Chest X-ray by dr hameed tareen

8/7/2019 Chest X-ray by dr hameed tareen

1/101

Chest XChest X--rayray

InterpretationInterpretation

Bucky Boaz, ARNP-C


2/101

IntroductionIntroduction Routinely obtained

Pulmonary specialist consultation Inherent physical exam limitations

Chest x-ray limitations

Physical exam and chest x-ray providecompliment


3/101

Essentials Before GettingEssentials Before Getting

StartedStarted Exposure

Overexposure

Underexposure

Sex of Patient

Male

Female


4/101


StartedStarted Path of x-ray beam

PA

AP

Patient Position

Upright

Supine


5/101


StartedStarted Breath

Inspiration

Expiration


6/101

Systematic ApproachSystematic Approach Bony Framework

Soft Tissues

Lung Fields and Hila

Diaphragm and Pleural Spaces

Mediastinum and Heart Abdomen and Neck


7/101

Systematic ApproachSystematic Approach Bony Fragments

Ribs

Sternum

Spine

Shoulder girdle

Clavicles


8/101

Systematic ApproachSystematic Approach Soft Tissues

Breast shadows

Supraclavicular areas

Axillae

Tissues along side of

breasts


9/101


10/101

Systematic ApproachSystematic Approach Diaphragm and

Pleural Surfaces

Diaphragm Dome-shaped

Costophrenic angles

Normal pleural is not

visible Interlobar fissures


11/101

Systematic ApproachSystematic Approach Mediastinum and

Heart

Heart size on PA

Right side

Inferior vena cava

Right atrium

Ascending aorta Superior vena cava


12/101

Systematic ApproachSystematic Approach Mediastinum and

Heart

Left side Left ventricle

Left atrium

Pulmonary artery

Aortic arch

Subclavian artery and

vein


13/101

Systematic ApproachSystematic Approach Abdomen and Neck

Abdomen

Gastric bubble Air under diaphragm

Neck

Soft tissue mass

Air bronchogram


14/101

Summary of DensitySummary of Density Air

Water

Bone

Tissue

Tissue


15/101

Pitfalls to Chest XPitfalls to Chest X--rayray

InterpretationInterpretation Poor inspiration

Over or under penetration

Rotation

Forgetting the path of the x-ray beam


16/101

Lung AnatomyLung Anatomy

Trachea

Carina

Right and Left PulmonaryBronchi

Secondary Bronchi

Tertiary Bronchi

Bronchioles Alveolar Duct

Alveoli


17/101

Lung AnatomyLung Anatomy

Right Lung

Superior lobe

Middle lobe

Inferior lobe

Left Lung

Superior lobe

Inferior lobe


18/101

Lung Anatomy on Chest XLung Anatomy on Chest X--rayray

PA View:

Extensive overlap

Lower lobes extendhigh

Lateral View:

Extent of lower lobes


19/101


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


20/101


The right middle lobe

is typically the

smallest of the three,and appears triangular

in shape, being

narrowest near the

hilum


21/101


The right lower lobe is thelargest of all three lobes,separated from the others by

the major fissure. Posteriorly, the RLL extend

as far superiorly as the 6ththoracic vertebral body, andextends inferiorly to the

diaphragm.

Review of the lateral plainfilm surprisingly shows thesuperior extent of the RLL.


22/101


These lobes can be separatedfrom one another by twofissures.

The minor fissure separatesthe RUL from the RML, andthus represents the visceralpleural surfaces of both ofthese lobes.

Oriented obliquely, themajor fissure extendsposteriorly and superiorlyapproximately to the level ofthe fourth vertebral body.


23/101


The lobar architecture

of the left lung is

slightly different thanthe right.

Because there is no

defined left minor

fissure, there are onlytwo lobes on the left;

the left upper


24/101


Left lower lobes


25/101


These two lobes areseparated by a majorfissure, identical to that

seen on the right side,although often slightlymore inferior in location.

The portion of the leftlung that corresponds

anatomically to the rightmiddle lobe isincorporated into the leftupper lobe.


