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chest ray
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2013
Chest X-Ray Interpretation: A Simplified Approach
Eugene Orientale, Jr, MD
1
National Conference of Family Medicine Residents and Medical Students August 1-3, 2013 Kansas City, MO
Chest X-Ray Interpretation: A Simplified Approach
Workshop Agenda:
1. Pretest 10 Minutes
2. CXR Basics 10 Minutes 3. CXR Algorithm with 60 Minutes
Clinical Vignettes 4. Pretest Revisited 10 Minutes
Eugene Orientale, Jr., MD Program Director
Professor, Family Medicine UCONN / St. Francis Family Medicine
Hartford, Connecticut
2
PRETEST
CXR (Chest X-Ray Workshop) Eugene Orientale, Jr., M.D.
Instructions: Please circle the appropriate response(s). Note: More than one answer may be correct.
1. This 60 year old male presents with dyspnea, orthopnea, and pedal edema. He is a non-smoker. Findings observed on this PA/Lat CXR include:
a. bilateral infiltrates b. cardiomegaly c. pleural effusion(s) d. Kerleys B-lines e. cephalization of pulmonary flow f. evidence of restrictive lung disease
2. This 63 year old male requires nasal cannula home O2 therapy to enable ambulation. He has a >60 pack/year smoking history. Findings observed on this PA/Lat CXR include:
a. hyperinflation b. increased AP diameter c. cardiomegaly d. flattening of diaphragms e. evidence of air trapping f. COPD
3. This 36 year old male complained of 3 days of progressive fever, cough productive of yellowish-green sputum, nocturnal chills, and rigors. The films on the right were taken 3 weeks after this acute illness. True statement(s) regarding this patients CXR include:
There is a: a. Left Lower Lobe infiltrate which subsequently cleared. b. Left Lingular infiltrate which subsequently cleared. c. Left Upper Lobe infiltrate which subsequently cleared. d. Silhouetting of the left heart border is present. e. Silhouetting: of the left heart border is absent.
4. Which clinic setting(s) is/are consistent with this CXR? a. aspiration pneumonia b. pneumonia c. tension pneumothorax d. total pneumonectomy e. lobar consolidation f. hemothorax
3
5. This 34 year old medical student presented with two weeks of nonproductive cough following his medicine rotation at the VA. Two days prior to being evaluated, he noted the onset of fever and cough, productive of yellowish white sputum. On further review of history, he notes recent exposure to patients with Legionella and Mycoplasma. This CXR illustrates:
a. bilateral infiltrates b. over-penetration c. under-penetration d. increased pulmonary markings secondary to over-penetration e. increased pulmonary markings secondary under-penetration f. normal lung markings.
6. A chest x-ray film that is unexposed to x-ray radiation, if developed, appears: a. white b. black
7. In a normal CXR, pulmonary (lung) markings represent: a. bronchioles b. acini c. pulmonary arteries d. pulmonary veins e. pulmonary lymphatics
8. Choose the best three landmarks utilized in the normal, well-positioned and exposed CXR that yield the most information about mediastinal shift:
a. corina b. left hilum c. right hilum d. trachea e. aortic knob f. left heart border g. right heart border
9. Causes of mediastinal shift include: a. pleural/pulmonary effusions b. air trapping c. tension pneumothorax d. pneumonectomy e. atelectasis f. fibrosis
10. Which of the following must one assess before establishing the validity of a CXR? a. adequacy of inspiration (i.e., 9-10 ribs present) b. degree of penetration (exposure) c. rotation, judged with respect to the clavicles d. rotation, judged with respect to the humerus and scapula e. name and date on film
4
I. Clinical Contest 1. Who is the patient? 2. Why was the test ordered? 3. Any relevant history? 4. Check name, date on film. . . 5. Determine projection (AP vs. PA lateral)
II. Validity: RIP R = Rotation judged with respect to clavicles
I = Inspiration adequate equals 9 to 10 ribs bilaterally
P = Penetration (=Exposure) assess with respect to vertebral spine should see intervertebral spaces to mid-thorax
III. Systematic Approach Must cover all major structures Consider Eccentric Circles approach Preffered approach
