1. Interpretation of Chest Radio Graph

Preview:

Citation preview

8/7/2019 1. Interpretation of Chest Radio Graph

http://slidepdf.com/reader/full/1-interpretation-of-chest-radio-graph 1/102

Dr. Anindita Mishra, MD

Associate Professor

Department of Radiodiagnosis

GSL Medical College

8/7/2019 1. Interpretation of Chest Radio Graph

http://slidepdf.com/reader/full/1-interpretation-of-chest-radio-graph 2/102

Introduction

Routinely obtained

Pulmonary specialist consultation

Inherent physical exam limitations

Chest x-ray limitations

Physical exam and chest x-ray provide

compliment

8/7/2019 1. Interpretation of Chest Radio Graph

http://slidepdf.com/reader/full/1-interpretation-of-chest-radio-graph 3/102

Essentials Before Getting Started

Exposure

 –  Overexposure

 –  Underexposure

Sex of Patient

 –  Male

 –  Female

8/7/2019 1. Interpretation of Chest Radio Graph

http://slidepdf.com/reader/full/1-interpretation-of-chest-radio-graph 4/102

Path of x-ray beam

 –  PA

 –  AP

Patient Position –  Upright

 –  Supine

8/7/2019 1. Interpretation of Chest Radio Graph

http://slidepdf.com/reader/full/1-interpretation-of-chest-radio-graph 5/102

Breath

 –  Inspiration

 – Expiration

8/7/2019 1. Interpretation of Chest Radio Graph

http://slidepdf.com/reader/full/1-interpretation-of-chest-radio-graph 6/102

Systematic Approach

Bony Framework 

Soft Tissues

Lung Fields and Hila

Diaphragm and Pleural Spaces

Mediastinum and Heart

Abdomen and Neck 

8/7/2019 1. Interpretation of Chest Radio Graph

http://slidepdf.com/reader/full/1-interpretation-of-chest-radio-graph 7/102

Bony Fragments

 –  Ribs

 – Sternum

 –  Spine

 –  Shoulder girdle

 –  Clavicles

8/7/2019 1. Interpretation of Chest Radio Graph

http://slidepdf.com/reader/full/1-interpretation-of-chest-radio-graph 8/102

Soft Tissues

 – Breast shadows

 –  Supraclavicular areas

 –  Axillae

 –  Tissues along side of 

breasts

8/7/2019 1. Interpretation of Chest Radio Graph

http://slidepdf.com/reader/full/1-interpretation-of-chest-radio-graph 9/102

Lung Fields and Hila

 –  Hilum

Pulmonary arteries

Pulmonary veins

 –  Lungs

Linear and fine nodular

shadows of pulmonary vessels

 –  Blood vessels

 –  40% obscured by other tissue

8/7/2019 1. Interpretation of Chest Radio Graph

http://slidepdf.com/reader/full/1-interpretation-of-chest-radio-graph 10/102

Diaphragm and

Pleural Surfaces

 –  Diaphragm

Dome-shaped

Costophrenic angles

 –  Normal pleural is not

visible

 – Interlobar fissures

8/7/2019 1. Interpretation of Chest Radio Graph

http://slidepdf.com/reader/full/1-interpretation-of-chest-radio-graph 11/102

Mediastinum and Heart

Heart size on PA 

Right sideInferior vena cava

Right atrium

Ascending aorta

Superior vena cava

Left side

Left ventricle

Left atrium

Pulmonary arteryAortic arch

Subclavian artery and vein

8/7/2019 1. Interpretation of Chest Radio Graph

http://slidepdf.com/reader/full/1-interpretation-of-chest-radio-graph 12/102

Abdomen and Neck 

 –  Abdomen

Gastric bubble Air under diaphragm

 – 

Neck  Soft tissue mass

Air bronchogram

8/7/2019 1. Interpretation of Chest Radio Graph

http://slidepdf.com/reader/full/1-interpretation-of-chest-radio-graph 13/102

Air

Water

Bone

Tissue

Tissue

8/7/2019 1. Interpretation of Chest Radio Graph

http://slidepdf.com/reader/full/1-interpretation-of-chest-radio-graph 14/102

Pitfalls to Chest X-ray

Interpretation

