Chest X-RayChest X-Ray CollectionCollection

ByBy

AMIR B.CHANNA FFARCS,DA (Eng)AMIR B.CHANNA FFARCS,DA (Eng)King Khalid Univ. Hospital King Khalid Univ. Hospital

Riyadh KSARiyadh KSA

Most important things when Most important things when reading a CXR…reading a CXR…

Have a SystemHave a System

Use it consistentlyUse it consistently

Know your anatomyKnow your anatomy Diff. diagnosis & Pathophysiology Diff. diagnosis & Pathophysiology

Step #1:Step #1:

Always, always, always…Always, always, always…

Confirm the patient’s name & check Confirm the patient’s name & check date on filmdate on film

Step #2:Step #2:

Know a good CXR when you see Know a good CXR when you see one… assess the film’s quality one… assess the film’s quality

HOW ?HOW ?

Assessing Quality: R.I.P.Assessing Quality: R.I.P.

RR Rotation Rotation– clavicles- symmetric & flush with sternumclavicles- symmetric & flush with sternum

II Inspiration Inspiration– want to see at least 8-9 ribs for a good filmwant to see at least 8-9 ribs for a good film

PP Penetration Penetration– should see should see vertebral bodies thru the heartvertebral bodies thru the heart

Step #3:Step #3:

Read the film…Read the film…

DO NOT JUMP TO DIAGNOSIS DO NOT JUMP TO DIAGNOSIS

My System: the Short Version:My System: the Short Version:((Use this for routine films)Use this for routine films)

AA Airways Airways BB Bones & soft tissues Bones & soft tissues CC Cardiac silhouette Cardiac silhouette DD Diaphragm Diaphragm EE Everything else… the lungs Everything else… the lungs

The Long Version:The Long Version:Use this system for more complicated films Use this system for more complicated films

on the wards & at Morning Reporton the wards & at Morning Report RR Rotation (clavicles- symmetric & flush with sternum) Rotation (clavicles- symmetric & flush with sternum) II Inspiration (want to see at least 8-9 ribs for good film) Inspiration (want to see at least 8-9 ribs for good film) PP Penetration (should see vertebral bodies thru the heart) Penetration (should see vertebral bodies thru the heart)

AA Airways (trachea shifted or irregular, bronchiectasis, ETT)Airways (trachea shifted or irregular, bronchiectasis, ETT) BB Bones (frxs, osteoporosis, lytic lesions, skeletal deform’s)Bones (frxs, osteoporosis, lytic lesions, skeletal deform’s) CC Cardiac silhouette (CM, chamber enlargements, aorta, CaCardiac silhouette (CM, chamber enlargements, aorta, Ca++++)) DD Diaphragm (R higher L?, phrenic nerve palsy, pleural lesions)Diaphragm (R higher L?, phrenic nerve palsy, pleural lesions) EE Effusions (pleural/pericardial; effusion size, does it layer out)Effusions (pleural/pericardial; effusion size, does it layer out) FF Free air (under diaphragm, in sub-Q tissue, mediastinum)Free air (under diaphragm, in sub-Q tissue, mediastinum) GG GI pathologyGI pathology gastric bubble (shifted by spleen) gastric bubble (shifted by spleen) HH Hilum (LAD, vascular congestion, calcifications/granulomas)Hilum (LAD, vascular congestion, calcifications/granulomas) IJIJ IJ catheters & other lines (confirm they are in the right place)IJ catheters & other lines (confirm they are in the right place) KK Kerley-B lines, Kypho-scoliosis and skeletal deformitiesKerley-B lines, Kypho-scoliosis and skeletal deformities LL And finally… the LUNGS!!!!!!! And finally… the LUNGS!!!!!!!

More Details on the Lungs:More Details on the Lungs:

Features to look for when characterizing Features to look for when characterizing parenchymal lung disease:parenchymal lung disease:

Over/under inflation (<8 or >9 ribs visible) suggests a Over/under inflation (<8 or >9 ribs visible) suggests a restrictive or obstructive processrestrictive or obstructive process

Pneumothorax, atelectasis or volume lossPneumothorax, atelectasis or volume loss Air bronchograms or bronchiectasisAir bronchograms or bronchiectasis Infiltrates (describe as lobar, multi-lobar, diffuse)Infiltrates (describe as lobar, multi-lobar, diffuse) Mass/nodule (+/-3cm), shape, cavity?, CaMass/nodule (+/-3cm), shape, cavity?, Ca++?++?