1. Clinical Context 2. Validity 3. Bones & Soft Tissues 4. Diaphragms 5. Cardiac Silhouette 6. Mediastinum 7. Lungs
a. Hilum b. Parenchyma c. Pleura
8. Interpretation
IV. Bones & Soft Tissue Relatively low yield unless clinical history indicates otherwise Inspect bones for lucency, old/new fractures Beware of costochondral calcifications Consider extra-pulmonic soft tissue densities
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Osteoblastic Osteolytic Mixed Other Cause Osteoblastic
Prostate Ca Multiple Myeloma Breast Ca OA Hodgkins Renal Ca GI Malignancies TB Lymphoma Thyroid Ca Pagets Disease Bone Sarcomas
V. Diaphragms Observe for relative symmetry Right is one rib-breadth higher than left Follow contour carefully, especially to costophrenic angels Observe lateral x-ray carefully for posterior costophrenic sulcus Look for silhouette sign
VI. Heart Primarily focus on enlargement using both views Cardiomegaly: cardiac diameter > widest thoracic diameter Beware of silhouetting Left Side (of CXR) Right Side of (CXR)
Azygos Vein (SVC) Aortic Knob Ascending Aorta Left Hilum Right Hilum Left Atrium Right Atrium Left Ventricle Cardiac Fat Pad Cardiac Fat Pad
VII. Mediastinum Beware of widening or asymmetry Lateral view is very helpful in assessing fullness in the retrosternal clear-space Look for shifting of the mediastinum due to either mass effect or volume loss
VIII. Lungs A. Hilum
complex tangle of veins, arteries, and bronchi left hilum is higher than the right look for calcifications note non-calcified adenopathy
B. Parenchyma normal lung parenchymal markings consist only of vasculature look for tapering of vasculature look at redistribution of vasculature infiltrate is a very nonspecific but nevertheless useful term localize infiltrate (look for silhouetting) describe infiltrate as appropriately as possible
6
air bronchograms? Kerley B lines? Examples: Airspace (lobar) pneumonia interstitial Bronchopneumonia Pneumococcus Mycoplasma Aspiration Klebsiella
C. Pleura look for visceral/parietal separation and clear demarcation of visceral pleura in a
pneumothorax look for pleural thickening or scarring
IX. Interpretation summarize findings in general terms generate a differential diagnosis based upon findings and clinical history formulate further diagnostic or therapeutic plan
7
Clinical Case Addendum
I. Interstitial Lung Disease findings: inflammation and/or fibrosis reticulonodular pattern
reticular = fine linear densities nodular = rounded densities (nodules) honeycombing = coarse reticular pattern, with airspaces >5mm diameter
Examples:
nodular reticular reticulonodular military TB asbestosis sarcoidosis silicosis drug-induced (e.g. bleomycin)
II. Obstructive Lung Disease findings: vary depending upon airway obstruction (bronchitis, asthma) vs. destruction
(emphysema). best defined by pulmonary function testing
typical findings; gyperlucent lungs, flattened diaphragms, chest enlargement, pruning of pulmonary vessels (I.e. pulmonary hypertension).
Examples:
Emphysema COPD Zebras: Alpha 1 antirypsin deficiency (early age) Cystic Fibrosis (early age, pseudomonas) Kartegeners Syndrome (triad: situs inversus, chronic sinusitis, infertility)
III. Pneumonias Immunocompetent Host:
A. lobar or airspace pneumonia (little airway inflammation, alveoli fill with inflammatory cells) 1. pneumococcal 2. klebsiella chronic alcoholic, currant jelly sputum 3. staphylococcal B. bronchopneumonia (usually no air bronchograms) 1. staph. Aureus pneumatoceles 2. aspiration pneumonia can lead to necrotizing lung abscess empyema
8
C. interstitial Pneumonia 1. mycoplasma 2. legionella
Immunocompormised Host: Examples: A. aspergillosis (nodular, cavitary) B. pneumocystis (diffuse) C. CMV (diffuse) D. Drug-induced (diffuse)
Caveat: dont forget CHF as a cause of pneumonia in the immunocompromised patient
IV. Hemoptysis
Findings: Normal CXR most common. Clinical history is paramount. Blood initially looks like fluid; resorption in 2-3 days results in a reticular pattern with RBCs degraded by macrophages in the interstitium and lymphatics. Within 2 weeks, CXR may return to normal.
