NORMAL ANATOMY OF CHEST X-RAY: NORMAL ANATOMY OF CHEST X-RAY PRESENTED BY: ASMA ARSHAD 4 th YEAR MIT KING EDWARD MEDICL UNIVERSITY What is chest x-ray ?: The chest x-ray is the most commonly performed diagnostic x-ray examination. A chest x-ray makes images of the heart, lungs , airways, blood vessels and the bones of the spine and chest. X-rays are the oldest and most frequently used form of medical imaging. What is chest x-ray ? Indications of chest radiography: Chest pain Investigation of repeated and persistent chest infection Chest trauma Localization of biopsy Evidence of metastatic disease Inhalation of foreign body Indications of chest radiography Projections of chest radiography: There are several projections of chest radiography: Standard views Additional views Projections of chest radiography VIEWS:: VIEWS: STANDARD VIEWS INDICATIONS: Erect PA LATERAL For fit and able bodied persons To diagnose any pathology To visualize pleural effusion To localize opacity Additional views: Additional views VIEWS: INDICATIONS: Supine AP Lateral decubitus view Expiratory view Penetrated PA view For ill patients and those with multiple injuries To visualize small effusion To visualize pneumothorax Useful for cardiac chamber visualization and left lower lobe visualization PA PROJECTION:: PA PROJECTION: PA projection is obtained with the film cassette place against the anterior chest and the x-ray travel from back to front. CENTERAL RAY: At the level of T6 AP PROJECTION:: AP PROJECTION: AP projection is obtained by placing the film cassette against the patients back while the x-ray travel from front to back. DIFFERENCE FROM PA: Magnification of heart occur. Scapula overlies on lungs Clavicles above apex PA VIEW D/W AP VIEW: PA VIEW D/W AP VIEW normal magnified How image is formed on chest xray: When you shine a beam of x-ray at a person and put a film on other side a shadow is produced of the inside of their body Different tissues in our body absorb x-ray at different extent: Bone -high absorption( white ) Tissue -Somewhere in middle absorption( grey ) Air -low absorption( black ) How image is formed on chest xray PowerPoint Presentation: white Black white grey How to check quality of film?: There are following factors by which we check quality of film: FACTORS: Inclusion Projection Rotation Inspiration Penetration How to check quality of film? INCLUSION:: INCLUSION: Chest x-ray should include entire thoracic cage. First rib Clavicle Lateral edges of ribs Costophrenic angles ROTATION:: Chest x-ray should not be taken with patient rotated Spinous process of thoracic vertebrae should lie in the midline. They should form a vertical line that lies equidistant from the medial ends of the clavicles EFFECTS OF ROTATION ON RADIOGRAPH : Become difficult to comment accurately on heart size. Changes in lung density due to asymmetry of overlying lung tissue ROTATION: PowerPoint Presentation: More on rotated side INSPIRATION:: Chest x-ray should be taken in second full inspiratory phase. HOW TO ACESS INSPIRATION : Anteriorly 6 th rib intersect the diaphragm at the mid clavicular line should be included. 9 to 10 posterior ribs should be present. INSPIRATION: PowerPoint Presentation: INSPIRATION VIEW EXPIRATION VIEW PENETRATION: PENETRATION Penetration is the degree to which x-ray pass through the body. CRITERIA OF WELL PENETRATED CHEST XRAY : A well penetrated x-ray is one where the thoracic vertebrae are just visible through the heart shadow but bony detail of spine are not usually seen PowerPoint Presentation: In radiograph all thoracic vertebrae visible through the heart shadow Lung field darker than normal-may obscure subtle pathologies Inadequate lung detail OVERPENETRATED RADIOGRAPH PowerPoint Presentation: UNDERPENETRATED RADIOGRAPH In underpenetrated radiograph you will not able to see thoracic vertebrae through the heart shadow. Lung tissue behind the heart can not be assessed Hemi diaphragm are obscured NORMAL PENETRATION AND INPIRATION ON LATERAL FILM:: NORMAL PENETRATION AND INPIRATION ON LATERAL FILM: On the lateral view you can look for that the spine appears to be darken as you move caudally REASON: This is due to more air in the lung in the lower lobes than chest wall. The sternum should be seen edge on and posteriorly you should see two set of ribs. TRACHEA AND MAJOR BRONCHI: Trachea is a cylindrical tube that extend from the level of cricoid cartilage C6 to T5(carina). Length 