Chest X-ray Simulasi

8/18/2019 Chest X-ray Simulasi

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Chest X-rayChest X-ray

InterpretationInterpretation


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IntroductionIntroduction

Routinely obtained

Pulmonary specialist consultation

Inherent physical exam limitations

Chest x-ray limitations

Physical exam and chest x-ray providecompliment


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Essentials Before GettingEssentials Before Getting

StartedStartedExposure

– Overexposure

– UnderexposureSex of Patient

– ale

– !emale


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StartedStartedPath of x-ray beam

– P"

– "PPatient Position

– Upri#ht

– Supine


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StartedStarted$reath

– Inspiration

– Expiration


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Systematic ApproachSystematic Approach

$ony !rame%or&

Soft 'issues

(un# !ields and )ila

*iaphra#m and Pleural Spaces

ediastinum and )eart"bdomen and +ec&


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$ony !ra#ments

– Ribs

– Sternum – Spine

– Shoulder #irdle

– Clavicles


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Soft 'issues

– $reast shado%s

– Supraclavicular areas – "xillae

– 'issues alon# side of

breasts


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(un# !ields and )ila – )ilum

Pulmonary arteries Pulmonary veins

– (un#s (inear and fine nodular

shado%s of pulmonary

vessels – $lood vessels

– ,. obscured by othertissue


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*iaphra#m and

Pleural Surfaces

– *iaphra#m *ome-shaped

Costophrenic an#les

– +ormal pleural is not

visible – Interlobar fissures


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ediastinum and

)eart

– )eart si/e on P" – Ri#ht side

Inferior vena cava

Ri#ht atrium

"scendin# aorta Superior vena cava


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ediastinum and

)eart

– (eft side (eft ventricle

(eft atrium

Pulmonary artery

"ortic arch

Subclavian artery and

vein


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"bdomen and +ec&

– "bdomen

0astric bubble "ir under diaphra#m

– +ec& Soft tissue mass

"ir broncho#ram


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Summary of DensitySummary of Density

"ir

1ater

$one'issue

'issue


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Pitfalls to Chest X-rayPitfalls to Chest X-ray

InterpretationInterpretationPoor inspiration

Over or under penetration

Rotation

!or#ettin# the path of the x-ray beam


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Lung AnatomyLung Anatomy

'rachea

Carina

Ri#ht and (eft Pulmonary$ronchi

Secondary $ronchi

'ertiary $ronchi

$ronchioles "lveolar *uct

"lveoli


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Lung AnatomyLung Anatomy

Ri#ht (un#

– Superior lobe

– iddle lobe – Inferior lobe

(eft (un#

– Superior lobe

– Inferior lobe


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Lung Anatomy on Chest X-rayLung Anatomy on Chest X-ray

P" 2ie%3

– Extensive overlap

– (o%er lobes extendhi#h

(ateral 2ie%3

– Extent of lo%er lobes


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'he ri#ht upper lobe

4RU(5 occupies the upper

678 of the ri#ht lun#9

Posteriorly: the RU( is

ad;acent to the first three

to five ribs9

"nteriorly: the RU(

extends inferiorly as far as

the ,th ri#ht anterior rib


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'he ri#ht middle lobe

is typically the

smallest of the three:and appears trian#ular

in shape: bein#

narro%est near the

hilum


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'he ri#ht lo%er lobe is thelar#est of all three lobes:separated from the others by

the ma;or fissure9 Posteriorly: the R(( extend

as far superiorly as the


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'hese lobes can be separatedfrom one another by t%ofissures9

'he minor fissure separates theRU( from the R(: and thusrepresents the visceral pleuralsurfaces of both of these lobes9

Oriented obli=uely: the ma;or

fissure extends posteriorly andsuperiorly approximately tothe level of the fourth vertebral body9


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'he lobar architecture

of the left lun# is

sli#htly different thanthe ri#ht9

$ecause there is no

defined left minor

fissure: there are onlyt%o lobes on the left>

the left upper


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(eft lo%er lobes


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'hese t%o lobes areseparated by a ma;orfissure: identical to that

seen on the ri#ht side:althou#h often sli#htlymore inferior in location9

'he portion of the left lun#that corresponds

anatomically to the ri#htmiddle lobe isincorporated into the leftupper lobe9


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he !ormal Chest X-rayhe !ormal Chest X-ray

P" 2ie%3

69 "ortic arch

?9 Pulmonary trun&

89 (eft atrial appenda#e

,9 (eft ventricle

@9 Ri#ht ventricle


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he !ormal Chest X-rayhe !ormal Chest X-ray

(ateral 2ie%3

69 Obli=ue fissure

?9 )ori/ontal fissure89 'horacic spine and

retrocardiac space

,9 Retrosternal space


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he Silhouette Signhe Silhouette Sign