Poor inspiration

Over or under penetration

Rotation

Forgetting the path of the x-ray beam

8/7/2019 1. Interpretation of Chest Radio Graph

http://slidepdf.com/reader/full/1-interpretation-of-chest-radio-graph 15/102

Lung Anatomy Trachea

Carina

Right and Left

Pulmonary Bronchi

Secondary Bronchi

Tertiary Bronchi

Bronchioles

Alveolar Duct

Alveoli

8/7/2019 1. Interpretation of Chest Radio Graph

http://slidepdf.com/reader/full/1-interpretation-of-chest-radio-graph 16/102

Lung Anatomy

Right Lung

 –  Superior lobe

 –  Middle lobe

 – Inferior lobe

Left Lung

 – Superior lobe

 –  Inferior lobe

8/7/2019 1. Interpretation of Chest Radio Graph

http://slidepdf.com/reader/full/1-interpretation-of-chest-radio-graph 17/102

Lung Anatomy on Chest X-ray

PA View: –  Extensive overlap

 –  Lower lobes extend high

Lateral View:

 –  Extent of lower lobes

8/7/2019 1. Interpretation of Chest Radio Graph

http://slidepdf.com/reader/full/1-interpretation-of-chest-radio-graph 18/102

Lung Anatomy on Chest X-ray

The right upper lobe(RUL) occupies the

upper 1/3 of the right

lung.

Posteriorly, the RUL is

adjacent to the first

three to five ribs.

Anteriorly, the RUL

extends inferiorly as far

as the 4th right anterior

rib

8/7/2019 1. Interpretation of Chest Radio Graph

http://slidepdf.com/reader/full/1-interpretation-of-chest-radio-graph 19/102

Lung Anatomy on Chest X-ray

The right middle lobe

is typically the smallest

of the three, andappears triangular in

shape, being narrowest

near the hilum

8/7/2019 1. Interpretation of Chest Radio Graph

http://slidepdf.com/reader/full/1-interpretation-of-chest-radio-graph 20/102

Lung Anatomy on Chest X-ray The right lower lobe is the

largest of all three lobes,

separated from the others

by the major fissure.

Posteriorly, the RLL extend

as far superiorly as the 6th

thoracic vertebral body,

and extends inferiorly to

the diaphragm.

Review of the lateral plain

film surprisingly shows the

superior extent of the RLL.

8/7/2019 1. Interpretation of Chest Radio Graph

http://slidepdf.com/reader/full/1-interpretation-of-chest-radio-graph 21/102

Lung Anatomy on Chest X-ray These lobes can be separated

from one another by twofissures.

The minor fissure separates

the RUL from the RML, andthus represents the visceral

pleural surfaces of both of 

these lobes.

Oriented obliquely, the major

fissure extends posteriorly

and superiorly approximately

to the level of the fourth

vertebral body.

8/7/2019 1. Interpretation of Chest Radio Graph

http://slidepdf.com/reader/full/1-interpretation-of-chest-radio-graph 22/102

Lung Anatomy on Chest X-ray

The lobar architectureof the left lung is

slightly different than

the right.

Because there is no

defined left minor

fissure, there are only

two lobes on the left;

the left upper

8/7/2019 1. Interpretation of Chest Radio Graph

http://slidepdf.com/reader/full/1-interpretation-of-chest-radio-graph 23/102

Lung Anatomy on Chest X-ray

Left lower lobes

8/7/2019 1. Interpretation of Chest Radio Graph

http://slidepdf.com/reader/full/1-interpretation-of-chest-radio-graph 24/102

Lung Anatomy on Chest X-ray

These two lobes are

separated by a major fissure,

identical to that seen on the

right side, although often

slightly more inferior in

location.

The portion of the left lung

that corresponds

anatomically to the rightmiddle lobe is incorporated

into the left upper lobe.