10-15 cm. Internal dia 10-18mm. 18-20 cartilaginous rings Divides at carina into bronchi Passes to the right of aorta TRACHEA AND MAJOR BRONCHI PowerPoint Presentation: Trachea HILUM:: HILUM: Hilum is the wedge shaped area on the central portion of each lung where the Bronchi Pulmonary Arteries Veins and nerves leave the lung IMP POINT: Left hilar point is usually higher than right Lungs:: Two lungs are soft, spongy and elastic each lung is covered by the visceral pleura and suspended in its own pleural cavity Two lungs are separated from each other by the heart and great vessels and other structures in the mediastinum Attached to the mediastinum only by its root Lungs: FISSURES AND LOBES OF LUNGS: Lungs have 2 major fissure and 1 minor fissure: MAJOR FISSURE S: Oblique fissure MINOR FISSURE : Horizontal fissure LOBES : Right lung has three lobes divided by the oblique and horizontal fissure Left lung has two lobes divided by the oblique fissure only there is no horizontal fissure FISSURES AND LOBES OF LUNGS PowerPoint Presentation: RIGHT LUNG : 3 LOBES Superior Middle Inferior LEFT LUNG: 2 LOBES: Superior lobe Lingula Superior Inferior Inferior lobe BRONCHOPULMONARY SEGMENT:: The bronchopulmonary segments are the anatomic, functional, and surgical units of the lungs It has a segmental bronchus, a segmental artery, lymph vessels, and autonomic nerves The segmental vein lies in the connective tissue between adjacent bronchopulmonary segments Because it is a structural unit, a diseased segment can be removed surgically BRONCHOPULMONARY SEGMENT: Right lung: Superior lobe: Apical, posterior, anterior Middle lobe: Lateral, medial Inferior lobe: Superior (apical), medial basal, anterior basal, lateral basal, posterior basal TOTAL: 10 Segments on right Right lung Left lung:: Superior lobe: Apico posterior, anterior, superior lingular, inferior lingular Inferior lobe: Superior (apical), anterior basal, lateral basal, posterior basal TOTAL: 8 Segments on left side Left lung: PowerPoint Presentation: Apical lateral Medial Anterior basal Lateral basal Anterior Apico posterior Anterior Superior lingular Inferior lingular Medial basal posterior Post basal anteriorbasal Lateral basal Post basal PowerPoint Presentation: RUL RML LUL LLL RLL IMAGE SHOWING LOCATION OF RIGHT UPPER LOBE:: IMAGE SHOWING LOCATION OF RIGHT UPPER LOBE: IMAGE SHOWING LOCATION OF RIGHT MIDDLE LOBE:: IMAGE SHOWING LOCATION OF RIGHT MIDDLE LOBE: IMAGE SHOWING RIGHT LOWER LOBE:: IMAGE SHOWING RIGHT LOWER LOBE: IMAGE SHOWING LOCATION OF LEFT UPPER LOBE:: IMAGE SHOWING LOCATION OF LEFT UPPER LOBE: IMAGE SHOWING LOCATION OF LEFT LOWER LOBE: IMAGE SHOWING LOCATION OF LEFT LOWER LOBE LUNG ZONES ON CHEST XRAY:: LUNG ZONES ON CHEST XRAY: On chest x-ray we consider zones of lungs. UPPER ZONE: Is present up to 2 nd intercostal space approximately MIDDLE ZONE : From 2 nd intercostal space-5 th intercostal space LOWER ZONE: From 5 th intercostals space to onward HEART CONTOUR:: Formed by borders of heart BORDERS: RIGHT BORDER: Formed by right atrium LEFT BORDER: Formed by left ventricle ANTERIOR BORDER: Formed by right ventricle POSTERIOR BORDER: Formed by left atrium HEART CONTOUR: PA HEART CONTOUR LATERAL: PA HEART CONTOUR LATERAL HEART SIZE:: HEART SIZE: Cardiac size is assessed as cardiothoracic ratio(CTR) CTR is the transverse cardiac diameter divided by the transverse chest diameter NORMAL CTR: IN ADULTS: Approximately 50 % IN NEONATES : Approximately 65% HEMIDIAPHRAGM:: HEMIDIAPHRAGM: COSTOPHRENIC ANGLES:: COSTOPHRENIC ANGLES: BONES:: BONES: Bones on chest x-ray involved are: Clavicle Ribs spinous process Scapula Little part of humerus IMP POINT: Check for any fracture any lesion or any abnormality SOFT TISSUE:: SOFT TISSUE: PowerPoint Presentation: COMBINING ALL THESE ANATOMIC SRUCTURES TOGETHER PowerPoint Presentation: sternum Rt ventricle Lft atrium Lft ventricle Trachea Vertebral body right hemidiaphragm ribs ANATOMY AND HOW TO ACCESSS HOW TO READ NORMAL XRAY: HOW TO READ NORMAL XRAY Check patient detail Check orientation, position Check quality of film NOW EITHER START FROM OUTSIDE TO INSIDE OR INSIDE TO OUTSIDE : Ensure trachea is visible in midline Check for widened mediastinum Check heart size and borders Check aorta Check diaphragms Check lung fields Check bones and soft tissue PowerPoint Presentation: Have a unique character like SALT, whose presence is not felt but ,whose absence makes everything tasteless…..!