Examples: Disease Process CXR Finding(s) Bronchogenic carcinoma solitary lesions without calcifications
Tuberculosis apical infiltrates (especially RUL, scarring)
hemoptysis and renal disease: consolidation with hemorrhage, Goodpastures which evolves into chronic Wegeners Granulomatosis interstitial fibrosis SLE or other Collagem Vascular Disease
Pulmonary embolism Hamptons Hump: wedge shaped infiltrate With its base along the pleural surface Westermark: cut-off sign
V. Cardiovascular
Disease Process CXR Finding(s) pulmonary hypertension pruning of pulmonary vessels prominent RV, RA
mitral regurgitation prominent LA, LV: possible mitral valve calcification
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mitral stenosis LA enlarged: increased pulmonary vasculature
aortic regurgitation LV enlargement
aortic stenosis LV enlarge: calcified aortic valve: prominent aorta
hypertension LV hypertrophy: prominent tortuous aorta
congestive heart failure LV enlarged: pulmonary vessel engorgement: Kerley B lines: cephalization of pulmonary vasculature
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Bibliography
1. Chest X-Ray in Primary Care. A Multimedia CME Program and Resource. Appleton & Lange New Media. PO Box 120041. Stamford, CT 06912-0041. 1-800-423-1359. Order via www.medinfosource.com ($149 personal/institutional)
2. Squires L. Fundamentals of Radiology. Cambridge, MA: Harvard University Press, 1975.
3. Bates BA. Guide to Physical Examination. Philadelphia, PA: Lippincott, 1979.
4. Macklis RM, et al. Manual of Introductory Clinical Medicine. Boston/Toronto: Little, Brown and Company, 1984.
5. Felson B, et al. Principles of Chest Roentgenology. Philadelphia, PA: W.B. Saunders, 1965.
6. Friedman M. Clinical Imaging. New York, NY: Churchill Livingston, 1988.
7. Krone KD, Weiner SA. How to Read a Chest X-Ray. Hospital Medicine. May 1988:137-172.
8. Squire L, et al. Exercises in Diagnostic Radiology: The Chest. Philadelphia, PA. W.B. Saunders, 1970.
9. Fanta CH. Clinical Case Presentation: Chest X-Ray Refresher. Harvard medical School CME Conference, 1991.
1Chest X-Ray Interpretation: A Simplified Approach
Eugene Orientale, Jr. MD
Program Director; Professor in Family Medicine
University of Connecticut / St. Francis Hospital Family
Medicine Residency Program
2013 National Conference of Family Medicine
Residents and Medical Students
August 1-3, 2013
All images are the property of Eugene Orientale, Jr, MD
2Workshop Format
Pretest 10 minutes
CXR Basics 10 minutes
CXR Algorithm 60 minutes
With Clinical Vignettes
Pretest revisited 10 minutes
Pretest: Question 1
3Pretest: Question 2
Pretest: Question 3
Pre-Treatment
PA and Lateral
Post-Treatment
PA and Lateral
4Pretest: Question 4
Pretest: Question 5
5Pretest
Please complete multiple choice questions 6-10
1 minute per question
All answers will be given at workshop
conclusion
CXR Basics
Who is the patient?
Why was the test ordered?
Relevant clinical history?
Check name, date on CXR
Establish plane of projection (AP vs. PA)
Obtain old films
6CXR: Normal
Key Point:Density: Bone > [Tissue + Fluid] > Fat > Air
CXR Validity
What constitutes a good Chest X Ray?
7CXR Validity: RIP
Rotation
Are the clavicles oriented in midline?
Inspiration
9-10 posterior ribs
6 anterior ribs
Penetration
Synonymous with exposure
Assess with respect to vertebral spine
Can the vertebrae be seen to the mid-thorax?
