X-ray Interpretation Slide 2 Objectives List the reasons for
obtaining a Chest x-ray Identify anatomical structures present on a
chest film. Recognize a normal chest radiograph. Recognize and name
the radiographic signs of atelectasis, consolidation, pneumothorax,
pleural effusions, and hyperinflation frequently seen in patients
with cardiopulmonary disease. Slide 3 A Chest x-ray is very
valuable in answering the following questions Is the heart enlarged
or normal? Are there signs of heart failure and fluid overload?
Does the patient have pneumonia or a collapsed lung? Is there
evidence of emphysema? Are there findings of an aneurysm involving
the aorta? Is there fluid in the sac that surrounds the lung? Is
there free air under the diaphragm to suggest a hole in the bowel
wall? Is there a tumor in the lung that could represent cancer? Are
there changes of bronchitis or emphysema? Slide 4 Standard PA or
posterior anterior Radiograph Patient usually upright Distance of
beam determines magnification and clarity Place the films on the
view box as though you were facing the patient with his left on
your right side. Slide 5 Standard Lateral Chest Radiograph Left
side of the chest against filmholder (cassette); beam from right at
a distance of six feet; Lesions located behind the left side of the
heart or in the base of the lung are often invisible on the PA view
because the heart or diaphragm shadow hides it the lateral will
generally show such lesions Slide 6 X-rays are a study of densities
DENSITIES Air < fat < liver < blood < muscle < bone
< barium < lead. Air least dense; most transparent or
radiolucent; unobstructed beam or air-filled densities appear black
Lungs, gastric bubble, trachea, ? bifurcation of bronchi Fat
breasts Fluid most of what you see; vessels, heart, diaphragm, soft
tissues, mediastinal structures Mineral most dense (or radiopaque)
of body structures; mostly Ca++; bones (marrow is aerated), aortic
calcifications such as the aortic knob, ? calcification of the
coronary arteries, old granulomas; bullets, safety pins, etc. Slide
7 Different Densities on an ICU Chest X-ray Slide 8 Anatomy
Silhouette Sign / Air Bronchogram Slide 9 What am I looking at?
Slide 10 Slide 11 Right Upper Lobe Slide 12 Slide 13 Right Middle
Lobe Slide 14 Right Lower Lobe Slide 15 Left Upper Lobe Slide 16
Left Lower Lobe Slide 17 Normal Cardiac Anatomy (PA view) Slide 18
Slide 19 Normal Cardiac Anatomy (Lateral view) Slide 20 Slide 21
Slide 22 Pleura Slide 23 How to Read a Chest X-ray Go from general
observations to specific details. Sometimes a change may be so
major that the old saw about missing the forest for the trees comes
true. Read the Chest X-ray in a systematic fashion: L shoulder L
chest wall Lower Chest R chest wall R shoulder Cervical spine and
soft tissue Chest / Ribs Hilum Lungs Pleura Slide 24 LEFT SHOULDER
GIRDLE Soft tissues - look at overall amount, then check for the
following: calcifications, obvious mass effect, abnormal air
collections Bones - look at each bone for abnormalities Joints- are
articular relationships normal, joint spaces narrowed, widened, any
calcification in the cartilages, air in the joint space, abnormal
fat pads, etc. Slide 25 LEFT SHOULDER GIRDLE Slide 26 LEFT CHEST
WALL Look for overall thickness, subcutaneous emphysema,
calcification. Look for sharp, distinct muscle fat planes Slide 27
BREAST TISSUE In males and females, some asymmetry can occur from
standing with unequal pressure against the film holder. Notice how
the apparent lung density changes from the lung area covered by the
soft tissue of the breast to the lung area inferior to the breast.
Slide 28 ABDOMEN The visibility of structures is highly variable
Gastric and bowel gas - Is amount and location normal? Check for
free peritoneal air position of patient will change location of
free air. Look for calcifications and masses - can they be
localized to a specific structure. Slide 29 RIGHT CHEST WALL Look
for overall thickness, subcutaneous emphysema, calcification. Look
for sharp, distinct muscle fat planes. Slide 30 RIGHT SHOULDER
GIRDLE Slide 31 NECK SOFT TISSUES AND SPINE Amount of soft tissue,
presence of calcifications, subcutaneous emphysema, position and
size of trachea. For the cervical spine, check alignment and note
any major congenital abnormalities. Then look at specific parts of
the vertebra and disc spaces, checking for erosions, boney
destruction, disc / joint narrowing or other abnormalities. Slide
32 THORACIC SPINE AND RIB CAGE Concentrate on the skeletal detail
-- "look through" the mediastinum and lungs. First check overall
alignment of the spine and symmetry of the rib cage, double check
bone density (this is a gross estimate). Slide 33 RIBS 1. Posterior
rib 2. Anterior Rib Compare individual ribs side to side Slide 34
Hilum (pleural = hila.) "lung root;" medusa-like tangle of arteries
and veins on either side of the heart shadow. Irregular medial
shadow in each lung where the bronchi and pulmonary arteries enter.
Other structures in these areas, particularly lymph nodes, are
normally so small as to be unapparent. Slide 35 Pulmonary hilum
Slide 36 FRONTAL VIEW OF THE HILA On the frontal view most of the
hilar shadows are the left and right pulmonary arteries. The left
pulmonary artery is always more superior than the right, thus
making the left hilum appear higher. Calcified lymph nodes may be
visible within the hilar shadows. Slide 37 LATERAL VIEW OF THE HILA
Slide 38 Hilar Adenopathy Slide 39 Slide 40 Lungs Slide 41 LUNGS
Compare overall size of one lung to the other, Look for major areas
of abnormal lucency or density Slide 42 Pleura Slide 43 Check the
frontal view for minor fissure thickness and location, and on the
lateral view, look for minor and major fissures These are normally
fine delicate structures that do not show up on the digitized
images. Slide 44 Pleura Slide 45 Slide 46 Stomach Anatomy Slide 47
Slide 48 Slide 49 Lets look at some examples Slide 50 Terminology
Silhouette sign Atelectasis Consolidation Pneumothorax Pleural
effusion Nodule Hyperinflation Loculated Lateral Decubitus Slide 51
Silhouette Sign When two objects of the same density touch each
other, the edge between them disappears AB Slide 52 Using the
Silhouette Sign Where is this patients heart? Right middle lobe
silhouettes right heart border Lingula silhouettes left heart
border Right lower lobe silhouettes right hemidiaphragm Left lower
lobe silhouettes left hemidiaphragm Slide 53 Silhouette Sign Slide
54 Silhouette of the Right Heart Border Right middle lobe
Infiltrate showing obliteration of the right heart border Slide 55
Atelectasis = collapse (volume loss) To diagnose atelectasis, there
must be evidence of volume loss such as displacement of a fissure
or hilum. Slide 56 Atelectasis of right lung shift of the
mediastinal structures TOWARDS the side of opacification Slide 57
Tension Pneumothorax Slide 58 Pleural Effusion Slide 59 Loculated
Hydropneumothorax Slide 60 Pulmonary Nodule Slide 61 Hyperinflation
Slide 62 Slide 63 Slide 64 Pneumonia Slide 65 Slide 66 Final Exam
Slide 67 Slide 68 Slide 69 Conclusion Should be able to look at a
CXR and determine whether it is normal Identify obvious
abnormalities on the CXR, including boney, soft tissue, cardiac and
pulmonary pathology Be able to understand basic radiology
terminology