8/7/2019 1. Interpretation of Chest Radio Graph

http://slidepdf.com/reader/full/1-interpretation-of-chest-radio-graph 25/102

The Normal Chest X-ray

PA View:1. Aortic arch

2. Pulmonary trunk 

3. Left atrial appendage

4. Left ventricle

5. Right ventricle

6. Superior vena cava

7. Right hemidiaphragm

8. Left hemidiaphragm

9. Horizontal fissure

8/7/2019 1. Interpretation of Chest Radio Graph

http://slidepdf.com/reader/full/1-interpretation-of-chest-radio-graph 26/102

The Normal Chest X-ray

Lateral View:

1. Oblique fissure

2. Horizontal fissure

3. Thoracic spine and

retrocardiac space

4. Retrosternal space

8/7/2019 1. Interpretation of Chest Radio Graph

http://slidepdf.com/reader/full/1-interpretation-of-chest-radio-graph 27/102

The Silhouette Sign

An intra-thoracic radio-

opacity, if in anatomic

contact with a border of 

heart or aorta, will obscure

that border. An intra-

thoracic lesion not

anatomically contiguous

with a border or a normal

structure will not obliterate

that border.

8/7/2019 1. Interpretation of Chest Radio Graph

http://slidepdf.com/reader/full/1-interpretation-of-chest-radio-graph 28/102

Putting It All Together 

8/7/2019 1. Interpretation of Chest Radio Graph

http://slidepdf.com/reader/full/1-interpretation-of-chest-radio-graph 29/102

8/7/2019 1. Interpretation of Chest Radio Graph

http://slidepdf.com/reader/full/1-interpretation-of-chest-radio-graph 30/102

Understanding Pathological Changes

Most disease states replace air with a

pathological process

Each tissue reacts to injury in a predictable

fashion

Lung injury or pathological states can be

either a generalized or localized process

8/7/2019 1. Interpretation of Chest Radio Graph

http://slidepdf.com/reader/full/1-interpretation-of-chest-radio-graph 31/102

Liquid Density

Liquid density Increased airdensityGeneralized  Localized

Diffusealveolar

Diffuse

interstitialMixed

Vascular

InfiltrateConsolidation

Cavitation

MassCongestion

Atelectasis

Localized airwayobstruction

Diffuse airway

obstructionEmphysema

Bulla

8/7/2019 1. Interpretation of Chest Radio Graph

http://slidepdf.com/reader/full/1-interpretation-of-chest-radio-graph 32/102

Consolidation

Lobar consolidation:

 –  Alveolar space filledwith inflammatoryexudate

 –  Interstitium and

architecture remainintact

 –  The airway is patent

 –  Radiologically:

A density correspondingto a segment or lobe

Airbronchogram, and

No significant loss of lung

volume

8/7/2019 1. Interpretation of Chest Radio Graph

http://slidepdf.com/reader/full/1-interpretation-of-chest-radio-graph 33/102

 Atelectasis

Loss of air

Obstructive atelectasis:

 –  No ventilation to the lobe

beyond obstruction

 –  Radiologically:

