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Introduction in chest radiology

Techniques - Projection
•P-A (relation of x-ray beam to patient)

Techniques - Projection (continued)
• ateral

• Orientation: In this !e are ma"ing reference to the position of the patient and the xray beam# A PA radiograph is obtained !ith the x-ray tra$ersing the patient from posterior to anterior and stri"ing the film# %imilarly an AP radiograph is positioned !ith the xray tra$ersing the patient from anterior to posterior stri"ing the film# The cardiac border or silhouette !ill appear larger on an AP radiograph due to the magnification effect of the more anteriorly located heart relati$e to the film# • Typically portable radiographs are obtained AP& as the patient is not able to stand# %tanding radiographs in the department are typically obtained PA !ith a corresponding lateral radiograph# The PA and lateral radiograph best demonstrate the actual cardiac si'e !ith minimal magnification compared to the AP exam# .

(rientation PA AP .

• Inspiration: The $olume of air in the hemithorax !ill affect the configuration of the heart !ith question of cardiac enlargement !ith a shallo! le$el of inspiration# The $ascular pattern in the lung fields !ill be accentuated !ith a shallo! inspiration since the same amount of blood flo! is no! distributed to a smaller $olume of lung# • The le$el of inspiration can be estimated by counting ribs# )isuali'ation of nine posterior ribs& or se$en anterior ribs on an upright PA radiograph projecting abo$e the diaphragm !ould indicate a satisfactory inspiration# .

Inspiration *xpiration .

than !ith an adequate film and can simulate pneumonia or effusion# In an ideal radiograph the thoracic spine should be barely perceptual $ie!ing through the cardiac silhouette# The soft tissues at the shoulder can also gi$e an estimate of the relati$e degree of penetration of the film# .• Penetration: +efers to adequate photons tra$ersing the patient to expose the radiograph# This is often limited in patients of large si'e such that there is poor $isuali'ation of structures in the lo!er lung fields and in a retrocardiac location# The lac" of penetration renders the area .!hiter.

Penetration .

• Rotation of the patient distorts mediastinal anatomy and ma"es assessment of cardiac chambers and the hilar structures especially difficult# .hest !all tissue also contributes to increased density o$er the lo!er lobe fields simulating disease# +otation of the radiograph is assessed by judging the position of the cla$icle heads and the thoracic spinous process# Ideally the cla$icle heads should be equidistant from the spinous process# .

+otation .

+otation (continued) .

+otation .

/o! to approach an 0-ray1 .

orrectly put of the film • Then perform your search pattern 4 !hich you al!ays follo! !hen loo"ing at any film 4 this !ay you !ill miss fe!er findings .hest 0-ray • 2irst thing3 4 .+eading a .

+eading a radiograph • %tart reading e$ery radiograph by scanning the areas of least interest first& !or"ing your !ay to the more important areas# • 5ou !ill be less li"ely to miss important secondary findings# .

hest 2ilm %earch Patterns • ABCs 4 4 4 4 Abdomen 6one .hest %oft tissues • ATMLL 4 4 4 4 4 Abdomen Thorax 7ediastium ung ung These are the t!o main search patterns that people use !hen e$aluating a chest film# ..


- %earch Pattern

• +emember • A 8 Abdomen • T 8 Thorax • 7 8 7ediastinum • 8 ungs (unilaterally) • 8 ungs (bilaterally)

%earching the ,Abdomen• %can across the upper abdomen se$eral times • *$aluate normal gas containing structures3 • %tomach • /epatic flexure of the colon • %plenic flexure of the colon • *$aluate the li$er and on occasion one can $isuali'e the spleen

Structures Visualized3 %tomach gas bubble %plenic flexure i$er /emidiaphragms Abdomen dz that can mimic Lun disease include3 %ubphrenic abscess 9iaphragmatic hernia /iatal /ernia .

%earching the 6ony .Thorax• %tart at the right base& loo" at the soft tissues of the chest !all& ribs& spine and shoulder girdle • :o up one side and come do!n on opposite side • +emember3 4 Posterior ribs descend medial to lateral 4 Anterior ribs descend lateral to medial .


la$icle %pine Thora! ca e dz that ma" stimulate chest dz3 6ony metastasis +ib . .Structures Visualized3 6reast Tissue Posterior +ibs Anterior +ibs %capula .la$icle fractures .

7ediastinum• An organi'ed search of the mediastinum is complicated because of all the o$erlapping structures# • %tart !ith a global loo" for contour abnormalities& then follo! !ith a more detailed search .%earching the .

Three searches o# the mediastinum: <# Trachea Trachea and andcarina carina $% Aorta =# Aorta and andthe theheart heart ># 'ilum &% /ilum .

