Chest X-Ray Interpretation for the Internist. Theresa Cuoco, MD August 2, 2012

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1 Chest X-Ray Interpretation for the Internist Theresa Cuoco, MD August 2, 2012

2 Disclaimer: I am NOT a radiologist!

3 Why do we need to know? To direct care while awaiting an official read Low level radiation for the patient Easily available and noninvasive Relatively inexpensive

4 Objectives Basics of technique Initial basics and type of film Identification of structures on a normal CXR Alveolar vs interstitial, lobar anatomy, silhouette sign, air bronchograms, and patterns of lung disease The mediastinum, pleura, and heart

5 The Basics ( the TIONS ) IdentificaTION InspiraTION PenetraTION RotaTION

6 Inspiration vs. Expiration Indications for an expiratory film? -To detect pneumothorax or look for air trapping (would remain inflated and black instead of white)

7 Penetration A B Heavy light exposure causes the film to be black (A) Little light exposure causes the film to be white (B)

8 Rotation

9 Technique PA and lateral AP Which is preferred and why? Less magnification, sharper images Better inspiratory effort, pleural fluid and air easier to see Lateral film left side of chest against x-ray cassette Decubitus films

10 Which is which? Crisp CPA More magnification, dull images, poor inspiratory effort

11 Normal Anatomy A. CPA B. Left diaphragm C. Heart D. Aortic knob E. Trachea F. Hilum G. Carina H. Stomach bubble J. Ascending aorta

12 The Normal Chest X-Ray A. Gas in splenic flexure B. CPA C. Heart D. Descending aorta E. Trachea F. Carina G. Hilum H. Aortic knob J. Ascending aorta K. Right diaphragm The left hilum is slightly higher than the right this is normal

13 Alveolar vs. Interstitial Alveolar = air sacs Radiolucent Can contain blood, mucous, tumor, or edema ( airless lung ) Interstitial = vessels, lymphatics, bronchi, and connective tissue Radiodense Interstitial disease: prominent lung markings with aerated lungs

14 Lobar Anatomy Anterior Right: Upper, middle, lower Left: Upper and lower Posterior The fissure has to be parallel to the x ray beam for it to be seen on the film. The oblique (major) fissures are not visible on the normal frontal projection

15 Lobar Anatomy Lateral Views Right Left

16 The Silhouette Sign There are 4 basic radiographic densities Gas, fat, soft tissue (water), and metal (bone) Anatomic structures are recognized on x-ray by their density differences Two substances of the same density in direct contact can t be differentiated Loss of the normal radiologic silhouette (contour) is called the silhouette sign

17 Localizing Lesions Where is the silhouette sign? Obscured right heart border Right middle lobe infiltrate

18 Localizing Lesions You can still see right heart border

19 Localizing Lesions A: lost heart border = lingular B: lost hemidiaphragm = LLL

20 Localizing Lesions A: loss of right hilum; ascending aorta B: lost aortic knob

21 Localizing Lesions: Review Ascending aorta, upper R heart border = RUL R heart border = RML R anterior hemidiaphragm = RLL Aortic knob = LUL L heart border = lingula L anterior hemidiaphragm or descending aorta = LLL

22 The Air Bronchogram When lung is consolidated and bronchi contain air, the dense lung delineates the air-filled bronchi Visualization of air in the intrapulmonary bronchi is called the air bronchogram sign Abnormal finding Can be seen in: PNA, edema, infarction Chronic lung lesions

23 NO Air Bronchograms In pneumonia if bronchi are filled with secretions If cancer obstructs a bronchus Interstitial fibrosis Asthma/emphysema (hyperinflation)

24 What do you see?

25 Lung and Lobar Collapse When a whole lung collapses, the trachea deviates TOWARD the side of collapse (due to volume loss) Left lung consolidated and collapsed

26 Fissures Formed by 2 visceral pleural layers Demarcate the boundaries of the lobes Shift of fissures is best sign of lobar collapse Minor fissure shifts up: RUL collapse Minor fissure shifts down: RML collapse Major fissures shift down: LL collapse

27 Which lobes have collapsed? Minor fissure is elevated RUL partially collapsed Heart has moved to right and silhouette sign of right diaphragm indicated RLL collapse

28 Hilar Displacement The left hilum is normally slightly higher than the right Hilar depression indicates collapse of lower lobe Hilar elevation indicates collapse of upper lobe

29 The Mediastinum A. Ascending aorta B. Aortic knob C. Descending aorta D. R heart border E. SVC F. R tracheal wall G. L heart X. retrosternal clear space Outside mediastinum: L. L pulmonary artery R. R pulmonary artery

30 The Mediastinum I: Anterior Mediastinum Heart Retrosternal clear space 4 T s II: Middle Mediastinum Esophagus Arch and descending aorta Trachea III: Posterior Mediastinum Paravertebral area; most masses neurogenic Lymph nodes in all 3!

31 The Pleura The posterior costophrenic angle is the deepest and only seen on the lateral film The lateral film is more sensitive for detection of small pleural effusions How much fluid can be seen on a radiograph? Erect PA: 175 ml Erect lateral: 75 ml Decubitus: >5 ml Supine: Several hundred ml

32 What do you see?

33 Pneumothorax Air enters pleural space with each breath but cant escape, increasing intrapleural pressure increased pressure depresses the diaphragm, collapses the lung, and shifts the mediastinum away Clinical signs: rapid onset respiratory failure, decreased breath sounds, deviated trachea, JVD

34 The Heart The horizontal width of the heart should be less than ½ the widest internal diameter of the thorax

35 Left and Right Ventricular Enlargement Left ventricular enlargement Frontal: LHB moves laterally and cardiac apex inferolaterally Lateral: LHB moves inferoposteriorly Right ventricular enlargement Frontal: RHB further right Lateral: Contacts lower half of sternum (instead of lower 3 rd )

36 Cephalization Enlargement of the upper lobe vessels Vascular redistribution Kerley B lines: interstitial edema thickening the interlobular septa causing short lines perpendicular to the pleural surface

37 Systematic approach ABCDE Airway Bones and breasts Cardiac and costophrenic Diaphragm Edges and extrathoracic Fields (lung fields and failure)

38 Cases

39

40

41

42

43 Young man with cancer

44 Osteosarcoma w Pulmonary Met Metal nipple markers have been placed 1. pulmonary nodule below right nipple marker where ribs cross 2. Right shoulder amputated: pulmonary met from osteosarcoma

45 Young man without symptoms

46 Anterior Mediastinal Mass Strange cardiomediastinal shape on left - causes silhouette of left atrium,pulmonary artery, and aortic arch Lateral shows density in retrosternal clear space

47 Dyspnea with sudden CP & fever

48 Heart Failure and Perf Ulcer Cephalization, enlarged heart, free air

49

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