NORMAL CHEST RADIOGRAPHY. Front and lateral view
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1 NORMAL CHEST RADIOGRAPHY Front and lateral view Dr Etienne Leroy-Terquem Centre hospitalier de Meulan les Mureaux. France French-cambodian association for pneumology (OFCP)
2 OFCP
3 How to obtain a good quality chest radiography (1) 3 functions are very important for good quality: The penetrating power of the x-ray beam (adjustment of x-ray tube voltage ) The x-ray tube current (milliampere) The exposure time adjustment
4 How to obtain a good quality chest radiography (2) The adjustment of the x-ray tube voltage controls the contrast: the difference of density levels of the different organs and tissues in the thorax The x-ray tube current and the exposure time controls the intensity of x-ray beams
5 How to obtain a good quality chest radiography (3) Adjustment of voltage High voltage: a range of 100 /120 kv: optimal contrast between lungs and bones, and good visualisation of mediastinum and vessels Exposure time seconds: decrease of motion artefact caused by the beating of the heart or respiratory movement
6 How to obtain a good quality chest radiography (4) A long distance between the tube focus and the film improves the image clarity and decreases the geometric blur
7 How to obtain a good quality chest radiography (5) Other criteria 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 Good quality electrical power supply Efficient and frequent maintenance of x-ray equipment Quality of films and good conditions of storage Good screen-film system Good techniques for x-ray film processing (developing, rinsing, fixing, washing and drying procedure). If possible automatic film processor.
8 What about digital X ray system?(1) composed with: Electronic flat-panel X ray detector High resolution grayscale diagnostic display High performance computer
9 What about digital X ray system?(2) Avantages: -feasible imaging quality adjusted by computer processing -easy and quick image processing -X-ray film and its processing procedures in dark room no more needed. Disadvantages: - Costly initial investment (61000 to $ - Significant trainning in digital technology needed for the radiological technicians and costly running maintenance
10 Incidences Front view profile view Other: radiography in expiration radiography in decubitus and lateral position Back view Other rare incidences: Oblique view Opacification of œsophagus Valsalva s test
11 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: Therefore, 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
12 Picture of 4 different solutions on a chest x-ray film calcium water oil Air
13 calcium water air oil
14 Dosage of x-rays type of investigation Equivalent of chest x-ray Equivalent of natural radiation chest x-ray 1 3 days TDM month-1year NMR: no radiation
15 Chest x-ray: criteria for quality Deep inspiration Adequate density Good position of the patient X-ray beam in postero-anterior incidence (the patient is standing)
16 OFCP
17 Poor inspiration False opacity of the inferior lobes Same patient with deep inspiration 9 posterieur parts of ribs over the diaphragm
18 cardiomegaly clavicles are high and horizontal The x-ray beam is antero posterior Same patient with correct postero-anterior x-ray beam incidence
19 The heart outline is bigger on D2 D1 D2 D1 D2 ( bird s-eye view of the patient)
20 Correct standing or sitting position for chest radiography
21 If the patient is in decubitus 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 is of poorer quality for analysis
22 Patient in decubitus patient standing up with postero-anterior X ray beam
23 Too low density No detail visible In the mediastinum area. Too high density no detail visible in the lung area
24 OFCP Correct density: Pulmonary vessels visible in the lungs, behind the diaphragm and behind the heart Para-aortic line visible Vertebra visible behind the mediastinum
25 Conditions for adequate density Correct x-ray factor (Kv, Mas, exposure time) Good conditions for developing and good quality of developing solution Correct temperature of developer correct quality of film
26 Exact front view : the vertical line connecting the spinous process of thoracic vertebrae is in the middle of the two sterno-claviculars joints.
27 exact front view left anterior oblique position
28 Front View l a o r a o D1 D2 D3 D3> D1>D2
29 Chest x-ray: to ensure top quality deep inspiration adequate density correct position of the patient (exact front view) x-ray beam in postero anterior incidence (the patient is standing)
30 Process for analysis of the chest radiography: the check list Verification of the name and the date Verification of the factors for good quality Analysis of the thoracic wall and thoracic skeleton Analysis of the mediastinum Analysis of each lung field, one after the other NO EXCEPTIONS IN THIS PROCESS!
