Practical Problem-based CHEST RADIOLOGY: Conventional Film: Practical Problem-based CHEST RADIOLOGY: Conventional Film Ronald E. Pust, MD Dept. of Family & Community Medicine College of Medicine University of Arizona Copyright 2004 Ronald E. Pust all rights reserved 1 Slide 2: 2 Objectives: Upon completion of this series, the participant should be able to: 1. Systematically “read” any chest roentgenogram, beginning with assessment of the film for radiographic quality. 2. Recognize normal and abnormal pulmonary anatomy on the chest film. 3. Delineate normal and abnormal cardiac anatomy on the chest film. 4. Discuss the chest film in terms of problem-solving : indications, sensitivity and specificity, cost-effectiveness in screening and other diagnostic situations. 5. Synthesize clinical case information with basic skills in chest film interpretation to arrive at a problem assessment or “differential diagnosis.” Slide 3: 3 Texts you may find useful on the basic chest film (old editions are as good as new editions): 1. Corne J, Carroll M, Brown, I, Delany, D. Chest X-ray Made Easy . London: Churchill Livingstone, 2000. 2nd edition. ($19.95 in AHSC Bookstore, pocket-sized, 127 pp.) (Excerpts are included in this manual.) 2. Felson B. Chest roentgenology . Philadelphia: W.B. Saunders Co., 1973. 3. Felson B. Principles of chest roentgenology, a programmed text . Philadelphia: W.B. Saunders Co., 1965. 2nd edition, 1999. 4. Forrest and Feigin. Essentials of Chest Radiology , W.B. Saunders Co., 1982. (Good basic text) 5. Lillington and Jamplis. A Diagnostic Approach to Chest Diseases: Differential Diagnoses Based on Roentgenographic Patterns . Baltimore: Williams and Wilkins Co., 3rd edition, 1987. 6. Mettler F. Essentials of Radiolog y, W.B. Saunders Co., 1996. 7. Squire, LF. Fundamentals of roentgenology (3rd ed.). (general principles). Cambridge: Harvard University Press, 1982 8. Squire, Colaice, and Strutynsky. Exercises in Diagnostic Radiology, Vol. 1: The Chest , 1972. (Paperback, problem oriented.) 9. Műller N,Fraser R, Colman N, Paré P.. Radiologic Diagnosis of Diseases of the Chest , W.B. Saunders Co., 2001. Slide 4: 4 Chest Radiology: Interpretation of Conventional Films Plunge in… I. Basics 4 Radiologic Densities Technique Normal film PA Left lateral Normal lung fields Normal heart & mediastinum II. Heart---Abnormal III. Lungs---Abnormal Lobar infiltrates Effusions Masses Cavities IV. Tuberculosis (Optional) Slide 5: 5 28 yo male , Sharp trauma left lateral thorax, BP 104/60, p=120, r=24, t=normal Using whatever background you may have, describe this film . . . Slide 6: 6 Abnormalities: severe com- pression of the left lung (white → ) and “air musculogram” of L. pectoralis major (black → ) caused by sub-q emphysema. What is the emergency “first aid” treatment? Slide 7: 7 Tension pneumothorax: physiology Slide 8: 8 Tension pneumothorax: “First-aid” Slide 9: 9 Classic R x for tension (or any) pneumo-thorax is chest tube inserted over 3 rd anterior rib in mid-clavicular line But, what appears in right chest 1-day post chest tube? Slide 10: 10 Partial right pneumothorax (non-tension) Now to review some basics and some normal films . . . Slide 11: 11 Basics: Assessing the film before “reading” it Use the previous 2 and the following 2 films to review: The 4 radiologic (and physical) densities: Air, fat, water (soft tissue), bone (calcium) The 2 orientation directions: Patient: Identify the left side, name and number. Beam direction: Posterior-to-anterior (PA) vs AP The 3 technical quality indicators (“built in”) Inspiration: Posteriorly, 9 or more ribs visible Rotation: Spinous process centered between medial ends of clavicles Penetration (correctly exposed?): Use the PA heart shadow, which increases in density from cephalad to caudad, as an “exposure indicator.” The intervertebral spaces should be visible through the top half of the heart shadow, but invisible in the lower half. Slide 12: 12 The next 5 frames provide normal PA and lateral radiographic chest anatomy 35 yo asymptomatic male, taken for a visa application. With the aid of the next film, describe the anatomy . . . Slide 13: 13 1. Trachea 2. R main bronchus 3. L main bronchus 4. L pulm artery 5. RUL pulm vein 6. R (desc) pulm artery 7. RLL and RML veins 8. Aortic arch 9. S. vena cava 10. Azygous vein Slide 14: 14 Left lateral view of same (asymptomatic) 35 yo man. The left lateral is the standard lateral, because it distorts the heart shadow the least. Review the anatomy with the aid of frame 16. Slide 15: 15 Because the textbook anatomy view in #16 (for some reason !?) shows the right lateral, this frame