Chest Radiographs

SAMUEL M. Y. GAMADEY 16TH SEPTEMBER,2010

CHEST X RAY A Chest X-ray (CXR) is normally taken erect and PA X(posterior anterior) at a distance of 5 or 6 feet (150 or 200cm).

PA VIEW

LATERAL VIEW

PA RADIOGRAPH

LATERAL RADIOGRAPH

LATERAL DECUBITUS

LORDOTIC POSITION

LATERAL DECUBITUS RADIOGRAPH

AP LORDOTIC RADIOG.

Chest Radiography : Basics Principles
A Structure is rendered visible on a radiograph by the juxtaposition two different densities

Silhouette Sign
Loss of expected interface normally created by the juxtaposition of two structures of different densities No boundary can be seen between two structures of similar densities.

ERECT FILMS Erect position is the most ideal technique for chest x ray because It reproduces the normal state of the lungs & mediastinum. mediastinum. Air rises to the apical region, making it easy to recognise a pneumothorax. pneumothorax. Fluid runs downwards, producing a level at the base with a curved line (meniscus). The diaphragms are lower showing more of the lung bases and the heart size can be accurately assessed.

POSTERIOR ± ANTERIOR VIEW The film is taken PA because: It is easier to clear the scapulae from the lung fields by moving the shoulders forward There is less magnification of the heart because the heart is lying adjacent to the film When the patient is too sick to stand unaided or unable to keep still the X-ray is taken supine. X-

PA VIEW

AP VIEW

EXPIRATORY FILM: This is taken when the patient has breathed out. This may help to show bronchial obstruction with air trapping (e.g. inhaled foreign body in a child): LATERAL FILM: A lateral film should never be part of a standard chest examination especially for medical purposes or for follow up of a known lesion. The PA film should be examined. If there is an abnormality, a lateral film may then be useful for further assessment & localisation of abnormalities seen or suspected on the PA film.

OBLIQUE VIEWS: These are helpful in assessing rib lesions & some pneumothoraces. pneumothoraces. LORDOTIC VIEWS They can be obtained to better visualize structures in the thoracic apex obscured by overlying bony structures. DECUBITUS VIEW The decubitus view can be done to locate fluid in the chest cavity. The patient will have to lie on either the right or left side for two minutes and a shoot through x-ray is taken. x-

Poor Quality CXR
Supine position
² Decreases lung volume, increased heart size ² Basilar infiltrates & interstitial spaces accentuated ² Increases venous return to the heart

SemiSemi-upright position
² Enlarges normal structures ² Changes air-fluid levels air-

Failure to hold breath
² Lung structures & diaphragm blurred

Expiration film
² Basilar infiltrates & interstitial spaces accentuated ² Increased heart size

Why order a CXR?
SYMPTOMS: SYMPTOMS: Bad or persistent cough Chest pain Chest injury Coughing up blood Fever Shortness of breath

Why order a CXR?
Pleural effusion Pneumothorax Hemothorax Pulmonary embolus Trauma Monitoring chest drainage TB Lung cancer Chest pain (MI?) Hypertension Screening Pneumonia COPD Asthma

The 12-Step Program 121: Name Pre-read 2: Date 3: Anatomical markings 4: What type of view(s) 5: Penetration 6: Inspiration Quality Control 7: Rotation 8: Angulation 9: Soft tissues / bony structures 10: 10: Mediastinum Findings 11: 11: Diaphragms 12: 12: Lung Fields

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Quality Control 5. Penetration ± Should faintly see ribs through the heart ± Barely see the spine through the heart so that lesions behind or in front of the heart will not be missed. ± Should see pulmonary vessels nearly to the edges of the lungs

Overpenetrated Film
‡ Lung fields darker than normal²may obscure subtle pathologies ‡ See spine well beyond the diaphragms ‡ Inadequate lung detail

Underpenetrated Film
‡Hemidiaphragms are obscured ‡Pulmonary markings more prominent than they actually are

A body section view may be done in addition to a routine PA chest to outline the lower regions of the chest in very obsessed patients.