31 Normal chest radiography and some pitfalls ( trouble-shooting)
32 OFCP Thoracic wall And skeleton
33 Thoracic wall Sus and retro clavicular field External side of Sternocleidomastoid muscle
34 Thoracic wall Sus and retro-clavicular field Pseudo aeric picture
35 thoracic wall The clavicles are projected on the level of the 3rd or 4th posterior part of ribs
36 Cervical ribs: minor malformation
37 Be wary of foreign substances on the chest x-ray trap picture: opacity of the superior part of right lung due to a hair braid
38 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
39 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
40 Always compare left and right TB infiltrate
41 Patient with fever, cough, AFB in sputum ++
42 You have no scanner. So use your eyes and Compare right and left! If you hesitate, ask for a chest X ray back against film
43 Normal chest x-ray, front close to the film Normal chest x-ray, back close to the film
44 Chest x-ray, front close to the film Chest x-ray, back close to the film
45 Thoracic wall physiological blur of the inferior side of the ribs Rib view section
46 You must always «read» a chest x-ray with methodical analysis: Example: for the chest wall, you must look at every rib, one after the other
47 Chest wall Top of the axillar hole Big pectoral muscle
48 Scapula thoracic wall
49 What is wrong with this chest x-ray? Congenital clavicles agenesy
50
51 Thoracic wall Breast silhouette
52 Be careful with false opacities in the inferior lobes, consequences of breast superposition.
53 Chest x-ray. Before and after right mastectomy
54 Thoracic wall Diaphragm The right side is usually higher than the left side (3cm )
55 OFCP Component elements of Mediatinum and hilus
56 AO AO PA LA RA RV LV RV LV
57 SVC AO PA AO RA LV RV PA LA LV Front view Lateral view LA RA LV RV
58
59
60 OFCP
61 Right pulmonary artery Left pulmonary artery
62
63 RSPV LPSV RIPV L A L V The pulmonary vena are not physiologiccally visible
64 OFCP
65 The main mediatinum lines
66 Mediastinum enlargment due to fat tissu
67 Courtesy of Dr. Anthoine
68 Be wary of false enlargment of mediastinum in cases of obesity, poor inspiration, oblique view or decubitus position
69 Trap: false mediastinum enlargment in the case of this older woman with cyphoscoliosis, in decubitus position
70 Component elements of lungs
71 On a normal chest x-ray, bronchi are not visible
72 but pulmonary arteries are visible.
73
74 Small fissura Big fissura Right view
75 Left fissura Left view
76
77 Normal lateral view
78 Lateral view
79 AO PA LA RV LV
80 SVC AO PA AO RA LV RV PA LA LV Front view Lateral view LA RA LV RV
81 Heart and Mediastinum vessels Superior vena cava Ascending Aorta Pulmonary arteria Right ventricle Descending aorta
82 Heart and Mediastinum vessels Left ventricle Inferior vena cava
83 Mediastinum vessels Aortic arch
84 mediastinum vessels Descending aorta
85 Mediastinum vessels Right pulmonary artery Left pulmonary artery
86 trachea 20 mm
87 Right superior lobe bronchus Left inferior lobe bronchus
88 Inferior vena cava
89 The «clear spaces» Retro sternal clear space Retro cardiac clear space
90 The «clear spaces» Retro tracheal space
91 enlargment of the clear spaces: Emphysema
92 Emphysema Normal lateral view
93 The retro sternal space is filled: thymoma. Normal view on the right
94 The retro sternal space is filled: thymoma
95 The clear spaces Retro cardiac clear space
96
97 Diaphragm
98 Thoracic wall Pectus excavatum sternum Pectus carinatum
99 Thoracic wall dorsal spinal column
100 Left lateral view Projection of the right posterior cul de sac Projection of the left posterior cul de sac
101 Projection of the left posterior cul de sac Projection of the right posterior cul de sac RIGHT LATERAL VIEW
The silhouette sign. Dr Etienne Leroy-Terquem Centre hospitalier de Meulan les Mureaux. France French-cambodian association for pneumology (OFCP)
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