Interstitial pattern (alveolar, reticular, miliary)Interstitial pattern (alveolar, reticular, miliary) Distribution of infiltrates: apical, basilar, pleuralDistribution of infiltrates: apical, basilar, pleural Vascular flow: oligemia? cephalization?Vascular flow: oligemia? cephalization?

InvestigationsInvestigations

Chest RadiographChest Radiograph PA PA APAP

– IllIll patient patient LateralLateral

– Mass localisation, cardiac chambers, hilaMass localisation, cardiac chambers, hila ExpiratoryExpiratory

1

2

3

4

5

6

7

1234

5

6

7

8

9

10

A

B

C

Heart size - Cardiothoracic Ratio (CTR)A+B/C

InvestigationsInvestigations

CTCT – Focal massesFocal masses– Diffuse lung diseaseDiffuse lung disease– Pulmonary emboliPulmonary emboli

UltrasoundUltrasound– Diaphragm, pleuraDiaphragm, pleura

Magnetic ResonanceMagnetic Resonance– MediastinumMediastinum– Lung apexLung apex

InterventionIntervention– Biopsy, DrainageBiopsy, Drainage

Slice width

Conventional CT

Spiral CT

AirAir

BoneBone

WaterWater

Normal Anatomy

Bone-CT Reconstruction

PA View

Clavicle

Rib Intercostal Space

Vertebral Column

Sternum

Rib

Bone Anatomy

Heart Size • Normal is <50% on PA upright radiograph

Lateral view

Cardiac Anatomy: Right Sided Chambers

Cardiac Anatomy: Left Sided Chambers

SVC Aortic Arch

Right DescendingPulmonary Artery

Left DescendingPulmonary Atery

• Lungs posteriorly should get darker as you go down more inferiorly

RetrosternalAirspace

Scapula

IVC

PulmonaryVessels

Hilum

Airway Anatomy• Trachea

– Cartilage– Membranous posteriorly

• Carina– Bifurcation

• Bronchus– Left and right– Lobar (RUL,RML,LUL,LLL)– Segmental (8 left, 10 right)

Trachea

Carina

R + L Main Bronchi

Lung Anatomy

• Lobes are separated by fissures

• Right– Upper Lobe– Middle Lobe– Lower Lobe

• Left– Upper Lobe (includes lingula)– Lower Lobe

Pleura and Fissures

• Pleura– Lubricates and prevents friction during

respiration– Potential Space – Don’t see unless abnormal

• Parietal pleura: Lines chest wall, mediastinal and diaphragmatic surfaces

• Visceral pleura: Lines lungs, fissures

Parietal Pleura

Visceral pleura

Diaphragms

Normal: Sharp costophrenic sulcus

Which is right and left diaphragm?

Approach to Chest Radiograph:Technical Factors

• Patient Identification (name and date)

• Markers (Left vs right)

• Assess for rotation (clavicles vs spinous process)

• Penetration (thoracic spine should be visible)

• Degree of Inpiration: 6th anterior or 10th posterior

Clavicles

Spinous Process

Vertebral BodyVisible

6

7

Counting anteriorribs

10

11

Counting posterior ribs

Inspiration/Expiration Images

• Expiration – Heart size appear larger– Mediastinum is wider– Pulmonary vasculature indistinct

4th Anterior

8th Posterior

Expiration Image

Inspiration: Same PatientExpiration

Abnormal Cases

• Bone

• Cardiovascular

• Airspace Disease including Silhouette Sign

• Interstitial Disease and Pulmonary Edema

• Atelectasis

• Pulmonary Nodule

• Pleura and Diaphragm

• Mediastinal Mass

Bone and Soft Tissues

Productive 1st rib changes:Can simulate nodule

Lordotic View

Better assess apices without bone overlap

Rib Fracture

Presenting CXR

MRI

Computed Tomography

Pancoast Tumour

Cardiovascular

Increased Cardiac Size: Can be Cardiac or Pericardial

Pericardial EffusionDilated Cardiomyopathy

What imaging would you use to differentiate between the two ?

