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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Nobuyuki Tanaka, MD Jeung Sook Kim, MD John D. Newell, MD Kevin K. Brown, MD Carlyne D. Cool, MD Richard Meehan, MD Takuya Emoto, MD Tsuneo Matsumoto, MD David A. Lynch, MB Index terms: Arthritis, rheumatoid,