Chest Radiography Interpretation: Reading Chest Films

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1 Chest Radiography Interpretation: Reading Chest Films Lisa Chen, M.D. Assistant Clinical Professor Pulmonary and Critical Care Division Department of Medicine San Francisco General Hospital Michael Gotway, MD Associate Clinical Professor, Radiology University of California, San Francisco

2 Approach to the CXR: Technical Aspects Inspiratory effort 9-10 posterior ribs Penetration thoracic intervertebral disc space just visible Positioning/rotation medial clavicle heads equidistant to spinous process

3 Low Lung Volumes

4 Over Exposure Proper Exposure

5 10

6

7 What to Evaluate Lungs Pleural surfaces Cardiomediastinal contours Bones and soft tissues Abdomen

8 Where to Look Apices Retrocardiac areas (left and right) Below diaphragm

9 Apical TB

10 Left Retrocardiac Opacity

11 Normal Anatomy: Frontal CXR Heart Aorta Pulmonary arteries Airways Diaphragm/costophrenic sulci Junction lines

12

13 Normal Anatomy: Lateral Heart Aorta Pulmonary arteries Airways Spine

14 AA RV LV

15 Chest Radiography: Basic Principles X-ray photon fates: completely absorbed in patient transmitted through patient; strike film scattered within patient; strike film X-ray absorption depends on: beam energy (constant) tissue density

16 Maximum x-rayx Transmission (least dense tissue) Blackest air fat soft tissue calcium bone Maximum x ray x Absorption (densest tissue) x-ray contrast metal Whitest

17 Chest Radiography: Basic Principles All cardiothoracic pathology and normal anatomy is visualized (or not) by 7 different densities How is this accomplished? differential x-ray x absorption

18 Differential X-Ray X Absorption A structure is rendered visible on a radiograph by the juxtaposition of two different densities

19 Silhouette Sign Loss of the expected interface normally created by juxtaposition of two structures of different density No boundary can be seen between two structures of similar density

20 Right Lower Lobe Pneumonia

21 Differential X-Ray X Absorption The absence of a normal interface may indicate disease; The presence of an unexpected interface may also indicate disease The presence of interfaces can be used to localize abnormalities

22 Chest Radiographic Patterns of Disease Air space opacity Interstitial opacity Nodules and masses Lymphadenopathy Cysts and cavities Lung volumes Pleural diseases

23 Chest Radiographic Patterns of Disease Cardiomediastinal contour abnormalities Bone and soft tissue abnormalities Below the diaphragm: abdominal and retroperitoneal disease

24 Air Space Opacity Components: air bronchogram: : air-filled bronchus surrounded by airless lung confluent opacity extending to pleural surfaces segmental distribution

25 Air Space Opacity: DDX Blood (hemorrhage) Pus (pneumonia) Water (edema) hydrostatic or non-cardiogenic Cells (tumor) Protein/fat: alveolar proteinosis and lipoid pneumonia

26 LUL Pneumonia

27 Interstitial Opacity Hallmarks: small, well-defined nodules lines interlobular septal thickening fibrosis reticulation

28 Interstitial Opacity: Small Nodules

29 Interstitial Opacity: Lines

30 Interstitial Opacity: Lines & Reticulation

31 Interstitial Opacity: DDX Idiopathic interstitial pneumonias Infections (TB, viruses) Edema Hemorrhage Non infectious inflammatory lesions sarcoidosis Tumor

32 Nodules and Masses Nodule: any pulmonary lesion represented in a radiograph by a sharply defined, discrete, nearly circular opacity 2-30 mm in diameter Mass: larger than 3 cm

33 Nodules and Masses Qualifiers: single or multiple size border definition presence or absence of calcification location

34 Well-Defined Ill-Defined Mass Calcification

35 Lymphadenopathy Non-specific presentations: mediastinal widening hilar prominence Specific patterns: particular station enlargement

36

37

38 Right Paratracheal Lymphadenopathy

39 Right Hilar LAN

40 Right Hilar LAN

41 Left Hilar LAN

42 Subcarinal LAN

43 Subcarinal LAN *

44 AP Window LAN

45 Cysts & Cavities Cyst: abnormal pulmonary parenchymal space, not containing lung but filled with air and/or fluid, congenital or acquired, with a wall thickness greater than 1 mm epithelial lining often present

46 Cysts & Cavities Cavity: abnormal pulmonary parenchymal space, not containing lung but filled with air and/or fluid, caused by tissue necrosis, with a definitive wall greater than 1 mm in thickness and comprised of inflammatory and/or neoplastic elements

47 Cysts & Cavities Characterize: wall thickness at thickest portion inner lining presence/absence of air/fluid level number and location

48 Benign Lung Cyst : PCP Pneumatocele Uniform wall thickness 1 mm Smooth inner lining

49 Benign Cavities : Cryptococcus max wall thickness 4 4 mm minimally irregular inner lining

50 Indeterminate Cavities max wall thickness 5-15 mm mildly irregular inner lining

51 Malignant Cavities: Squamous Cell Ca max wall thickness 16 mm Irregular inner lining

52 Pleural Disease: Basic Patterns Effusion angle blunting to massive mobility Thickening distortion, no mobility Mass Air Calcification

53 Pleural Effusion

54 Pleural Effusion

55 Subpulmonic Effusion

56 Pleural Calcification

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