and show a detailed outline of spinal column. Overpenetration leads to a dark film with more spinal detail. Underpenetrated films are whiter with little spinal detail. Rotation: Space between medial clavicle and margin of adjacent vertebrae should be roughly equal on each side.
Also look for indwelling lines or objects (eg, endotracheal tube, feeding tube, airway obstruction) that may reveal clues to pathology in film 17
Penetration (Exposure)
Underpenetrated
Overpenetrated 18
Inspiration/Expiration
19
Rotation
20
Rotation cont’d.
21
Anatomy
22
Anatomy
23
Anatomy
24
Lobes Right upper lobe:
25
Lobes cont’d. Right middle lobe:
26
Lobes cont’d. Right lower lobe:
27
Lobes cont’d. Left lower lobe:
28
Lobes cont’d. Left upper lobe with Lingula:
29
Lobes cont’d. Lingula:
30
Lobes cont’d. Left upper lobe - upper division:
31
Heart Right border: Edge of (r) Atrium 2. Left border: (l) Ventricle + Atrium 3. Posterior border: Left Ventricle 4. Anterior border: Right Ventricle 32
Heart cont’d
33
Heart cont’d. Valves
34
Mediastinum
35
Hilum Made of: 1. Pulmonary Art. + Veins 2. The Bronchi Left Hilus higher (max 1-2, 5 cm) Identical: size, shape, density
36
Ribs
37
Lateral CXR
38
Lateral CXR cont’d. Tracheoesophageal Stripe
39
Lateral CXR cont’d.
40
CXR Interpretation
41
Technical Details • Type • Orientation • Rotation • Inspiration/expiration • Penetration To be studied along side Reading Chest X-Ray Notes.pdf (“The A-B-C-D Sequence”) 42
Lungs: •Lungs • Density • Symmetry • Lesions
43
Heart Size:
44
Heart • Size of heart • Size of individual chambers of heart • Size of pulmonary vessels • Evidence of stents, clips, wires and valves • Outline of aorta and IVC and SVC
45
Mediastinum:
• Width • Contour • AP window • Size • Location
46
Review areas: • • • • • • •
Apices Behind the heart CP angles Below diaphragm Soft tissues ( breast, surgical emphysema) Ribs & clavicle Vertebrae
47
Identify the lesion → localize lesion → describe lesion → give a DDx Never stop looking, carry on w your systematic approach!!
48
Pathology Following radiographic plates are scan-ins from: Felson, B., et al.: Principles of Chest Roentgenology. Philadelphia, W.B. Saunders Co., 1973. Fraser, R., et al.: Diagnosis of Diseases of the Chest, 3rd edition. Philadelphia, W.B. Saunders Co., 1988.
49
RUL pneumonia
50
RML pneumonia
51
RLL pneumonia
52
LUL pneumonia
53
LLL pneumonia
54
• Consolidation on CT
55
Hilar mass
56
The Enlarged Hila • Causes: 1. Adenopathies (neoplasia, infection) 2. Primary Tumor 3. Vascular 4. Sarcoidosis 57
• Multiple Masses 58
Hilar Lymphadenopathy - BL 59
Hilar Lymphadenopathy - BL
60
Pleural Effusion 61
Pulmonary Fibrosis
62
Heart failure
63
Pneumothorax
64
RUL collapse 65
LLL collapse 66
Air under diaphragm
67
Emphysema
68
Cavitating lesion
69
Hiatus hernia
70
Miliary shadowing
71
Chest Tube, NG Tube, Pulm. artery cath. 72
See next slide for links to tools and resources for further study.
73
Further study: IVMS CXR Video Education Cloud folder Reading Chest X-Ray Notes.pdf (“The A-B-C-D Sequence”) eBook Eng P, Cheah KF. Interpreting Chest X-Rays: 100 Illustrated Cases. Cambridge: Cambridge University, 2005. Radiology Online Study Resources: RadiologyEducation.com, curated by Michael P. D'Alessandro, M.D. http://www.radiologyeducation.com/
74