NORMAL CHEST X RAY. Dr Etienne Leroy Terquem Pr Pierre L Her SPI / ISP Soutien Pneumologique Internationa / International Support for Pulmonology
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1 NORMAL CHEST X RAY Dr Etienne Leroy Terquem Pr Pierre L Her SPI / ISP Soutien Pneumologique Internationa / International Support for Pulmonology
2 THE CHEST RADIOGRAPHY (CXR) The CXR, is very usefull for all lung problems, it extends the clinical examination and provides essential data for diagnosis Its technical realization, simple, uses X-rays Principle : 1. The rays emitted by the X-ray tube through the chest 2. They are absorbed or mitigated to varying degrees by the different structures crossings 3. The changes are recorded on X-ray film in a cassette lead, then visualized (developing hand or in a machine after opening the cassette in the darkroom)
3 Chest X ray Reproduce 1 volume (thorax) on 1 plan (film) On this flat reproduction, you must recognize normal anatomic structures of the thorax and find out what is abnormal X Rays
4 Calcium Water Oil Air Opacity Clarity Radiography of 4 identical tubes containing calcium, water, oil, air One containing Ca stop X-rays => its image is white Air is transparent to X-rays => its radiological picture is black Fat and water have an intermediate absorption => white - gray
5 The thorax is composed of: Bone (vertebrae, ribs, scapula ). The main component is calcium, which absorbs the x-ray considerably: the bone image is very opaque (white on the radiography) Blood and soft tissue (heart, mediastinum, vessels). The absorption of x-rays is less complete than bones: the image is less opaque (light grey) Fat tissue. the absorption of x-rays is lower: the image is dark grey Air (in lungs) which does not absorb the x-ray at all. The image of the lungs is black
6 calcium Fluid / soft tissu air Fat
7 The chest X ray 3 constants regulate its quality: the quantity of electrons which pass through the chest (milliampere) the speed of the electron (kilovoltage) the exposure time A chest X-ray of good quality requires : high voltage ( kv) => Contrast a short time of exposure deep inspiration 0.05 sec. Movement artefacts Difference of density levels of the different organs and tissues in the thorax A long distance between X-ray tube focus and film
8 How to obtain a good quality chest X-ray A long distance between X-ray tube focus and film improves picture clarity and reduces geometric blur
9 How to obtain a good quality chest X-ray Other criteria Good quality electrical power supply Effective & frequent maintenance of equipment Quality films and good storage conditions Good film processing (development, rinsing, fixing, washing, drying). If possible automatic developing machine Quality of the x-ray grid: the flat metallic plate with very narrow lead trips close to the film: increase in the image clarity and reduction of the scattered radiation from the patient
10 And digital radiography? The X-ray tube is identical the radiographic film is replaced by an X-ray receiver which enables scanning in numeric * The image display is done in grayscale high resolution on a powerful computer * For computed radiography (CR) a reusable cassette containing a luminescent screen memory ("phosphor plates") introduced in a reader connected to the computer For direct "digital Radiography (DR) direct scanning receiver that transmits the image directly on the computer
11 And digital radiography? The X-ray tube is identical the radiographic film is replaced by an X-ray receiver which enables scanning in numeric * The image display is done in grayscale high resolution on a powerful computer X-Ray Tube Analog Rx Film - Chemical Development CR Reusable plate with radio-luminescent memory screen + reader DR Electronic panel X-ray detector
12 Digital Radiography Advantages : Quick and easy image processing Adjusting the picture quality (Processing) No films, No chemicals No darkroom Data Storage Transfer remote to an expert "telemedicine Disadvantages: Expensive initial investment ( to U.S.). But prices decrease.. Need for training for operators of Radiology Need for maintenance