Density corresponding to a

segment or lobe

Significant loss of volume

Compensatory

hyperinflation of normal

lungs

8/7/2019 1. Interpretation of Chest Radio Graph

http://slidepdf.com/reader/full/1-interpretation-of-chest-radio-graph 34/102

Stages of Evaluating an Abnormality

1. Identification of abnormal shadows2. Localization of lesion

3. Identification of pathological process

4. Identification of etiology5. Confirmation of clinical suspension

Complex problems

Introduction of contrast medium

CT chest

MRI scan

8/7/2019 1. Interpretation of Chest Radio Graph

http://slidepdf.com/reader/full/1-interpretation-of-chest-radio-graph 35/102

Putting It Into Practice

8/7/2019 1. Interpretation of Chest Radio Graph

http://slidepdf.com/reader/full/1-interpretation-of-chest-radio-graph 36/102

Case 1

8/7/2019 1. Interpretation of Chest Radio Graph

http://slidepdf.com/reader/full/1-interpretation-of-chest-radio-graph 37/102

8/7/2019 1. Interpretation of Chest Radio Graph

http://slidepdf.com/reader/full/1-interpretation-of-chest-radio-graph 38/102

A single, 3cm relatively thin-walled cavity is noted in the left mid lung. This

finding is most typical of squamous cell carcinoma (SCC). One-third of SCC

masses show cavitation

8/7/2019 1. Interpretation of Chest Radio Graph

http://slidepdf.com/reader/full/1-interpretation-of-chest-radio-graph 39/102

Case 2

8/7/2019 1. Interpretation of Chest Radio Graph

http://slidepdf.com/reader/full/1-interpretation-of-chest-radio-graph 40/102

8/7/2019 1. Interpretation of Chest Radio Graph

http://slidepdf.com/reader/full/1-interpretation-of-chest-radio-graph 41/102

LUL Atelectasis: Loss of heart borders/silhouetting. Notice

over inflation on unaffected lung

8/7/2019 1. Interpretation of Chest Radio Graph

http://slidepdf.com/reader/full/1-interpretation-of-chest-radio-graph 42/102

Case 3

8/7/2019 1. Interpretation of Chest Radio Graph

http://slidepdf.com/reader/full/1-interpretation-of-chest-radio-graph 43/102

8/7/2019 1. Interpretation of Chest Radio Graph

http://slidepdf.com/reader/full/1-interpretation-of-chest-radio-graph 44/102

Right Middle and Left Upper Lobe Pneumonia

8/7/2019 1. Interpretation of Chest Radio Graph

http://slidepdf.com/reader/full/1-interpretation-of-chest-radio-graph 45/102

Case 4

8/7/2019 1. Interpretation of Chest Radio Graph

http://slidepdf.com/reader/full/1-interpretation-of-chest-radio-graph 46/102

8/7/2019 1. Interpretation of Chest Radio Graph

http://slidepdf.com/reader/full/1-interpretation-of-chest-radio-graph 47/102

Cavitation:cystic changes in the area of consolidation due to the

bacterial destruction of lung tissue. Notice air fluid level.

8/7/2019 1. Interpretation of Chest Radio Graph

http://slidepdf.com/reader/full/1-interpretation-of-chest-radio-graph 48/102

Cavitation

8/7/2019 1. Interpretation of Chest Radio Graph

http://slidepdf.com/reader/full/1-interpretation-of-chest-radio-graph 49/102

Case 5

8/7/2019 1. Interpretation of Chest Radio Graph

http://slidepdf.com/reader/full/1-interpretation-of-chest-radio-graph 50/102

8/7/2019 1. Interpretation of Chest Radio Graph

http://slidepdf.com/reader/full/1-interpretation-of-chest-radio-graph 51/102

Tuberculosis

8/7/2019 1. Interpretation of Chest Radio Graph

http://slidepdf.com/reader/full/1-interpretation-of-chest-radio-graph 52/102

Case 6

8/7/2019 1. Interpretation of Chest Radio Graph

http://slidepdf.com/reader/full/1-interpretation-of-chest-radio-graph 53/102

8/7/2019 1. Interpretation of Chest Radio Graph

http://slidepdf.com/reader/full/1-interpretation-of-chest-radio-graph 54/102

COPD: increase in heart diameter, flattening of the

diaphragm, and increase in the size of the retrosternal air

space. In addition the upper lobes will become hyperlucent due

to destruction of the lung tissue.

8/7/2019 1. Interpretation of Chest Radio Graph

http://slidepdf.com/reader/full/1-interpretation-of-chest-radio-graph 55/102

Chronic emphysema effect on the lungs

8/7/2019 1. Interpretation of Chest Radio Graph

http://slidepdf.com/reader/full/1-interpretation-of-chest-radio-graph 56/102

Case 7

8/7/2019 1. Interpretation of Chest Radio Graph

http://slidepdf.com/reader/full/1-interpretation-of-chest-radio-graph 57/102

8/7/2019 1. Interpretation of Chest Radio Graph

http://slidepdf.com/reader/full/1-interpretation-of-chest-radio-graph 58/102

Pseudotumor: fluid has filled the minor fissure creating a density

that resembles a tumor (arrow). Recall that fluid and soft tissue

are indistinguishable on plain film. Further analysis, however,

reveals a classic pleural effusion in the right pleura. Note the right

lateral gutter is blunted and the right diaphram is obscurred.