is a mirror image of the previous frame. This should aid in anatomical interpretation from the next frame - #16) Slide 16: 16 1. Trachea 2. R main bronchus 3. LUL bronchus 4. RUL bronchus 5. L pulmonary artery 6. R pulmonary artery 7. Pulmonary vein 8. Aortic arch 9. Brachiocephalic vessels Note: Vascular details are variable from film to film Slide 17: 17 Same pt. as #12 and #14, 20 years later, now 55 yo. Is this a good example of a normal PA for a 55 yo? Slide 18: 18 55 yo with four recently fractured ribs (L 2, 3, 4, 5), otherwise it’s a good normal 48 yo Tucson female, with chronic dyspnea. Describe and interpret film . . . Slide 19: 19 Prior frame shows high clavicles, low diaphragms and the changes of bronchiectasis and emphysema. The symmetric small masses in lower lung fields are nipple shadows. 13 yo boy with chronic low-grade fever. Can the likely cause be diagnosed from this film? Slide 20: 20 Heart: Normal vs. Abnormal Identifying the 4 chambers PA view: right atrium & left ventricle Lateral view: left atrium & right ventricle Slide 21: 21 22 yo Sonoran woman Complaint: dyspnea upon exertion after 1/2 block, chronic. Describe the film. Concentrate on mediastinal/ heart shadows. Slide 22: 22 Left lateral of same patient, describe . . . Slide 23: 23 46 yo Tucson male, admits to alcohol problem, complains of swelling of the legs over 6 weeks. BP 95/60, P 112, R 22, Temp normal, 4+ edema/anasarca. EKG normal, except for low voltage and rate of 112. Heart exam normal except S3 gallop with distant heart sounds, PMI @ AAL. Describe. . . Slide 24: 24 III. Lungs---Abnormal Lobar infiltrates Effusions Masses Cavities Slide 25: 25 24 yo male. T=103, cough, rusty sputum. Describe the abnormal elements in radiological and anatomical terms. . . Slide 26: 26 Prior film: Classic RUL consolidation with air bronchogram. Classic film of pneumococcal pneumonia. Review lobar and segmental anatomy radiologically . . . Slide 27: 27 Acute pneumococcal pneumonia: What lobe/segment (s) are involved? Slide 28: 28 Prior film: Posterior segment RUL pneumonia, (w/some apical segment involvement). Anterior segment clear (bounded inferiorly by the visible normal/horizontal minor fissure.) Chronic cough, acute fever in 45 yo male. Describe the abnormality radiologically and locate it anatomically. Describe the heart shadow . . . Slide 29: 29 Lower Lobe Shadows: Complete lobe & 2 of the 5 segments Slide 30: 30 13 yo boy with mild chronic cough for 2 months. Admitted with T=103 °. Describe the abnormality radiologically and anatomically. . . Slide 31: 31 Middle lobe (and lingular) shadows: Complete vs. segmental Slide 32: 32 This R lateral is classic confirmation of “RML syndrome.” It shows both partial RML atelectasis and partial RML (mainly lateral segment) consolidation. Slide 33: 33 The diagnosis is given for this 55 yo man with acute temperature of 103 °. Work backwards to describe the abnormalities of heart and lungs on the PA chest film. . . Slide 34: 34 52 yo male with weight loss and shortness of breath, both mild and of gradual onset. Describe radiologically and anatomically . . . Slide 35: 35 Prior film shows classic meniscus sign of right pleural fluid 93 yo Tohono O’odham female rancher who fell on right chest. Now sharp chest wall pain, some shortness of breath. Vital signs normal. Describe this PA and the next lateral film . . . Slide 36: 36 Lateral of same 93 yo great-grandmother How would you prove that this is mobile fluid and not old, stable pleural changes? Slide 37: 37 40 R lateral decubitus of 93 yo woman, showing “free flow” and horizontal layering of fluid. Slide 38: 38 2-1/2 yo boy in Papua New Guinea (PNG), T=100 ° , other vitals normal. Dull left chest percussion. Describe the two abnormalities . . . Slide 39: 39 Film 38 shows loculated L empyema, causing R mediastinal shift. This film is of PNG male, 30 yo, with fever, weight loss x 3 months. Describe . . . Slide 40: 40 The next film is of a Tohono O’odham non-smoking man of 55. Referred because of PPD of 18 mm. Denies symptoms. Exam normal except T = 100.4 ° What is the differential of this pleural-based infiltrate? Prior film shows: Rightward shift of heart and media- stinum, severe chronic left pleural thickening, and an air/fluid level without a meniscus. This is a chronic bacterial empyema with a left broncho- pleural fistula. Slide 41: 41 Slide 42: 42 The wedge-shaped shadow could be : infectious, neoplastic, vascular (pulmonary infarct), or uncommonly another cause . Note the air in the transvere colon, overlying the liver. 