13 But prices decreases,especially for DDR.
14 Clearly WHO recommands X-ray D DR and Xpert See Internet
15 See Internet
16 In summary Digital X ray system (Direct Digitalised System) composed with: Electronic flat-panel X ray detector High resolution grayscale diagnostic display High performance computer The top!,expansive but prices decreases
17 Direct digital radiography (DR) comprises: A flat panel electronic X-ray detector Display high resolution grayscale A high performance computer
18 Transportable DR unit
19 Possible compromise with computed radiography (CR system) Digital radiography using a Photo stimulable Phosphor plate (PSP, also called Imaging Plate, IP) enclosed in a cassette as a detector, instead of a film screen. The IP is then introduced into a CR Reader which reads the film and converts the recorded signal into a digital grey scale image Same avantages than digitalised system Lower cost than DR system, because can be used with the existing X ray equipment. Only a CR reader and CR cassette (with Imaging Plates) need to be purchased
20 Computed Radiograpy (CR) CENAT Phnom Penh Cambodge Dr Peou Satha
21 IMIS Hospital Port-au-Prince Haïti CMETE Paris
22 Dosage of x-rays type of investigation Equivalent of chest x-ray Equivalent of natural radiation chest x-ray 1 3 days CT-Scan month-1year NMR: no radiation
23 CXR - Basic radiographic views: Front view : Postero - anterior view Lateral view Other views : Expiration Radiography CXR in suppine position Radiography in suppine and lateral position Back view Antero-posterior view
24 CXR - Quality Criteria Deep inspiration Adequate density / contrast Good position of the patient (strictly front) X-ray beam in postero-anterior incidence (patient standing)
25
26 Poor inspiration False opacity of the inferior lobes Same patient with deep inspiration Adequate inspiration if you can count 9 posterior or 6 anterior parts of ribs over the diaphragm
27 posterior arches or 6 anterior arches above the diaphragm
28 AP versus PA view False cardiomegaly clavicles are high and horizontal The x-ray beam is antero posterior Same patient with correct postero-anterior x-ray beam incidence PA is the correct view The technician should specify the position of the patient if AP view
29 The heart outline is bigger on D2 PA AP D1 D2 D1 D2 ( bird s-eye view of the patient)
30 Correct standing or sitting Postero Anterior position for chest radiography
31 Standing or sitting position not always easy to obtain
32 If the patient is in supine position (too ill to stand up), the cardiac outline and Mediastinum is enlarged. The scapula may be on the lung field. The chest x-ray has poor quality for analysis
33 Patient in supine position Standing patient with postero-anterior X ray beam The technician should specify the patient position if supine
34 Light film Under penetration No detail visible in the mediastinum area. Dark film no detail visible in the lung area
35 OFCP Correct density and good contrast: - Pulmonary vessels visible in the lungs, below the diaphragm and behind the heart -Para-aortic line visible - Vertebra visible behind the mediastinum
36 Conditions for adequate contrast / density Correct x-ray factor (Kv, Mas, exposure time) Good conditions of developing and good quality of processing chemicals Correct temperature of developer Correct quality of film In case of digitalised or computerised system, imaging quality is adjusted by computer processing and the 3 last conditions are no more needed.
37 Exact front view : the vertical line connecting the spinous processes of thoracic vertebrae is in the middle of the two sterno-clavicular joints
38 Front View l a o r a o D1 D2 D3 D3> D1>D2
39 exact PA view left anterior oblique position cardiac silhouette is smaller
40 right anterior oblique position ( false enlargment of cardiac silhouette)
41 Chest x-ray: to ensure top quality Deep inspiration Adequate contrast / density Correct position of the patient (exact front view) X-ray beam in postero anterior view (the patient is standing)
42
43 Normal chest radiography and some pitfalls ( trouble-shooting)
44 What do you read in this triangle? Courtesy Martina Martins, Charles Perrot and Nigel Howarth (Radiology depatment university hospital Geneva
45
46 Did you notice that «the» was written twice? Courtesy Martina Martins, Charles Perrot and Nigel Howarth (Radiology depatment univerity hospital Geneva
47 Unstructured gaze leads to no results (exemple: the watch that we watch dozens of times) Color and shape of the dial? Arabic or Roman numerals? Form of needles? Location of brand name? Where is the date stamp? Look at your watch: How many mistakes have you done Probably a lot. And yet... this is the subject most frequently watched in the day!!!
48 To enjoy reading the chest radiograph, the gase should be disciplined To discipline the gase one must have resort to a method of examination
49 Young man with a right chest pain and shortness of breath with sudden onset Le syndrome de New York
50 You had of course noticed the large right pneumothorax
51 Did you see that he also had a small left pneumothorax? L imagerie thoracique pour l ECN Pr C. H. Marquette- Pr B. Padovanni
52 Process for analysis of the chest radiography: the check list Verification of name and date Clinical history and findings Verification of the factors for good quality Assess - Thoracic wall and thoracic skeleton («first circle») - Each lung field, one after the other («2 nd circle») - Mediastinum («third circle») Do not skip any item in the checklist!