"n intra-thoracic radio-

opacity: if in anatomic

contact %ith a border of

heart or aorta: %ill obscurethat border9 "n intra-

thoracic lesion not

anatomically conti#uous

%ith a border or a normalstructure %ill not

obliterate that border9


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Putting It All ogether Putting It All ogether


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"nderstanding Pathological"nderstanding Pathological

ChangesChangesost disease states replace air %ith a

patholo#ical process

Each tissue reacts to in;ury in a predictablefashion

(un# in;ury or patholo#ical states can be

either a #enerali/ed or locali/ed process


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Li#uid DensityLi#uid Density

Liquid density Increased air density

Generalized Localized

*iffuse alveolar

*iffuse interstitialixed

2ascular

Infiltrate

ConsolidationCavitation

ass

Con#estion

"telectasis

(ocali/ed air%ay obstruction

*iffuse air%ay obstructionEmphysema

$ulla


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ConsolidationConsolidation

(obar consolidation3 – "lveolar space filled %ith

inflammatory exudate

– Interstitium andarchitecture remain intact

– 'he air%ay is patent

– Radiolo#ically3 " density correspondin# to

a se#ment or lobe "irbroncho#ram: and +o si#nificant loss of lun#

volume


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Atelectasis Atelectasis

(oss of air

Obstructive atelectasis3

– +o ventilation to the lobe beyond obstruction

– Radiolo#ically3 *ensity correspondin# to a

se#ment or lobe

Si#nificant loss of volume Compensatory

hyperinflation of normallun#s


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Stages of E$aluating anStages of E$aluating an

A%normality A%normality69 Identification of abnormal shado%s

?9 (ocali/ation of lesion

89 Identification of patholo#ical process,9 Identification of etiolo#y

@9 Confirmation of clinical suspension

Complex problems Introduction of contrast medium

C' chest

RI scan


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Putting It Into PracticePutting It Into Practice


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Case &Case &


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" sin#le: 8cm relatively thin-%alled cavity is noted in the left

midlun#9 'his findin# is most typical of s=uamous cell carcinoma

4SCC59 One-third of SCC masses sho% cavitation


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Case 'Case '


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(U( "telectasis3 (oss of heart borders7silhouettin#9 +otice

over inflation on unaffected lun#


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Case (Case (


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Ri#ht iddle and (eft Upper (obe Pneumonia


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Case )Case )


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Cavitation3cystic chan#es in the area of consolidation due to the

bacterial destruction of lun# tissue9 +otice air fluid level9


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Cavitation


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Case *Case *


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'uberculosis


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Case +Case +


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COP*3 increase in heart diameter: flattenin# of the diaphra#m: and

increase in the si/e of the retrosternal air space9 In addition the

upper lobes %ill become hyperlucent due to destruction of the lun#

tissue9


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Chronic emphysema effect on the lun#s


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Case ,Case ,


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Pseudotumor3 fluid has filled the minor fissure creatin# a density that

resembles a tumor 4arro%59 Recall that fluid and soft tissue are

indistin#uishable on plain film9 !urther analysis: ho%ever: reveals a

classic pleural effusion in the ri#ht pleura9 +ote the ri#ht lateral #utter

is blunted and the ri#ht diaphram is obscurred9


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Case Case


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Pneumonia3a lar#e pneumonia consolidation in the ri#ht lo%er

lobe9 Dno%led#e of lobar and se#mental anatomy is important in

identifyin# the location of the infection


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Case .Case .


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C)!3a #reat deal of accentuated interstitial mar&in#s:

Curly lines: and an enlar#ed heart9 +ormally indistinct

upper lobe vessels are prominent but are also mas&ed

by interstitial edema9


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?, hours after diuretic therapy


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Case &/Case &/


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Chest %all lesion3 arisin# off the chest %all and not the lun#


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Case &&Case &&


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Pleural effusion3 +ote loss of left hemidiaphra#m9 !luid drained

via thoracentesis


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Case &'Case &'


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(un# ass


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Case &(Case &(


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Small Pneumothorax3 (U(


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Ri#ht iddle (obe Pneumothorax3 complete lobar collapse


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Post chest tube insertion and re-expansion


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Case &+Case &+


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etastatic (un# Cancer3 multiple nodules seen


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Case &,Case &,


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Ri#ht upper lo%er lobe pulmonary nodule


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Case &Case &


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'uberculosis


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Case &.Case &.


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Perihilar mass3 )od#&ins disease


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Case '/Case '/


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1idened ediastinum3 "ortic *issection


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Case '&Case '&


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Pulmonary artery stenosis %ith cardiome#ally li&ely

secondary to stenosis9


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Chest X-ray Simulasi