68 yo male UMC patient. Where is the mass? Slide 43: 43 Film 42 – the apical mass appears to widen the mediastinum. It was a lung carcinoma in the apical segment of the R U L. 45 yo male in UMC. No chest symptoms. Describe . . . Slide 44: 44 Film 43: “coin lesion” overlies posterior 9 th rib. Coin lesion differential is very broad. Dx: coccidioidomycosis Nodule (on biopsy) 73 yo female, St. E’s Clinic patient, smoker w/chronic cough. Describe 2 abnormalities: one is general/obvious and other is specific/small. Also use lateral (next frame) . . . Slide 45: 45 Lateral of same patient Slide 46: 46 1. PA showed flat, low diaphragm to 11 th rib 2. Lateral (and PA !) shows calcified azygous lymph node. This is the most subtle example in this series of chest “masses.” Slide 47: 47 50 yo Navajo diabetic woman with cough, PPD = 22 mm Describe . . . Slide 48: 48 Film 47: one cavity, thin walled, over ribs 5, 6. Broad differential of cavities includes… ? 56 yo Hispanic man with 3 months of cough, 6 lb. weight loss, smoker. Describe . . . . Slide 49: 49 Woman from PNG, 37. Where is the cavity? What is wrong in the right upper lobe? Is the mediastinum normal? Film 48: Fibronodular infiltrate, RUL > LUL. Dx: Active TB , no cavity. Slide 50: 50 Slide 51: 51 IV. Tuberculosis (Optional) This final third of the series goes into more detail on the radiographic variability in pulmonary tuberculosis. Slide 52: 52 TB: The world’s most lethal bacterium in past and present Slide 53: 53 Hispanic, 39 yo, father of two, with cough, fever, weight loss, see also lateral (next frame). Describe . . . Slide 54: 54 Lateral of same 39 yo. Slide 55: 55 Slide 56: 56 Film 53/54: giant URL cavity with fluid level; loculated effusion. Dx: active TB His daughter; no symptoms. Describe . . . Slide 57: 57 Film 56: Primary TB, right lung; incidental thymic shadow and left air bronchogram. Son, 3 years-10 months old, of the 39 yo man; also see lateral (next frame). Describe PA and lateral . . . Slide 58: 58 Primary TB, mainly R hilar adenopathy. Slide 59: 59 Kenyan girl, 9 yo, with HIV. Describe . . . Slide 60: 60 Film 59: “Progressive primary” TB with TB pneumonia, left lung. Note minor fissure on R. PNG male, 35 yo, T=100 °. Describe . . . Slide 61: 61 Film 60: TB pleural effusion in HIV negative man; resolved with TB Rx. Navajo male, 20 yo, with acute cough, T=103 °. Describe . . . Slide 62: 62 Film 61: R lung volume loss from healed TB; acute pneumonia and fluid level in damaged RUL. Same patient; after Rx of pneumonia. Slide 63: 63 Tohono O’odham cowboy 84 yo, who had LUL resection in 1962 for TB. Describe residual abnormalities and predict physical findings . . . Slide 64: 64 Same film: arrow shows calcified aortic arch. Orient yourself from there . . . Slide 65: 65 Lateral of previous patient: Abnormalities not as obvious as on PA. Slide 66: 66 Navajo teacher, 60 yo female. Surgery for TB at age 13. Describe radiologically and anatomically . . . Slide 67: 67 Thoracoplasty for TB: note resected and “bent” ribs. Horizontal arrow points to linear pleural calcification; vertical arrow points to air/fluid level. Patient has no acute symptoms: in what organ is the fluid? Slide 68: 68 Lateral of this Navajo teacher: Fluid is in colon – prolapsed through a hiatal hernia in the diaphragm. Slide 69: 69 Now, see how simple it is to interpret this chest film…. See the syllabus and next slide for further texts and reading. Best wishes… from Family & Community Medicine, University of Arizona Slide 70: 70 Texts you may find useful on the basic chest film (old editions are as good as new editions): 1. Corne J, Carroll M, Brown, I, Delany, D. Chest X-ray Made Easy . London: Churchill Livingstone, 2000. 2nd edition. ($19.95 in AHSC Bookstore, pocket-sized, 127 pp.) (Excerpts are included in this manual.) 2. Felson B. Chest roentgenology . Philadelphia: W.B. Saunders Co., 1973. 3. Felson B. Principles of chest roentgenology, a programmed text . Philadelphia: W.B. Saunders Co., 1965. 2nd edition, 1999. 4. Forrest and Feigin. Essentials of Chest Radiology , W.B. Saunders Co., 1982. (Good basic text) 5. Lillington and Jamplis. A Diagnostic Approach to Chest Diseases: Differential Diagnoses Based on Roentgenographic Patterns . Baltimore: Williams and Wilkins Co., 3rd edition, 1987. 6. Mettler F. Essentials of Radiolog y, W.B. Saunders Co., 1996. 7. Squire, LF. Fundamentals of roentgenology (3rd ed.). (general principles). Cambridge: Harvard University Press, 1982 8. Squire, Colaice, and Strutynsky. Exercises in Diagnostic Radiology, Vol. 1: The Chest , 1972. (Paperback, problem oriented.) 9. Műller N,Fraser R, Colman N, Paré P.. Radiologic Diagnosis of Diseases of the Chest , W.B. Saunders Co., 2001.