Chest X-ray Interpretation: Chest X-ray Interpretation Dr.DURGA PRASAD Introduction: Introduction Routinely obtained Pulmonary specialist consultation Inherent physical exam limitations Chest x-ray limitations Physical exam and chest x-ray provide compliment Essentials Before Getting Started: Essentials Before Getting Started Exposure Overexposure Underexposure Sex of Patient Male Female Essentials Before Getting Started: Essentials Before Getting Started Path of x-ray beam PA AP Patient Position Upright Supine Essentials Before Getting Started: Essentials Before Getting Started Breath Inspiration Expiration Systematic Approach: Systematic Approach Bony Framework Soft Tissues Lung Fields and Hila Diaphragm and Pleural Spaces Mediastinum and Heart Abdomen and Neck Systematic Approach: Systematic Approach Bony Fragments Ribs Sternum Spine Shoulder girdle Clavicles Systematic Approach: Systematic Approach Soft Tissues Breast shadows Supraclavicular areas Axillae Tissues along side of breasts Systematic Approach: Systematic Approach Lung Fields and Hila Hilum Pulmonary arteries Pulmonary veins Lungs Linear and fine nodular shadows of pulmonary vessels Blood vessels 40% obscured by other tissue Systematic Approach: Systematic Approach Diaphragm and Pleural Surfaces Diaphragm Dome-shaped Costophrenic angles Normal pleural is not visible Interlobar fissures Systematic Approach: Systematic Approach Mediastinum and Heart Heart size on PA Right side Inferior vena cava Right atrium Ascending aorta Superior vena cava Systematic Approach: Systematic Approach Mediastinum and Heart Left side Left ventricle Left atrium Pulmonary artery Aortic arch Subclavian artery and vein Systematic Approach: Systematic Approach Abdomen and Neck Abdomen Gastric bubble Air under diaphragm Neck Soft tissue mass Air bronchogram Summary of Density : Summary of Density Air Water Bone Tissue Tissue Pitfalls to Chest X-ray Interpretation: Pitfalls to Chest X-ray Interpretation Poor inspiration Over or under penetration Rotation Forgetting the path of the x-ray beam Lung Anatomy: Lung Anatomy Trachea Carina Right and Left Pulmonary Bronchi Secondary Bronchi Tertiary Bronchi Bronchioles Alveolar Duct Alveoli Lung Anatomy: Lung Anatomy Right Lung Superior lobe Middle lobe Inferior lobe Left Lung Superior lobe Inferior lobe Lung Anatomy on Chest X-ray: Lung Anatomy on Chest X-ray PA View: Extensive overlap Lower lobes extend high Lateral View: Extent of lower lobes Lung Anatomy on Chest X-ray: Lung Anatomy on Chest X-ray 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 Lung Anatomy on Chest X-ray: Lung Anatomy on Chest X-ray The 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: Lung Anatomy on Chest X-ray The right lower lobe is the largest of all three lobes, separated from the others by the major fissure. 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. Lung Anatomy on Chest X-ray: Lung Anatomy on Chest X-ray These 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: Lung Anatomy on Chest X-ray The 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: Lung Anatomy on Chest X-ray Left lower lobes Lung Anatomy on Chest X-ray: Lung Anatomy on Chest X-ray These 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. The Normal Chest X-ray: The Normal Chest X-ray PA View: Aortic arch Pulmonary trunk Left atrial appendage Left ventricle Right ventricle Superior vena cava Right hemidiaphragm Left hemidiaphragm Horizontal fissure The Normal Chest X-ray: The Normal Chest X-ray Lateral View: Oblique fissure Horizontal fissure Thoracic spine and retrocardiac space Retrosternal space The Silhouette Sign: The 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 normal structure will not obliterate that border. Putting It All Together: Putting It All Together Understanding Pathological Changes: Understanding Pathological Changes 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 Liquid Density: Liquid Density Liquid density Increased air density Generalized Localized Diffuse alveolar Diffuse interstitial Mixed Vascular Infiltrate Consolidation Cavitation Mass Congestion Atelectasis Localized airway obstruction Diffuse airway obstruction Emphysema Bulla Consolidation: Consolidation Lobar consolidation: Alveolar space filled with inflammatory exudate Interstitium and architecture remain intact The airway is patent Radiologically: A density corresponding to a segment or lobe Airbronchogram, and No significant loss of lung volume Atelectasis: Atelectasis Loss of air Obstructive atelectasis: No ventilation to the lobe beyond obstruction Radiologically: Density corresponding to a segment or lobe Significant loss of volume Compensatory hyperinflation of normal lungs Stages of Evaluating an Abnormality: Stages of Evaluating an Abnormality 1. 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 Putting It Into Practice: Putting It Into Practice Case 1: Case 1 Slide 39: 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 Case 2: Case 2 Slide 42: LUL Atelectasis: Loss of heart borders/silhouetting. Notice over inflation on unaffected lung Case 3: Case 3 Slide 45: Right Middle and Left Upper Lobe Pneumonia Case 4: Case 4 Slide 48: Cavitation:cystic changes in the area of consolidation due to the bacterial destruction of lung tissue. Notice air fluid level. Slide 49: Cavitation Case 5: Case 5 Slide 52: Tuberculosis Case 6: Case 6 Slide 55: 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. Slide 56: Chronic emphysema effect on the lungs Case 7: Case 7 Slide 59: 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. Case 8: Case 8 Slide 62: 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: Case 9 Slide 65: 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. Slide 66: 24 hours after diuretic therapy Case 10: Case 10 Slide 69: Chest wall lesion: arising off the chest wall and not the lung Case 11: Case 11 Slide 72: Pleural effusion: Note loss of left hemidiaphragm. Fluid drained via thoracentesis Case 12: Case 12 Slide 75: Lung Mass Case 13: Case 13 Slide 78: Small Pneumothorax: LUL Case 15: Case 15 Slide 81: Right Middle Lobe Pneumothorax: complete lobar collapse Slide 82: Post chest tube insertion and re-expansion Case 16: Case 16 Slide 85: Metastatic Lung Cancer: multiple nodules seen Case 17: Case 17 Slide 88: Right upper lower lobe pulmonary nodule Case 18: Case 18 Slide 91: Tuberculosis Case 19: Case 19 Slide 94: Perihilar mass: Hodgkin’s disease Case 20: Case 20 Slide 97: Widened Mediastinum: Aortic Dissection Case 21: Case 21 Slide 100: Pulmonary artery stenosis with cardiomegally likely secondary to stenosis. Questions?: Questions?