%earching the . ungs• %ince most chest x-rays are ordered to e$aluated for lung disease& so the lungs are examined last# • They are important& so their e$aluation should be more through& therefore !e e$aluate them t!ice# 4 (nce indi$idually 4 %econd time comparing right and left .


ostophrenic angles ung fields Pulmonary $asculature +ight minor fissure .Structures Visualized3 .

eft ateral .hest 2ilm • • • • )aluable radiographic study /elps to better locali'e lesions Allo!s to $isuali'e o$erlapping tissues Allo!s the $isuali'ation of hidden pathology .

hest 2ilm • The pattern is the same3 <) Abdomen =) Thoracic cage strutures >) 7ediastinum ?) ungs .%earching the ateral .

Search Pattern3 Abdomen Abdomen Thoraciccage Thoracic ca eand and bones bones Mediastinum 7ediastinum Lun ungs s .

6ut before that !e need to ha$e a good understanding of @ormal +adiographic Anatomy .

eft /emidiaphragm %tomach gas bubble Let(s loo) at some o# *isual abdominal structures +ight i$er %plenic flexure of the large intestines the /emidiaphragm .

Let(s loo) at the Bon" thora! +ibs %pine .hest !all .la$icle %capula .

Let(s loo) at the Bon" thora! +ibs %pine %ternum .

Trachea on .0+ /ilum etAs loo" at the normal 7ediastinal %tructures .

%uperior )ena .a$a Ascending Aorta +ight Atrium Inferior )ena .a$a )essels Aortic Arch Pulmonary Artery eft Atrium eft )entricle .

Arch 9escending Aorta eft Atrium eft )entricle Inferior )ena .a$a Ascending Aorta +ight )entricle .Aortic Bnob.

CT . (liniile numerotate indica nivelurile la care au fost facute sectiunile de mai jos) .mediastinum Imagine toracica normala.

5. 2 . 'rtera carotida co&una stanga. #. 14*.ilara stanga. Coasta +. (ena brahiocefalica dreapta. 'rtera subclavie dreapta. Muschiul infraspinos. 4*. *capula. 'rtera carotida co&una dreapta. Micul pectoral. Muschiul supraspinos. 2. 12. . Muschiul dintat anterior. Muschiul erector spinae. 15. 'rtera subclavie stanga. 1$. 4. .1. (ena )ugulara interna stanga. Traheea. Muschiul subscapular. Marele pectoral. Clavicula dreapta. (ena a. Clavicula stanga. !. Muschiul trapez. 14. %atissi&us dorsi. Esofag. 1 . 21. 1". ". 13. 1!. 3. 11. 13a. Manubriul sternal.

'rtera brahiocefalica. !. Muschiul trapez 5. . 'rterele carotide co&une. 21. 11. 'rtere subclavii. 13. . Marele pectoral. Muschi subscapular. Esofag. Micul pectoral. 1". %atissi&us dorsi. 2!. #. Traheea. 12. 3. 21*. 14*. ". Muschi supraspinos. 13a. 2. Muschi infraspinos. Muschiul erector spinae. (ene brahiocefalice. *capula. 14. 1 .1. Manubriul sternal.

3. 2!. 1"*. Muschiul trapez. 2. 24. 'rtera brahiocefalica. Corpul sternului. 14. 12. . Muschi subscapular. 1 . %atissi&us dorsi. *capula. 11. Marele pectoral.1. Traheea. 'rtere subclavii. 5. Esofag. 'rterele carotide co&une. 21*. Muschiul rotund &are. (ene brahiocefalice. 13. Muschiul erector spinae. ". 21.

2.1. *capula. Muschiul rotund &ic. 1"*. 1#*. 3. ". Marele pectoral. 1 . 'rterele carotide co&une. Muschiul subscapular. (ene brahiocefalice. Corpul sternului. 'orta ascendenta. Muschiul rotund &are. 2!. 'rcul aortei. 21. . 5. Esofag. 'rterele subclavii. 21*. 24. 11. Muschiul erector spinae. 22. 25. Muschiul trapez. Traheea. %atissi&us dorsi. . (ena cava superioara. 'rtera brahiocefalica. 14. 12. Muschiul infraspinos. 1#. 13.

Esofag. %atissi&us dorsi. Muschiul trapez. 11. 3. 24. (ena cava superioara. 1#. Muschiul erector spinae. 5. . Muschiul rotund &ic. Muschiul infraspinos. . 12. Traheea. 1"*.1. 2. 22. Muschiul subscapular. Corpul sternului. 'rcul aortei. 25. Muschiul rotund &are.

Muschiul dintat anterior. 1$. %atissi&us dorsi. Esofag. 1 . . 3. (ena cava superioara. 5. Muschiul subscapular. . *capula. 2$*. Muschiul rotund &are. 2$. 24. 'orta descendenta. Muschiul trapez. Muschiul infraspinos. Muschiul rotund &ic. 22. 11. Corpul sternului. 2. 1#*. 1#-. Traheea. (ena az. 'orta ascendenta. 'rcul venei az.1.gos.gos. 1"*. 25.