CXR: Normal
8AP Chest X-Ray
Key Point:AP = Widened, dumb-belled shaped ends of clavicles; No accompanying lateral view
Approach to CXR Interpretation
Typical errors:
No clinical history
Validity disregarded
Type of film not assessed
Lungs looked at first
Common omissions
Soft tissues and bones
Diaphragm
Mediastinum
Pleura
9CXR Algorithm
Clinical context
Validity: RIP
Eccentric Circles Approach
Bones and soft tissues
Diaphragms
Cardiac silhouette
Mediastinum
Lungs (Hilum, Parenchyma, Pleura)
Interpretation
CXR: Normal
10
Bones and Soft Tissues
Relatively low yield unless clinical history
indicates otherwise
Inspect bones for lucency, old/new fractures
Beware of costochondral calcifications
Consider extra-pulmonic soft tissue
densities
32 yo male s/p MVA, unrestrained driver, thrown from vehicle. Confused, intoxicated at scene. Brought in by paramedics, agitated and combative.
11
35 y.o. female complaining of chest wall discomfort. Hx of GSW 10 years prior.
Hemi-Diaphragms
Observe for symmetry
Right is higher (one rib breadth)
Think of liver pushing up right while heart
weighs down left
Follow contour to costophrenic angles
Look at lateral, esp. posterior costophrenic
sulcus
12
CXR: NormalNote diaphragmatic relationships
60 yo male s/p right pneumonectomy for lung cancer
13
Cardiac Silhouette
Patients Right
Azygos to SVC
Ascending Aorta
Right Hilum
Right Atrium
Cardiac Fat Pad
Patients Left
Aortic Knob
Left Hilum
Left Atrium
Left Ventricle
Cardiac Fat Pad
CXR: Normal
14
50 yo female smoker, 30 pack year history
Mediastinum
Beware of widening or asymmetry
Lateral view helpful in assessing fullness in the retrosternal clear space
Look for shifting due to
Mass effect
Volume loss
15
Mediastinal widening in a 60 year old smoker due to a tortuous uncoiled aorta
75 yo German female s/p radiation therapy for lung cancer: RT received in Germany without a tissue diagnosis.
16
Lungs
Hilum
Parenchyma
Pleura
Hilum
Complex tangle of
veins, arteries, and
nerves
Look for calcifications
Note non-calcified
adenopathy
Left hilum is higher than
the right
17
Parenchyma
Normal lung markings
consist only of
vasculature
Tapering of vasculature:
think branches or roots
of a tree
Look at redistribution
of vasculature
Parenchyma
Infiltrate is a
nonspecific term
Describe features of
infiltrate
Localize infiltrate
Example of a right middle lobe infiltrate: Note Silhouetting of the right heart border.
18
Important Radiologic Terms
Silhouetting
Absence or loss of an
interface when objects
of equal density are
adjacent to one
another.
Air Bronchograms
Air filled bronchiolar tree
becomes visible when
edema (or thickening) of
the bronchiolar walls
occurs.
Trachea is best example
of an air bronchogram in
a normal CXR.
55 yo female smoker needing CXR for employment physical. Diagnosis: Solitary pulmonary nodule
19
Pleura
Look for visceral /
parietal separation and
clear demarcation of
visceral pleura in setting
of pneumothorax
Look for pleural
thickening or scarring
20 yo male smoker with acute onset dyspnea
Pretest: Question 1
20
Pretest: Question 2
Pretest: Question 3
Pre-Treatment
PA and Lateral
Post-Treatment
PA and Lateral
21
Pretest: Question 4
Pretest: Question 5
22
Pretest Answers
6. A chest x-ray film that is unexposed to x-ray
radiation, if developed, appears:
a. white
7. In a normal CXR, pulmonary (lung) markings
represent
c. pulmonary arteries
d. pulmonary veins
Pretest Answers
8. Best three landmarks for mediastinal shift
a. trachea
b. aortic knob
c. right atrium
9. Causes of mediastinal shift
All are correct:
a-c. by mass effect
d-f. by volume loss
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Pretest Answers
10. Which must be assessed before establishing
the validity of a CXR?
a. adequacy of inspiration
b. degree of penetration (exposure)
c. rotation, judged with respect to the
clavicles
e. name and date on film
Contact Information
Eugene Orientale, Jr. MD
Program Director
University of Connecticut / St Francis
Family Medicine Residency Program
Hartford, CT
Work: 860-714-6738
FAX: 860-714-8079
Webpage: http://uconnfamilymedicine
Email: [email protected]
24
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