26/101

The Normal Chest XT

he Normal Chest X--rayray PA View:

1. Aortic arch

2. Pulmonary trunk3. Left atrial appendage

4. Left ventricle

5. Right ventricle

6. Superior vena cava

7. Right hemidiaphragm

8. Left hemidiaphragm

9. Horizontal fissure


27/101

The Normal Chest XT

he Normal Chest X--rayray Lateral View:

1. Oblique fissure

2. Horizontal fissure3. Thoracic spine and

retrocardiac space

4. Retrosternal space


28/101

The Silhouette SignT

he 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 normalstructure will not

obliterate that border.


29/101

Putting It All

Together

Putting It All

Together


30/101


31/101

Understanding PathologicalUnderstanding Pathological

ChangesChanges 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


32/101

Liquid DensityLiquid Density

Liquid density Increased air density

Generalized Localized

Diffuse alveolar

Diffuse interstitialMixed

Vascular

Infiltrate

Consolidation

Cavitation

Mass

Congestion

Atelectasis

Localized airway obstruction

Diffuse airway obstructionEmphysema

Bulla


33/101

ConsolidationConsolidation Lobar consolidation:

Alveolar space filled withinflammatory exudate

Interstitium andarchitecture remain intact

The airway is patent

Radiologically:

A density corresponding toa segment or lobe

Airbronchogram, and

No significant loss of lungvolume


34/101

AtelectasisAtelectasis Loss of air

Obstructive atelectasis:

No ventilation to the lobebeyond obstruction

Radiologically:

Density corresponding to asegment or lobe

Significant loss of volume Compensatory

hyperinflation of normallungs


35/101

Stages ofEvaluating anStages ofEvaluating an

AbnormalityAbnormality1. Identification of abnormal shadows

2. Localization of lesion

3. Identification of pathological process

4. Identification of etiology

5. Confirmation of clinical suspension

Complex problems Introduction of contrast medium

CT chest

MRI scan


36/101

Putting It Into PracticePutting It Into Practice


37/101

Case 1Case 1


38/101


39/101

A single, 3cm relatively thin-walled cavity is noted in the left

midlung. This finding is most typical of squamous cell carcinoma

(SCC). One-third of SCC masses show cavitation


40/101

Case 2Case 2


41/101


42/101

LUL Atelectasis: Loss of heart borders/silhouetting. Notice

over inflation on unaffected lung


43/101

Case 3Case 3


44/101


45/101

Right Middle and Left Upper Lobe Pneumonia


46/101

Case 4Case 4


47/101


48/101

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

bacterial destruction of lung tissue. Notice air fluid level.


49/101

Cavitation


50/101

Case 5Case 5


51/101


52/101

Tuberculosis


53/101

Case 6Case 6


54/101


55/101

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.


56/101

Chronic emphysema effect on the lungs


57/101

Case 7Case 7


58/101


59/101

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.


60/101

Case 8Case 8


61/101


62/101

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


63/101

Case 9Case 9


64/101


65/101

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.


66/101

24 hours after diuretic therapy


67/101

Case 10Case 10


68/101


69/101

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


70/101

Case 11Case 11


71/101


72/101

Pleural effusion: Note loss of left hemidiaphragm. Fluid drained

via thoracentesis


73/101

Case 12Case 12


74/101


75/101

Lung Mass


76/101


77/101


78/101

Small Pneumothorax: LUL


79/101

Case 15Case 15


80/101


81/101

Right Middle Lobe Pneumothorax: complete lobar collapse


82/101

Post chest tube insertion and re-expansion


83/101

Case 16Case 16


84/101


85/101

Metastatic Lung Cancer: multiple nodules seen


86/101

Case 17Case 17


87/101


88/101

Right upper lower lobe pulmonary nodule


89/101

Case 18Case 18


90/101


91/101

Tuberculosis


92/101

Case 19Case 19


93/101


94/101

Perihilar mass: Hodgkins disease


95/101

Case 20Case 20


96/101


97/101

Widened Mediastinum: Aortic Dissection


98/101

Case 21Case 21


99/101


100/101

Pulmonary artery stenosis with cardiomegally likely

secondary to stenosis.


101/101

Questions?Questions?

Documents

Chest X-ray by dr hameed tareen