53 First Circle: Soft part of the chest wall diaphragmatic areas bony thorax
54 Second Circle: Lung tissue Reading from top to bottom Comparing left and right side
55 Third circle: Mediastinum: The container (= edges) The content (= behind the heart Hilus areas
56 The hidden area There are some areas that need special attention, because pathology in these areas can easily be overlooked: Apical zones Hilar zones Retrocardial zone Zone below the dome of diaphragm
57 OFCP Thoracic wall And skeleton
58 Thoracic wall Clavicles External side of Sterno cleido-mastoid muscle
59 Thoracic wall 1 The clavicles are projected on the level of the 3rd or 4th posterior part of ribs 3 4
60 Cervical ribs Minor malformation
61 RUL TB infiltrate?
62 Be aware of foreign body or artefacts on the chest x-ray trap picture: opacity of the superior part of right lung due to a hair braid
63 Breast implant
64 Woman, cough but no fever, no woresening condition. Diagnosis: Right inferior lobe pneumonia
65 Breast prosthesis superposition! (past history of breast cancer )
66 The retro-clavicular fields are always difficult to analyse, because of bone superposition: - Clavicles - Anterior part of first rib - Posterior part of third and fourth rib, - Sterno-clavicular joint
67 There are 2 ways to correctly analyse the retro-clavicular fields: Always compare right and left Ask for a chest x-ray with the patient s back against the film (AP view, lordotic position)
68 Always compare left and right RUL TB infiltrate
69 Patient with fever, cough, AFB sputum positive
70 You have not CT scan. So use your eyes and Compare right and left! If any doubt, request AP/ lordotic chest X ray
71 Special incidence for apex view Courtezy DR Nay Wunn Linn NTP Myanmar
72 Normal chest x-ray, front close to the film Normal AP chest x-ray, back close to the film
73 Chest x-ray, front close to the film Chest x-ray, back close to the film And clavicles out of the field by raising hands
74 Fever and weight loss. No respiratory symptoms
75 Small infiltrate in the right apex well visible on PA view. Notice the difference between right and left apex.
76 Chest x-ray back close to the film
77 Thoracic wall physiological blur of the inferior side of the ribs Rib view section
78 Is this CXR normal?
79 6th and 9th ribs missing on this CXR You must always read a chest x-ray with methodology: For the chest wall, you must look at every rib, one after the other
80 Chest wall Top of the axillar hole Big pectoral muscle
81 Scapula thoracic wall
82 What is wrong with this chest x-ray?
83 What is wrong with this chest x-ray? Congenital clavicles agenesy
84
85 Thoracic wall Breast silhouette
86 Be careful with false opacities in the inferior lobes, consequences of breast superposition.
87 Chest x-ray. Before and after right mastectomy
88 Carefull with the nipples. (not only in women CXR)
89 Thoracic wall Diaphragm The right side is usually higher than the left side (3cm )
90
91 Component elements of lungs
92 On a normal chest x-ray, bronchi are not visible except trachea and proximal part of main right and left bronchi (opacification with iodin hydrosoluble solution)
93 The grey part of this diagrammis visible on the CXR
94 Only trachea and proximal part of main left and right bronchi are visible on the chest X ray
95 but pulmonary arteries are visible.
96 but pulmonary arteries are visible.