Quality Control 6. Inspiration
2

1

± Should be able to count 9-10 posterior 9ribs ± Heart shadow should not be hidden by the diaphragm

3 4 5 6 7

8

9 10

Poor inspiration can crowd lung markings producing pseudopseudo-airspace disease
8

About 8 posterior ribs are showing

With better inspiration, the ³disease process´ at the lung bases has cleared
9

9-10 posterior ribs are showing

Quality Control 7. Rotation ± Medial ends of bilateral clavicles are equidistant from the midline or vertebral bodies

If spinous process appears closer to the right clavicle (red arrow), the patient is rotated toward their own left side

If spinous process appears closer to the left clavicle (red arrow), the patient is rotated toward their own right side

Quality Control 8. Angulation
2

1

± Clavicle should lay over 3rd rib

3

Pitfall Due to Angulation

Apical lordotic

Same patient, not lordotic

A film which is apical lordotic (beam is angled up toward head) will have an unusually shaped heart and the usually sharp border of the left hemidiaphragm will be absent

Findings 9. Soft tissue and bony structures ± Check for Symmetry Deformities Fractures Masses Calcifications Lytic lesions

Findings 10. 10. Mediastinum ± Check for Cardiomegaly Mediastinal and Hilar contours for increase densities or deformities

Measurement of the cardiothoracic ratio.

Maximum transverse diameter of the heart on a normal PA film is not more than 15.5cm in adult males and 14.5cm in adult females. When the cardiothoracic ratio is used it should not exceed 50%. A+B = the transverse diameter of the heart. C= the transverse diameter of the thorax which is measured at the level of the diaphragms from the inner ribs A+B divided by C = the cardiothoracic ratio (CTR)

Findings 11. 11. Diaphragms ± Check sharpness of borders ± Right is normally higher than left ± Check for free air, gastric bubble, pleural effusions

Findings
L

12. 12. The Lung Fields! ± To help you determine abnormalities and their location« Use silhouettes of other thoracic structures Use fissures

Lung Anatomy
Right Lung
± Superior lobe ± Middle lobe ± Inferior lobe

Left Lung
± Superior lobe ± Inferior lobe

Lung Anatomy on Chest X-ray XThe right upper lobe (RUL) occupies the upper 1/3 of the right lung. Posteriorly, Posteriorly, the RUL is adjacent to the first three to five ribs. Anteriorly, Anteriorly, the RUL extends inferiorly as far as the 4th right anterior rib

Lung Anatomy on Chest X-ray XThe right middle lobe is typically the smallest of the three, and appears triangular in shape, being narrowest near the hilum

Lung Anatomy on Chest X-ray XThe right lower lobe is the largest of all three lobes, separated from the others by the major fissure. Posteriorly, Posteriorly, the RLL extend as far superiorly as the 6th thoracic vertebral body, and extends inferiorly to the diaphragm. Review of the lateral plain film surprisingly shows the superior extent of the RLL. RLL.

Lung Anatomy on Chest X-ray XThese lobes can be separated from one another by two fissures. The minor fissure separates the RUL from the RML, and thus represents the visceral pleural surfaces of both of these lobes. Oriented obliquely, the major fissure extends posteriorly and superiorly approximately to the level of the fourth vertebral body.

Lung Anatomy on Chest X-ray XThe lobar architecture of the left lung is slightly different than the right. Because there is no defined left minor fissure, there are only two lobes on the left; the left upper

Lung Anatomy on Chest X-ray XLeft lower lobes

Lung Anatomy on Chest X-ray XThese two lobes are separated by a major fissure, identical to that seen on the right side, although often slightly more inferior in location. The portion of the left lung that corresponds anatomically to the right middle lobe is incorporated into the left upper lobe.

