channa6thfeb10cxrppt

7/28/2019 channa6thfeb10cxrppt

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Chest X-RayCollection

By

AMIR B.CHANNA FFARCS,DA (Eng)King Khalid Univ. Hospital

Riyadh KSA


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Most important things when

reading a CXR

Have a System

Use it consistently

Know your anatomy

Diff. diagnosis & Pathophysiology


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Step #1:

Always, always, always

Confirm the patients name & checkdate on film


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Step #2:

Know a good CXR when you seeone assess the films quality

HOW ?


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Assessing Quality: R.I.P.

R Rotation clavicles- symmetric & flush with sternum

I Inspiration want to see at least 8-9 ribs for a good film

P Penetration should see vertebral bodies thru the heart


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Step #3:

Read the filmDO NOT JUMP TO DIAGNOSIS


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My System: the Short Version:(Use this for routine films)

A Airways

B Bones & soft tissues C Cardiac silhouette

D Diaphragm

EEverything else the lungs


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The Long Version:Use this system for more complicated films

on the wards & at Morning Report R Rotation (clavicles- symmetric & flush with sternum) I Inspiration (want to see at least 8-9 ribs for good film) P Penetration (should see vertebral bodies thru the heart) A Airways (trachea shifted or irregular, bronchiectasis, ETT) B Bones (frxs, osteoporosis, lytic lesions, skeletal deforms) C Cardiac silhouette (CM, chamber enlargements, aorta, Ca++) D Diaphragm (R higher L?, phrenic nerve palsy, pleural

lesions)

E Effusions (pleural/pericardial; effusion size, does it layer out) F Free air (under diaphragm, in sub-Q tissue, mediastinum) G GI pathology gastric bubble (shifted by spleen) H Hilum (LAD, vascular congestion, calcifications/granulomas) IJ IJ catheters & other lines (confirm they are in the right

place)

K Kerley-B lines, Kypho-scoliosis and skeletal deformities


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More Details on the Lungs:

Features to look for when characterizingparenchymal lung disease:

Over/under inflation (9 ribs visible) suggests arestrictive or obstructive process

Pneumothorax, atelectasis or volume loss

Air bronchograms or bronchiectasis

Infiltrates (describe as lobar, multi-lobar, diffuse)

Mass/nodule (+/-3cm), shape, cavity?, Ca++?

Interstitial pattern (alveolar, reticular, miliary)

Distribution of infiltrates: apical, basilar, pleural

Vascular flow: oligemia? cephalization?


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Investigations

Chest Radiograph

PA

APIllpatient

Lateral

Mass localisation, cardiac chambers, hila Expiratory


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1

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1234

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A

B

C

Heart size - Cardiothoracic Ratio (CTR)

A+B/C


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Investigations

CT Focal masses

Diffuse lung disease

Pulmonary emboli

Ultrasound

Diaphragm, pleura

Magnetic Resonance

Mediastinum Lung apex

Intervention

Biopsy, Drainage


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Slicewidth

Conventional CT


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Spiral CT


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Air

Bone

Water


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Normal Anatomy

B CT R i


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Bone-CT Reconstruction

PA View

Clavicle

Rib Intercostal

SpaceVertebral

Column


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Sternum

Rib

Bone Anatomy


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Heart Size Normal is


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Lateral view

Cardiac Anatomy: Right Sided


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Cardiac Anatomy: Right Sided

Chambers

C di A t L ft Sid d


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Cardiac Anatomy: Left Sided

Chambers


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SVC Aortic Arch

Right Descending

Pulmonary Artery

Left Descending

Pulmonary Ater

Lungs posteriorly


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Lungs posteriorly

should get darker as

you go down more

inferiorlyRetrosternalAirspace

Scapula

IVC

Pulmonary

Vessels

Hilum

Ai A t


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Airway Anatomy

Trachea

Cartilage

Membranous posteriorly

Carina

Bifurcation

Bronchus

Left and right

Lobar (RUL,RML,LUL,LLL)

Segmental (8 left, 10 right)


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Trachea

Carina

R + L Main

Bronchi


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Lung Anatomy

Lobes are separated by fissures Right

Upper Lobe

Middle LobeLower Lobe

Left

Upper Lobe (includes lingula)Lower Lobe


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Pleura and Fissures Pleura

Lubricates and prevents friction during

respiration

Potential SpaceDont see unless abnormal

Parietal pleura: Lines chest wall,

mediastinal and diaphragmatic surfaces

Visceral pleura: Lines lungs, fissures


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Parietal Pleura

Visceral pleura


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Diaphragms

Normal: Sharp costophrenic sulcus


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Which is right and left diaphragm?