8/7/2019 1. Interpretation of Chest Radio Graph

http://slidepdf.com/reader/full/1-interpretation-of-chest-radio-graph 59/102

Case 8

8/7/2019 1. Interpretation of Chest Radio Graph

http://slidepdf.com/reader/full/1-interpretation-of-chest-radio-graph 60/102

8/7/2019 1. Interpretation of Chest Radio Graph

http://slidepdf.com/reader/full/1-interpretation-of-chest-radio-graph 61/102

Pneumonia:a large pneumonia consolidation in the right lower

lobe. Knowledge of lobar and segmental anatomy is important

in identifying the location of the infection

8/7/2019 1. Interpretation of Chest Radio Graph

http://slidepdf.com/reader/full/1-interpretation-of-chest-radio-graph 62/102

Case 9

8/7/2019 1. Interpretation of Chest Radio Graph

http://slidepdf.com/reader/full/1-interpretation-of-chest-radio-graph 63/102

8/7/2019 1. Interpretation of Chest Radio Graph

http://slidepdf.com/reader/full/1-interpretation-of-chest-radio-graph 64/102

CHF:a great deal of accentuated interstitial markings, Curly

lines, and an enlarged heart. Normally indistinct upper lobe

vessels are prominent but are also masked by interstitial edema.

8/7/2019 1. Interpretation of Chest Radio Graph

http://slidepdf.com/reader/full/1-interpretation-of-chest-radio-graph 65/102

24 hours after diuretic therapy

8/7/2019 1. Interpretation of Chest Radio Graph

http://slidepdf.com/reader/full/1-interpretation-of-chest-radio-graph 66/102

Case 10

8/7/2019 1. Interpretation of Chest Radio Graph

http://slidepdf.com/reader/full/1-interpretation-of-chest-radio-graph 67/102

8/7/2019 1. Interpretation of Chest Radio Graph

http://slidepdf.com/reader/full/1-interpretation-of-chest-radio-graph 68/102

Chest wall lesion: arising off the chest wall and not the lung

8/7/2019 1. Interpretation of Chest Radio Graph

http://slidepdf.com/reader/full/1-interpretation-of-chest-radio-graph 69/102

Case 11

8/7/2019 1. Interpretation of Chest Radio Graph

http://slidepdf.com/reader/full/1-interpretation-of-chest-radio-graph 70/102

8/7/2019 1. Interpretation of Chest Radio Graph

http://slidepdf.com/reader/full/1-interpretation-of-chest-radio-graph 71/102

Pleural effusion: Note loss of left hemidiaphragm. Fluid drained

via thoracentesis

8/7/2019 1. Interpretation of Chest Radio Graph

http://slidepdf.com/reader/full/1-interpretation-of-chest-radio-graph 72/102

Case 12

8/7/2019 1. Interpretation of Chest Radio Graph

http://slidepdf.com/reader/full/1-interpretation-of-chest-radio-graph 73/102

8/7/2019 1. Interpretation of Chest Radio Graph

http://slidepdf.com/reader/full/1-interpretation-of-chest-radio-graph 74/102

Lung Mass

8/7/2019 1. Interpretation of Chest Radio Graph

http://slidepdf.com/reader/full/1-interpretation-of-chest-radio-graph 75/102

Case 13

8/7/2019 1. Interpretation of Chest Radio Graph

http://slidepdf.com/reader/full/1-interpretation-of-chest-radio-graph 76/102

8/7/2019 1. Interpretation of Chest Radio Graph

http://slidepdf.com/reader/full/1-interpretation-of-chest-radio-graph 77/102

Small Pneumothorax: LUL

8/7/2019 1. Interpretation of Chest Radio Graph

http://slidepdf.com/reader/full/1-interpretation-of-chest-radio-graph 78/102

Case 15

8/7/2019 1. Interpretation of Chest Radio Graph

http://slidepdf.com/reader/full/1-interpretation-of-chest-radio-graph 79/102

8/7/2019 1. Interpretation of Chest Radio Graph