. 'orta ascendenta. 2#. 11. 3. Muschiul infraspinos. (ena cava superioara. 'rtera pul&onara dreapta. Muschiul trapez. 3$. 12. 1 . 3$* 'rtera pul&onara stanga. %atissi&us dorsi. 22. 'orta descendenta. Corpul sternului. (ena az. Esofag. 2$. Muschiul erector spinae. Trunchiul pul&onar. Muschiul rotund &are. 1#*.gos.2. 1"*. 24. 1#-. *capula. .

Muschiul dintat anterior. Muschiul erector spinae. 22. 'orta descendenta. . Carina traheala. 2$. *capula. 3$. 3. (ena cava superioara. 32. 1$.gos. 2#. Muschiul rotund &are. 1#*. %atissi&us dorsi. 'rtera pul&onara stanga. Esofag. 12. 1 .2. Corpul sternului. Trunchiul pul&onar. 1"*. 1#-. 3$*. 'rtera pul&onara dreapta. 11. Muschiul trapez. (ena az. 'orta ascendenta. 24.

Trunchiul pul&onar. %atissi&us dorsi. 1$. 'triul drept.2. Muschiul trapez. Esofag. 11. 'orta ascendenta. (ena cava superioara. 1#-. .gos. 1#*. *capula. 34. 22. (ena az. 3$. (entriculul drept. 2#. 2$. 'rtera pul&onara dreapta. 'orta descendenta. 1 . 3. Muschiul dintat anterior. 33.

gos. 33. 'triul drept. 3!. 3 . 35. (entriculul stang. 3". (entriculul drept. (ena pul&onara dreapta. 3!*. 'orta ascendenta. 1#*. 34. 1#-. .1"*. *eptul interventricular. (ena pul&onara stanga. Corpul sternului. 2$. 'orta descendenta. (ena az. 'triul stang.

1#-. (entriculul stang.ifoid al sternului.1"-. 'orta descendenta. (ena pul&onara stanga. 'triul stang. 4$. (ena az. 3#. 33. 2$. /rocesul . 'triul drept. 3 . (entriculul drept. 34. . *eptul interventricular. *inusul coronar. 3!. (alva tricuspida.gos. 35. 3!*. 3". (ena pul&onara dreapta.

Lun +ields Cpper etAs loo" at the normal ung %tructures 7iddle o!er .

+etrosternal .lear %pace +etrocardiac .lear %pace .

ateral .ostophrenic %ulci (+ecesses& Angles) .ardiophrenic %ulci (+ecesses& Angles .

ostophrenic %ulci (+ecesses& Angles) .Posterior .

Dhat are the Pulmonary 2issures1 • They are the coming together of the $isceral pulmonary pleura# • +ight lung 4 (blique (major) fissure 4 /ori'ontal (minor) fissure • eft ung 4 (blique (major) fissure .


+ight (blique 2issure /ori'ontal 2issure eft (blique 2issure .

+C A closer loo" at the fissures C +7 + .



obes • +ight upper lobe3 .

obes (continued) • +ight middle lobe3 .

obes (continued) • +ight lo!er lobe3 .

obes (continued) • eft lo!er lobe3 .

obes (continued) • eft upper lobe !ith ingula3 .

C. 1$. ". II. *eg&entul anterior. Lo ul inferior. . *eg&entul posterior. 2. *eg&entul &ediobazal. 3. Lateral. 5. 4. *eg&entul apical. I. #. *eg&entul laterobazal. *eg&entul posterobazal. *eg&entul apical. !. Posterior ". *eg&entul anterobazal. Lo ul su!erior. B. Anterior III. Basal. . *eg&entul lateral. 1. #edial $. Lo ul mijlociu. *eg&entul &edial.Lung segments – right lung A.

#edial II. *eg&entul anterobazal. Posterior ". *eg&entul posterobazal. *eg&entul &ediobazal. Basal. *eg&entul anterior.Lun se ments . 1$. le#t lun A. ". 1. . Lateral. $. *eg&entul lingular superior. *eg&entul laterobazal. B. I. Lo ul inferior. Anterior C. !. *eg&entul lingular inferior. 3. 4. *eg&entul posterior. . *eg&entul apical. *eg&entul apical. Lo ul su!erior. 2. #. 5.

CT .!ulmonar% &indo& Lo ul su!erior dre!t Bronhia !rinci!ala drea!ta Lo ul su!erior stang Traheea Lo ul su!erior dre!t Lo ul su!erior stang Lo ul inferior dre!t Bronhia !rinci!ala stanga Lo ul inferior stang .

Lo ul su!erior dre!t Cordul Lo ul su!erior stang Lo ul mijlociu dre!t Cordul Lo ul su!erior stang Lo ul inferior dre!t Bronhii lo are Lo ul inferior stang Lo ul inferior dre!t Lo ul inferior stang .