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Approach to Chest Radiograph:


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Approach to Chest Radiograph:

Technical Factors

Patient Identification (name and date)

Markers (Left vs right)

Assess for rotation (clavicles vs spinousprocess)

Penetration (thoracic spine should be

visible) Degree of Inpiration: 6th anterior or 10th

posterior

Clavicles


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Clavicles

Spinous Process

Vertebral Body

Visible6

7

Counting anterior

ribs

10

11

Counting posterior ribs


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Inspiration/Expiration Images

Expiration

Heart size appear larger

Mediastinum is wider

Pulmonary vasculature indistinct


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4th Anterior

8th Posterior

Expiration Image


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Inspiration: Same PatienExpiration

Abnormal Cases


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Abnormal Cases

Bone

Cardiovascular

Airspace Disease including Silhouette Sign

Interstitial Disease and Pulmonary Edema Atelectasis

Pulmonary Nodule

Pleura and Diaphragm Mediastinal Mass


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Bone and Soft Tissues


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Productive 1st rib changes:

Can simulate nodule

Lordotic View


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Lordotic View

Better assess apices without bone over

Rib Fracture


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Presenting CXR


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MRI

Computed Tomography

Pancoast Tumour

Cardiovascular


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Increased Cardiac Size: Can be


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Increased Cardiac Size: Can be

Cardiac or Pericardial

Pericardial EffusionDilated Cardiomyopathy

What imaging would you use to differentiate between the t


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Left Ventricular Enlargement

Enlargement of Left Ventricle

Left

Ventricle

IVC


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Airspace Disease and Silhouette

Sign


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Airspace Disease

Filling in of acini (air space)

Air space (acinar) nodules

Coalesce to consolidation

Air bronchograms

Silhouette Sign


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Air Space Disease: Etiology

Water-Pulmonary Edema

Pus-Infections, Non-infectious

inflammatory process Blood-Pulmonary Hemmorhage Protein-Alveolar Proteinosis

Tumour-BAC, Lymphoma


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Bronchopneumonia Pattern: Airspace Nodules

Acinar Nodules


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Acinar Nodules

Computed

Tomography

Air Bronchogram


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Air Bronchogram

Airways are not normally seen in a normal

chest radiograph because they are an air

structure within an aerated lung

When the aerated lung opacify, the bronchii

become visualized because of the

surrounding contrast effect.


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Silhouette Sign


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g Definition: The effacement of a normal structure

Example: Airspace disease may silhouette:

right heart margin with right middle lobe pneumonia

diaphragm with lower lobe pneumonia

Where is the Pneumonia?


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What Types of CXRs AreAvailable?


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When to get special views


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When to get special views

- Decubitus: Excellent to assess effusions before thoras

Want to see >10mm (1cm) fluid that layers freely

Supine:

Patient is vented or too ill to go to X-ray

Oblique: Good for rib views to r/o frxs

Lordotic: Used to look at the lung apices (TB infection)

Expiratory: Used to exclude small PTX (after thoras)


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Case #201


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CXR 201


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P ti t t t th WSVA


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Patient presents to the WSVA

emergency room with severe abd pain,

nausea & vomiting the lab calls and

says their machine is broken

A Portable film was obtained in the

ER you have only this CXR withwhich to make your Dx


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35 yo with chronic cough, new

onset oligoarthritis & painfulnodules on his BLEs

A Portable film was obtained in the

ER


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Case #204


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44 yo alcoholic presents withnew onset SOB

PA & lat from the ED

CXR 204


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CXR 204 (lat)


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Identify the problem with this patient having this

CXR, what are its anesthetic implications

Identify the


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y

problems

with thispatient

having thisCXR, what

are its

anestheticimplications


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Identify the


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Identify the

problemswith this

patient

having thisCXR, what

are its

anesthetic

implications


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Identify the problem with this patient having this CXR, what

are its anesthetic implications & how will you manage this


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Identify the problem with this patient having this CXR, what

are its anesthetic implications & how will you manage this

patient


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Identify the problem with this patient having this CXR,

what do the arrows point toward

& what are its anesthetic implications


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Case #205

Same 44 yo alcoholic presents 1


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Same 44 yo alcoholic presents 1

week later with fevers & chills

PA/lat CXR performed in the ED


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CXR 205 (lat)


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50 yo male with sinusitis, fever


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& progressive cough/DOE for 8weeks

An AP film was obtained in the ED

CXR 206


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Case #207


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40 yo with HIV (refused HAART),


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y ( )

presents with new SSCP

A portable film was obtained in theED

CXR 208


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Case #209


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CXR 209


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Case #210

60 yo with 1 week of progressive DOE


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followed by SOB at rest

AP film was obtained in the ED

CXR 210


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CXR from 3

months prior


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70 yo presents with 6 weeks of

progressive DOE chronic n-p cough


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progressive DOE, chronic n-p cough

and now SOB at rest

PA & lateral films were obtained in

the ED

CXR 211


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CXR 211 (lat)


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55 yo with severe epigastric pain x 2

days followed by 4 hours of new


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days followed by 4 hours of new

onset SSCP and worsing abd pain

Portable film obtained in the ED


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Case #213

45 yo smoker gets this pre-op CXRbefore an elective Nissen

fundapplication


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fundapplication

Hes been having a lingering non-

productive cough x 6 weeks

This PA film was obtained

CXR 213


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Case #214


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CXR 215A


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CXR 215B


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CXR 215C


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End CXR 201


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Happy CXR reading!

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