Left Ventricular Enlargement

Enlargement of Left Ventricle

Left Ventricle

IVC

Airspace Disease and Silhouette Sign

Airspace Disease

• Filling in of acini (air space)

• Air space (acinar) nodules

• Coalesce to consolidation

• Air bronchograms

• Silhouette Sign

Air Space Disease: Etiology

• Water-Pulmonary Edema

• Pus-Infections, Non-infectious inflammatory process

• Blood-Pulmonary Hemmorhage• Protein-Alveolar Proteinosis

• Tumour-BAC, Lymphoma

Bronchopneumonia Pattern: Airspace Nodules

Acinar Nodules

ComputedTomography

Air Bronchogram

• Airways are not normally seen in a normal chest radiograph because they are an air structure within an aerated lung

• When the aerated lung opacify, the bronchii become visualized because of the surrounding contrast effect.

CT Consolidation: Air Bronchograms

Silhouette Sign• Definition: The effacement of a normal structure• Example: Airspace disease may silhouette:

– right heart margin with right middle lobe pneumonia

– diaphragm with lower lobe pneumonia

Where is the Pneumonia?

What Types of CXRs Are What Types of CXRs Are Available?Available?

Different CXR Views:Different CXR Views: Posterior-Anterior (PA)Posterior-Anterior (PA) Anterior-Posterior (AP)Anterior-Posterior (AP) LateralLateral SupineSupine ObliqueOblique ExpiratoryExpiratory Lateral DecubitusLateral Decubitus LordoticLordotic

Routine CXR Views:Routine CXR Views:

Erect or Posterior-Anterior (PA):Erect or Posterior-Anterior (PA):» Standard view & most reliable techniqueStandard view & most reliable technique» Erect films detect air under the diaphragmErect films detect air under the diaphragm

Lateral view:Lateral view:» Done at the same time as the PA filmDone at the same time as the PA film» Helps localize infiltratesHelps localize infiltrates» Also helps with CM, effusions & LADAlso helps with CM, effusions & LAD

Anterior-posterior (AP):Anterior-posterior (AP):» Portable- patient is too ill to go to X-ray, usually patient is Portable- patient is too ill to go to X-ray, usually patient is

sitting upright in bedsitting upright in bed» Poor quality but may be the best you can doPoor quality but may be the best you can do» Remember- AP films may cause the mediastinum & heart to Remember- AP films may cause the mediastinum & heart to

appear larger than they areappear larger than they are

When to get special views…When to get special views…

- - Decubitus:Decubitus:» Excellent to assess effusions before thora’sExcellent to assess effusions before thora’s» Want to see >10mm (1cm) fluid that layers freelyWant to see >10mm (1cm) fluid that layers freely

– Supine:Supine:» Patient is vent’ed or too ill to go to X-rayPatient is vent’ed or too ill to go to X-ray

– Oblique:Oblique:» Good for rib views to r/o frxsGood for rib views to r/o frxs

– Lordotic:Lordotic:» Used to look at the lung apices (TB infection)Used to look at the lung apices (TB infection)

– Expiratory:Expiratory:» Used to exclude small PTX (after thora’s)Used to exclude small PTX (after thora’s)

Enough Basics…Enough Basics…

Lets read some films!Lets read some films!

**Don’t feel bad if you miss some **Don’t feel bad if you miss some things… these are not easy films**things… these are not easy films**

Case #201Case #201

Patient is brought to the ED after Patient is brought to the ED after a restrained MVA…he complains a restrained MVA…he complains

of CP and abd pain…of CP and abd pain…

A Portable film was obtained in the A Portable film was obtained in the ER…ER…

CXR 201

Case #202Case #202

Patient presents to the WSVA emergency Patient presents to the WSVA emergency room with severe abd pain, nausea & room with severe abd pain, nausea &

vomiting… the lab calls and says their vomiting… the lab calls and says their machine is broken…machine is broken…

A Portable film was obtained in the A Portable film was obtained in the ER… you have only this CXR with ER… you have only this CXR with

which to make your Dx…which to make your Dx…

CXR 202

CXR 202 (lat)

Case #203Case #203

35 yo with chronic cough, new 35 yo with chronic cough, new onset oligoarthritis & painful onset oligoarthritis & painful

nodules on his BLE’s…nodules on his BLE’s…

A Portable film was obtained in the A Portable film was obtained in the ER…ER…

CXR 203

Case #204Case #204

44 yo alcoholic presents with 44 yo alcoholic presents with new onset SOB…new onset SOB…

PA & lat from the ED…PA & lat from the ED…

CXR 204

CXR 204 (lat)

CXR 204 (decub)

These are the two CXRs of the same patient taken few seconds apart, what is evident from it