Chest Radiographic Patterns of Diseases
Air Space Opacity Interstitial Opacity Nodules and Masses Lymphadenopathy Cysts and Cavities Lung Volumes Pleural Diseases

AIR SPACE OPACITY /ALVEOLAR /ALVEOLAR SHADOWING The alveoli are filled with fluid or solid tissue and appear as small separate rounded 6mm opacities in the early stages. The vessels are obscured and there may be an air bronchogram and silhouette sign. When the alveoli fill with fluid or other substances, it is called consolidation

Components Air bronchogram : air ± filled bronchus sorrounded by airless lung. Confluent opacity extending to pleural surfaces. Segmental distribution Blood (hemorrhage)

Water (edema) i.e. hydrostatic or non ± cardiogenic Cells (tumor) Protein/fat: alveolar proteinosis and lipoid pneumonia Pus (pneumonia)

Air bronchograms. The bronchi in the upper lobes are visible as dark lines because the surrounding alveoli are filled with exudate due to pneumonia.

LUL PNEUMONIA

Interstitial opacity
This is due to a disease in the interstitium .i.e. the tissue in which the blood vessels and bronchi lie within the lungs. This leads to a non homogenous pattern of shadowing which may take many forms. The normally visualised blood vessels become ill defined or obscured and may be diffuse or localised. localised.

Hallmarks :
Small, well ± defined nodules Lines i.e. interlobular septal thickening or fibrosis Reticulation . Idiopathic interstitial pneumonias Infections ( TB , Viruses)

Edema Hemorrhage Non ± infectious inflammatory lesions e.g. scarcoidosis Tumor

Normal interstitium

Interstitial disease

Reticulo nodular pattern

Close up of interstitial shadowing in a patient with fibrosing alveolitis. alveolitis. There is a nodular pattern super-imposed on a fine network of lines. superLoss of vessels.

Nodules and Masses
Nodule: any pulmonary lesion represented in a radiograph by a sharply defined, discrete nearly circular opacity 2 ± 30 mm in diameter Mass: larger than 3cm

Qualifies :
Single or multiple Size Border definition Presence or absence of calcification Location

Well Defined

Calcifications

Ill Defined

Mass

The solitary nodule

Lymphadenopathy
Chronic abnormal enlargement of the lymph nodes Non ± specific presentations 1. Mediastinal widening 2. Hilar prominence Specific patterns : 1. Particular station enlargement

Right paratracheal lymphadenopathy

Left Hilar Lymphadenopathy

Cysts and Cavities
Cyst: abnormal pulmonary parenchymal space, not containing lung tissues but filled with air and/or fluid, congenital or acquired , with a wall thickness greater than 1mm Epithelial lining often present

Cavity: Cavity: abnormal pulmonary parenchymal space , not containing lung but filled with air and / or fluid . It is caused by tissue necrosis, with a definitive wall greater than 1mm in thickness and comprised of inflammatory and / or neoplastic elements.

Cysts and cavities
1. 2. 3. 4.

Characterize: Wall thickness at the thickest portion Inner lining Presence/ absence of air/fluid level Number and location

Benign Lung Cyst :PCP Pneumatocele Uniform Wall Thickness 1mm Smooth Inner lining

Malignant Cavities: Squamous Cell Cavities Maximum Wall Thickness 16mm Irregular Inner Lining

Pleural Effusion

Right Side leural Effusion

Fracture of posterior rib # 

cavitation 

Fibrosis Calcifications 

Consolidation Granuloma Hilar Lymphadenopathy

(Tuberculoma) Tuberculoma) 

Miliary Shadowing Pericardial Effusion 

Pleural

Manifestation of pulmonary tuberculosis

effusion

Pericardial effusion

Atelectasis -

Collapse/ incomplete expansion.

