To understand chest x ray for FM final revision

To understand chest x ray –final revision: 

To understand chest x ray –final revision Saeed Salah Abduljalil

Objectives : 

Objectives The main objectives of the session are To understand basic chest x ray reading . To be able to correctly solve or read included x ray films To be ready for the exam …and PRACTICE

Background: 

Normal Reading Techniques Anatomy System Background

Postroanterior PA: 

Postroanterior PA

Slide 6: 

lateral

The Lateral Chest Film : 

The Lateral Chest Film Find abnormalities hidden on the frontal film Confirm abnormalities suspected from frontal film Don ’ t be afraid to look at it! Our best friend!

Technically adequate : 

Technically adequate Inspiration The patient should be examined in full inspiration. This greatly helps the radiologist to determine if there are intrapulmonary abnormalities. The diaphragm should be found at about the level of the 8th - 10th posterior rib or 5th - 6th anterior rib on good inspiration.

Slide 9: 

1 3 5 9 10

Technical Factors: 

Technical Factors Depth of inspiration Visualization of pathology depends on contrast provided by air in the lungs Count ribs! 10

Short of breath: 

8 Short of breath One minute later 8

Penetration hard or soft film : 

Penetration hard or soft film Adequate penetration of the patient by radiation is also required for a good film. On a good PA film, the thoracic spine disc spaces should be barely visible through the heart but bony details of the spine are not usually seen. On the other hard penetration is sufficient that bronchovascular structures can usually be seen through the heart.

Slide 13: 

On the lateral view you can look for proper penetration and inspiration by observing that the spine appears to be darken as you move caudally . This is due to more air in lung in the lower lobes and less chest wall. The sternum should be seen edge on and posteriorly you should see two sets of ribs.

Slide 15: 

soft Hard

Slide 16: 

Rotation The technologists are usually very careful to x-ray the patient flat against the cassette. If there is rotation of the patient, the mediastinum may look very unusual. One can access patient rotation by observing the clavicular heads and determining whether they are equal distance from the spinous process of the thoracic vertebral bodies.

Slide 17: 

This is a normal PA film without any rotation.

Effect of obliquity on heart size: 

Effect of obliquity on heart size

Slide 19: 

"This is a frontal chest radiograph of a young male patient. The patient has taken a good inspiration and is not rotated ; the film is well penetrated ." COMMENT

Slide 20: 

This image outlines the specific anatomy of the PA chest x-ray .

Slide 21: 

This image indicates the locations of each lung margin on chest x-ray.

Slide 22: 

The right minor fissure ( A ) and the inferior borders ( B ) of the major fissures bilaterally.  The superior border of the major fissures ( B ) bilaterally. 4th 6th

Slide 23: 

On the lateral view, both lungs are superimposed. Think about them separately, the left lung has only a major fissure as shown. The right lung will have both the major and minor fissure.

Slide 24: 

How do you look at a chest x-ray? Avoid tunnel vision! or

Have a system !!: 

Have a system !!

Frontal Chest X-Ray: 

Frontal Chest X-Ray 1st circle = outside the bony thorax (skin, soft tissues, mammary glands and sub-diaphragmatic area) 2nd circle = the bony thorax and diaphragms

THE LUNG FIELDS: 

THE LUNG FIELDS Infiltrates Increased interstitial markings Masses Absence of normal margins Increased vascularity Scan both lungs, starting at the apices and working down, comparing left with right at the same level, just as you would when listening to the chest with your stethoscope. The lungs extend behind the heart, so look here too.

Frontal Chest X-Ray: 

Frontal Chest X-Ray 4th circle = the mediastinum Identification of the main mediastinal junction lines and stripes Analysis of the 4 most important regional nodal stations

Slide 30: 

PA technique for looking at films.  Encompassing the entire lung boundaries (left) , scanning with fovea over each part of lung (right).

Slide 31: 

Lateral scanning technique

Slide 32: 

Mediastinum, heart and hila

Frontal Chest X-Ray: 

Frontal Chest X-Ray MEDIASTINUM

Slide 34: 

« concentrically » from the periphery towards the centre

Frontal Chest X-Ray: 

Frontal Chest X-Ray ???? If you see nothing abnormal on the x-ray, and yet clinical examination or history suggests otherwise, what do you do?

Frontal Chest X-Ray: 

Frontal Chest X-Ray With your eyes, you define the 4 following target zones

Slide 37: 

Right retroclavicular opacity

Frontal Chest X-Ray: 

Frontal Chest X-Ray Pancoast’s tumour

Frontal Chest X-Ray: 

Frontal Chest X-Ray The second target is : the hilum Density, size, abnormal opacity, lymph nodes

Slide 40: 

Right hilar neoplasm

Slide 41: 

Pulmonary arterial hypertension

Frontal Chest X-Ray: 

Frontal Chest X-Ray The third target is: the retrocardiac region ( bronchopneumonia, atelectasis, neoplasm )

Frontal Chest X-Ray: 

Frontal Chest X-Ray Bronchopneumonia in the posterior and lateral basal segments of the LLL

Slide 44: 

Complete resolution following treatment: back to a clear definition of the normal thoracic silhouette

Frontal Chest X-Ray: 

Frontal Chest X-Ray Large hiatus hernia

Frontal Chest X-Ray: 

Frontal Chest X-Ray The fourth target is: the subdiaphragmatic zone (abdominal and abdomino -thoracic diseases )

Frontal Chest X-Ray: 

Frontal Chest X-Ray With such a systematic bombardment, you are unlikely to miss your target! So GO FOR IT !!!