Identify the problem with this patient having this CXR, what are its anesthetic implications

Identify the problem with this patient having this CXR, what are its anesthetic implications

Identify the problems with this patient having this CXR, what are its anesthetic implications

Identify the problems with this patient having this CXR, what other investigations would you do for this patient who is scheduled for chest surgery

Identify the problems with this patient having this CXR, what are its anesthetic implications

Identify the problem with this patient having this CXR, what are its anesthetic implications & how will you manage this

patient

Identify the problem with this patient having this VQ scan, what are its anesthetic implications

& how will you manage this patient

Identify the problem with this patient having this CXR, what are its anesthetic implications & how will you manage this

patient

Identify the problems with this child having this CXR, what are its anesthetic implications

Identify the problem with this patient having this CXR, what do the arrows point toward

& what are its anesthetic implications

Identify the problems with this patient having this CXR, what are its anesthetic implications

Case #205Case #205

Same 44 yo alcoholic presents 1 Same 44 yo alcoholic presents 1 week later with fevers & chills…week later with fevers & chills…

PA/lat CXR performed in the ED…PA/lat CXR performed in the ED…

CXR 205

CXR 205 (lat)

Case #206Case #206

50 yo male with sinusitis, fever 50 yo male with sinusitis, fever & progressive cough/DOE for 8 & progressive cough/DOE for 8

weeks…weeks…

An AP film was obtained in the ED…An AP film was obtained in the ED…

CXR 206

Case #207Case #207

25 yo female presents with acute L 25 yo female presents with acute L sided chest pain…sided chest pain…

AP & lateral films were obtained in AP & lateral films were obtained in the ED…the ED…

CXR 207

CXR 207 (lat)

Case #208Case #208

40 yo with HIV (refused HAART), 40 yo with HIV (refused HAART), presents with new SSCP…presents with new SSCP…

A portable film was obtained in the A portable film was obtained in the ED…ED…

CXR 208

Case #209Case #209

40 yo with HIV on HAART x 10 40 yo with HIV on HAART x 10 years (cd4 count 250) presents with years (cd4 count 250) presents with new onset fever & night sweats…new onset fever & night sweats…

Portable film obtained in the ED…Portable film obtained in the ED…

CXR 209

Case #210Case #210

60 yo with 1 week of progressive DOE 60 yo with 1 week of progressive DOE followed by SOB at rest…followed by SOB at rest…

AP film was obtained in the ED…AP film was obtained in the ED…

CXR 210

CXR from 3 CXR from 3 months prior…months prior…

Case #211Case #211

70 yo presents with 6 weeks of 70 yo presents with 6 weeks of progressive DOE, chronic n-p cough progressive DOE, chronic n-p cough

and now SOB at rest…and now SOB at rest…

PA & lateral films were obtained in PA & lateral films were obtained in the ED…the ED…

CXR 211

CXR 211 (lat)

Case #212Case #212

55 yo with severe epigastric pain x 2 55 yo with severe epigastric pain x 2 days followed by 4 hours of new days followed by 4 hours of new

onset SSCP and worsing abd pain…onset SSCP and worsing abd pain…

Portable film obtained in the ED…Portable film obtained in the ED…

CXR 212

Case #213Case #213

45 yo smoker gets this pre-op CXR 45 yo smoker gets this pre-op CXR before an elective Nissen before an elective Nissen

fundapplication…fundapplication…He’s been having a lingering non-He’s been having a lingering non-

productive cough x 6 weeksproductive cough x 6 weeks

This PA film was obtained…This PA film was obtained…

CXR 213

Case #214Case #214

40 yo previously healthy immigrant 40 yo previously healthy immigrant presents with new onset massive presents with new onset massive

(>400cc) hemoptysis…(>400cc) hemoptysis…

A portable CXR was obtained in the A portable CXR was obtained in the ED…ED…

CXR 214

Case #215Case #215

40 yo previously healthy female presents 40 yo previously healthy female presents with 1 day fever, cough & SOBwith 1 day fever, cough & SOB

She is admitted to the floor for She is admitted to the floor for dehydration but then develops hypoxemia dehydration but then develops hypoxemia

requiring increasing O2…requiring increasing O2…

Serial CXR’s over the next 12 hours Serial CXR’s over the next 12 hours were obtained…were obtained…

CXR 215A

CXR 215B

CXR 215C

End CXR 201End CXR 201

Happy CXR reading!Happy CXR reading!