http://slidepdf.com/reader/full/1-interpretation-of-chest-radio-graph 80/102

Right Middle Lobe Pneumothorax: complete lobar collapse

8/7/2019 1. Interpretation of Chest Radio Graph

http://slidepdf.com/reader/full/1-interpretation-of-chest-radio-graph 81/102

Post chest tube insertion and re-expansion

8/7/2019 1. Interpretation of Chest Radio Graph

http://slidepdf.com/reader/full/1-interpretation-of-chest-radio-graph 82/102

Case 16

8/7/2019 1. Interpretation of Chest Radio Graph

http://slidepdf.com/reader/full/1-interpretation-of-chest-radio-graph 83/102

8/7/2019 1. Interpretation of Chest Radio Graph

http://slidepdf.com/reader/full/1-interpretation-of-chest-radio-graph 84/102

Metastatic Lung Cancer: multiple nodules seen

8/7/2019 1. Interpretation of Chest Radio Graph

http://slidepdf.com/reader/full/1-interpretation-of-chest-radio-graph 85/102

Case 17

8/7/2019 1. Interpretation of Chest Radio Graph

http://slidepdf.com/reader/full/1-interpretation-of-chest-radio-graph 86/102

8/7/2019 1. Interpretation of Chest Radio Graph

http://slidepdf.com/reader/full/1-interpretation-of-chest-radio-graph 87/102

Right upper lower lobe pulmonary nodule

8/7/2019 1. Interpretation of Chest Radio Graph

http://slidepdf.com/reader/full/1-interpretation-of-chest-radio-graph 88/102

Case 18

8/7/2019 1. Interpretation of Chest Radio Graph

http://slidepdf.com/reader/full/1-interpretation-of-chest-radio-graph 89/102

8/7/2019 1. Interpretation of Chest Radio Graph

http://slidepdf.com/reader/full/1-interpretation-of-chest-radio-graph 90/102

Tuberculosis

8/7/2019 1. Interpretation of Chest Radio Graph

http://slidepdf.com/reader/full/1-interpretation-of-chest-radio-graph 91/102

Case 19

8/7/2019 1. Interpretation of Chest Radio Graph

http://slidepdf.com/reader/full/1-interpretation-of-chest-radio-graph 92/102

8/7/2019 1. Interpretation of Chest Radio Graph

http://slidepdf.com/reader/full/1-interpretation-of-chest-radio-graph 93/102

Perihilar mass: Hodgkin’s disease 

8/7/2019 1. Interpretation of Chest Radio Graph

http://slidepdf.com/reader/full/1-interpretation-of-chest-radio-graph 94/102

Case 20

8/7/2019 1. Interpretation of Chest Radio Graph

http://slidepdf.com/reader/full/1-interpretation-of-chest-radio-graph 95/102

8/7/2019 1. Interpretation of Chest Radio Graph

http://slidepdf.com/reader/full/1-interpretation-of-chest-radio-graph 96/102

Widened Mediastinum: Aortic Dissection

8/7/2019 1. Interpretation of Chest Radio Graph

http://slidepdf.com/reader/full/1-interpretation-of-chest-radio-graph 97/102

Case 21

8/7/2019 1. Interpretation of Chest Radio Graph

http://slidepdf.com/reader/full/1-interpretation-of-chest-radio-graph 98/102

8/7/2019 1. Interpretation of Chest Radio Graph

http://slidepdf.com/reader/full/1-interpretation-of-chest-radio-graph 99/102

Pulmonary artery stenosis with cardiomegally likely secondary

to stenosis.

8/7/2019 1. Interpretation of Chest Radio Graph

http://slidepdf.com/reader/full/1-interpretation-of-chest-radio-graph 100/102

Questions?

8/7/2019 1. Interpretation of Chest Radio Graph

http://slidepdf.com/reader/full/1-interpretation-of-chest-radio-graph 101/102

 Acknowledgement

ARNP Bucky Boaz – Chest X-Ray

radiography

8/7/2019 1. Interpretation of Chest Radio Graph

http://slidepdf.com/reader/full/1-interpretation-of-chest-radio-graph 102/102

Thank You

Recommended