Frontal Chest X-Ray: 

Frontal Chest X-Ray * A PEX * H ILUM * H EART * A BDOMEN ( retrocardiac space ) A H H A !

Slide 50: 

Case Opaque hemi thorax Total lung collapse Pleural effusion Massive pneumonia Post pneumonectomy

Which is this?: 

Which is this? Atelectasis Pneumonia Effusion

Correct This is Atelectasis: 

Correct This is Atelectasis There is opacification of the right hemithorax with shift toward that side

Which is this?: 

Which is this? Atelectasis Pneumonia Effusion

Correct This is Pneumonia : 

Correct This is Pneumonia There is opacification of the left hemithorax with no shift There are air bronchograms

Which is this?: 

Which is this? Atelectasis Pneumonia Effusion

Correct This is a Large Pleural Effusion: 

Correct This is a Large Pleural Effusion There is opacification of the left hemithorax with shift away from that side

Which is this?: 

Which is this?

Slide 58: 

The left hemithorax is opaque There is a shift of the heart and trachea toward that side indicating volume loss Pneumonectomy on the left The left 5 th rib has been resected

Important Points opaque hemithorax: 

Important Points opaque hemithorax In atelectasis, there is s shift toward the side of the opacification In pleural effusion, there is a shift away from the side of the opacification In pneumonia, there is no shift In pneumonectomy , the 5 th rib is usually absent

Slide 60: 

Case

Cavitary Lung Lesions Three main Causes: 

Cavitary Lung Lesions Three main Causes Cavitating Bronchogenic carcinoma Tuberculous Cavity Chronic Abscess

Cavitary Lung Lesions Differentiation Points: 

Cavitary Lung Lesions Differentiation Points Thickness of the wall Inner margin of the cavity Air-fluid level

Slide 65: 

Carcinoma TB Abscess Thickness of Wall Inner Margin A|F Level Thick Thick Thin Nodular Smooth Smooth No Yes +/- Cavities

Slide 66: 

Thick-walled with nodular inner margin – carcinoma of the left lower lobe

Slide 67: 

Thick-walled with smooth inner margin – RUL abscess

Slide 68: 

Thin-walled with smooth inner margins, RUL –Tuberculosis

Pneumonia: 

Pneumonia Signs: Air bronchogram Silhouette - “ positive ” or “ negative ” Dense hilum “ Spine ” sign All are signs of any air space process Dx of pneumonia depends on appropriate clinical scenario.

Right middle lobe: 

Right middle lobe

Right upper lobe: 

Right upper lobe

Slide 72: 

Dense hilum, spine sign

Slide 73: 

Did you notice the mass?

Slide 74: 

Lymphoma

Slide 75: 

Right lateral calcification due to pleural fibrosis (past history of TB) Did you notice the right mastectomy?

Slide 76: 

Cardiomegaly first comes to mind, BUT… 1-The right mastectomy? 2-The right effusion? 3-Hilar ADP with lymphangitis carcinomatosis? 4- lytic rib lesion on the left?

CASE 1: 

CASE 1 A 55-year-old non-smoker presented with on and off haemoptysis and purulent sputum for 1 year.There was no fever or constitutional symptoms. Physical examination showed fi nger clubbing and coarse crepitations over the lung base. Blood tests were essentially normal and an initial CXR was performed.

Questions: 

Questions What abnormality can you see on CXR ? Clusters of cystic spaces with air-fluid levels involving multiple zones bilaterally. What is the most likely diagnosis ? 9/21/2010 Dr Saeed Salah Abduljalil 84

Case discussion: 

Case discussion Cystic bronchiectasis The air-fl uid levels within the cystic spaces represent retained secretions within the dilated bronchioles. CT thorax is the imaging modality of choice for diagnosis and to demonstrate the extent and severity of the disease. 9/21/2010 Dr Saeed Salah Abduljalil 85

CASE 2: 

CASE 2 A 65-year-old man presented to the Emergency Department with crushing chest pain and shortness of breath and a CXR was performed 9/21/2010 Dr Saeed Salah Abduljalil 86

QUESTIONS: 

QUESTIONS What are the chest radiograph findings - Cardiomegaly - Upper lobe venous diversion - Septal lines ( Kerley B lines) best seen in the right lower zone - Sharply outlined haziness in the right upper zone with no evidence of an air bronchogram suggestive of fl uid in the right horizontal fissure What is the diagnosis? 9/21/2010 Dr Saeed Salah Abduljalil 87

Case 2 discussions: 

Case 2 discussions Congestive cardiac failure probably secondary to myocardial infarction with the given clinical history 9/21/2010 Dr Saeed Salah Abduljalil 88

Which is this?: 

Which is this? Right pleural effusion Chronic abcess Cavitating carcinoma

Which is this?: 

Which is this? TB acess metastsis Cystic broniectasis

Mention 4 radilogical finding : 

Mention 4 radilogical finding Chest radiograph of a patient with mitral stenosis,Tricuspid regurgitation left atrial dilatation Pulmonary hupertension Cardiomegaly (right and left ) Right atrial enlargement Lung congestion

Slide 92: 

Bilateral pneoumotharax (barotrauma )

Total atelectasis , right lung : 

Total atelectasis , right lung

Calcified aneurysm ,left ventricle: 

Calcified aneurysm ,left ventricle

Congestive heart failure: 

Congestive heart failure

Slide 97: 

Thank you Saeedfm@hotmail.com @ saeed_salah on twitter