Endobronchial± Endobronchial± mucus plug/ tumor. Extrinsic compression± mass/ effusion/ ascites. compression± ascites. Scarring-Scarring-- post TB/ Radiation/ inflammation. Linear/curved/wedge(apex-hilum) Linear/curved/wedge(apex-hilum) density with hilar/tracheal/mediahilar/tracheal/mediastinal/diaphragm stinal/diaphragm deviation with volume loss +/- compensatory +/hyper- inflation. hyper- inflation.

Right upper and lower lobe atelectasis

Right middle lobe pneumonia

Type of pneumonia
Lobar - entire lobe consolidated and air bronchograms common Lobular - multifocal, patchy. Interstitial - starts perihilar ,can become confluent and/or patchy as disease progresses, no air bronchograms Aspiration pneumonia Diffuse pulmonary infections - nosocomial (Pseudomonas, debilitated, mechanical vent, high mortality rate, patchy opacities, cavitation, immunocavitation, immunocompromised host(bacterial, fungal, Pneumocystic Carinii Pneumonia) Pneumonia)

Major differentiating factors between atelectasis and pneumonia

Atelectasis

Pneumonia

Volume Loss Associated Ipsilateral Shift Linear, Wedge-Shaped WedgeApex at Hilum

normal or increased volume no shift/ contralateral shift air space process not centered at hilum

Air bronchograms can occur in both.

Dextrocardia

Aortic Aneurysm

Putting It Into Practice

Case 1 

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

midlung. This finding is most typical of squamous cell carcinoma (SCC). One-third of SCC masses show cavitation One-

Case 2 

LUL Atelectasis: Loss of heart borders/silhouetting.

Notice over inflation on unaffected lung

Case 3 

Right Middle and Left Upper Lobe Pneumonia

Case 4 

Cavitation:cystic changes in the area of consolidation due to

the bacterial destruction of lung tissue. Notice air fluid level. 

Cavitation

Case 5 

Tuberculosis

Case 6 

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. 

Chronic emphysema effect on the lungs

Case 7 

Pseudotumor: fluid has filled the minor fissure creating a Pseudotumor:

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. obscurred.

Case 8 

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

Case 9 

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. 

24 hours after diuretic therapy

Case 10 

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

Case 11 

Pleural effusion: Note loss of left hemidiaphragm. Fluid

drained via thoracentesis

Case 12 

Lung Mass

Case 13 

Small Pneumothorax: LUL

Case 15 

Right Middle Lobe Pneumothorax: complete lobar collapse Pneumothorax: 

Post chest tube insertion and re-expansion re-

Case 16 

Metastatic Lung Cancer: multiple nodules seen

Case 17 

Right upper lower lobe pulmonary nodule

Case 18 

Tuberculosis

Case 19 

Perihilar mass: Hodgkin¶s disease

Case 20 

Widened Mediastinum: Aortic Dissection

Case 21 

Pulmonary artery stenosis with cardiomegally

likely secondary to stenosis.

PA view: RML consolidation and loss of right heart silhouette Lateral View: RML wedge shaped consolidation RML pneumonia

RUL infiltrate / consolidation, bordered by minor fissure inferiorly Patchy LLL infiltrate that obscures the left hemidiaphragm; right and left heart borders obscured RUL and LLL pneumonia

Multiple bilateral cavitary lesions with air-fluid levels c/w pulmonary abscesses

Tuberculosis

RML consolidation that appears wedge shaped on lateral view RML pneumonia

RLL infiltrate / consolidation RLL pneumonia

Patient BIBA to ER s/p airplane crash.

Widened mediastinum Concern for aortic injury

Obscuring of the right and left heart borders; infiltrate at the bases Bilateral aspiration pneumonia

Diffuse bilateral fluffy interstitial infiltrates Pneumocystis carinii pneumonia

LUL pneumonia

Left lung opacity Later diagnosed as lung cancer

Cardiomegaly, increased pulmonary vascular markings, fluid in the horizontal fissure CHF

Kerley B lines

The End

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