97 Pulmonary arteries and bronchial tree are parallelic ( it is not the case for pulmonary veni )
98
99 Small fissura Big fissura Right view
100 Left fissura Left view
101 minor fissure Right superior lobe pneumonia Large oblique fissure posterior part minor fissure
102
103 Right inferior pneumonia Large oblique fissure
104
105 minor fissure Large fissure (anterior part) Small pleural effusion Middle lobe pneumonia
106
107 External segment of middle lobe pneumonia
108 External segment of middle lobe pneumonia
109 Left upper lobe pneumonia
110
111 Left inferior pneumonia Left fissure
112
113
114 Component elements of Mediatinum and hilus
115 AO AO PA PA LA RV RA RV LV LV
116 SVC AO PA AO RA LV RV PA LA LV Front view SVC: superor vena cava AO : aortic vessel PA: pulmonary artery RA: right atrium LV; left ventricle LA: left atrium RV: right ventricle Lateral view LA RA LV RV
117
118
119 Left pulmonary artery Right pulmonary artery
120
121 RSPV LPSV RIPV L A L V The pulmonary vena are not physiologiccally visible
122 RSPV LPSV RIPV L A L V The pulmonary vena are not physiologiccally visible
123 Mediastinum lines X ray beam crossing thorax and mediastinum meets in some places pleural thickness, producing images on the CXR like lines defining mediastinum lines
124 Mediastinum lines 1. Sub clavicle arterial line 2. Posterior mediastinum line 3. Brachio cepahalic vena line 4. para-azygos line Too complicated And not so usefull 5. Anterior mediastinum line 6. Descending aortic line 7. Right and left paravertébral line 8. Inferior veina cava line 9. para-œsophageal line 10. para-trachéal line 6
125 Right paratracheal line Aorto pulmonary line Para-aortic line 3 of them are really important.
126 Para tracheal line Aorto- pulmonary line Para aortic line
127 Mediastinum enlargment due to fat tissu
128 Mediastinum enlargment due to fat tissu
129 Be aware of false enlargment of mediastinum if obesity, poor inspiration, oblique view or supine position
130 Trap: false mediastinum enlargment in the case of this older woman with cyphoscoliosis, in supine position
131
132 Normal lateral view
133 Lateral view
134 AO PA LA RV LV
135 SVC AO PA AO RA LV RV PA LA LV Front view SVC: superor vena cava AO : aortic vessel PA: pulmonary artery RA: right auricle LV; left ventricle LA: left auricle RV: right venticle Lateral view LA RA LV RV
136 Superior vena cava area Ascending Aorta Pulmonary arteria Right ventricle Descending aorta Heart and mediastinum vessels
137 Heart and Mediastinum vessels Left ventricle Inferior vena cava
138 Mediastinum vessels Aortic arch
139 mediastinum vessels Descending aorta
140 Mediastinum vessels Right pulmonary artery Left pulmonary artery
141 normal CXR Lateral view is very useful for diagnosis of mediastinal adenopathies
142 Lateral view is very useful for diagnosis of mediastinal adenopathies
143 trachea 20 mm
144 Right superior lobe bronchus Left superior lobe bronchus
145
146 The «clear spaces» Retro sternal clear space Retro cardiac clear space
147 The «clear spaces» Retro tracheal space
148 enlargment of the clear spaces: Emphysema
149 Emphysema ( notice clear space enlargment and flattened diaphragm ) Normal lateral view
150 The retro sternal space is filled: thymoma
151 The retro sternal space is filled: thymoma. Normal view on the right
152 Diaphragm Right diaphragm Left diaphragm
153 Summary normal CXR
154 Normal frontal chest view Aortic arch (AA) Descending aorta (DA) Proximal left pulmonary artery (PLPA) Left interlobar pulmonary artery (LPA) Aortopulmonary window (AW) Left main bronchus (LB) Left atrial appendage (LAA) Left ventricle (LV) Superior vena cava (SVC) Right paratracheal stripe (RPS) Azygos vein (AV) Aortic arch (AA) Right interlobar pulmonary artery (RIPA) Right atrium (RA) Trachea (T) RD SVC RPTS AV RIPA RA T A A A W DA LPA LB LV LD
155 Normal lateral chest view Posteriorly: vertebral bodies (V) and intervertebral disc spaces (*) Anteriorly: retrosternal clear space (RSCS) Trachea (T) Orifice of Right Upper Lobe bronchus (RUL) appears as circular lucency projecting over the continuation of the tracheal air column Left pulmonary artery (LPA) Right pulmonary artery (RPA) Left auricle (LA) Left ventricle (LV) Right ventricle (RV) Aortic arch (AA) Postero costo phrenic angle (PCPA) Right diphragm (RD) Left diaphragm (LD) Inferior vena cava (IVC) Scapula (Sc) Retro cardiac clear space (RCCS) RD RSCS RPA RUL RV LV T AA LA RCCS IVC LD Sc LPA V * PCPA
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