WORKSHOP THOMAS HANDOYO CHEST X RAY INTEPRETATION IN PULMONOLOGY DIVISION OF RESPIROLOGY AND CRITICAL CARE DEPARTEMENT OF INTERNAL MEDICINE DR KARIADI HOSPITAL / FK UNDIP SEMARANG
WORKSHOP
THOMAS HANDOYO
CHEST X RAY INTEPRETATION IN PULMONOLOGY
DIVISION OF RESPIROLOGY AND CRITICAL CAREDEPARTEMENT OF INTERNAL MEDICINE
DR KARIADI HOSPITAL / FK UNDIP SEMARANG
Curriculum vitae
Dr. Thomas Handoyo, SpPD-KP
Pendidikan
S1 : FK Universitas Diponegoro Semarang lulus tahun 2001
Spesialis : Ilmu Penyakit Dalam FK Universitas Diponegoro Semarang tahun 2010
Konsultan : Konsultan Pulmonologi Kolegium IPD bulan Maret tahun 2019
Pekerjaan
Staf Medis Fungsional Ilmu Penyakit Dalam RSUP Dr. Kariadi/ FK UNDIP Semarang.
Ketua TB MDR RSUP Dr. Kariadi Semarang (2013 – sekarang)
Ketua Koalisi Organisasi Profesi TB Jawa Tengah ( 2019 – sekarang)
Pokja (TWG) TB MDR Kementerian Kesehatan)
INTRODUCTION
• X-rays are a type of electromagnetic radiation with wavelengthsbetween 0.01 and 10 nm.
• On the electromagnetic spectrum, the wavelength of X-rays is shorter than that of ultraviolet radiation and longer than that of gamma radiation.
• Shorter wavelength X-rays (0.10–0.01 nm) are referred to as ‘hard’ because they can penetrate solid objects. It is these that are used in medical imaging.
• Since their discovery in 1895 by the German physicist Wilhelm Roentgen, X-rays have been used widely for medical imaging and remain key to diagnosing and treating patients.
Figure 1. An X-ray tube. Electrons are emitted by a cathode into the vacuum, emitting X-rays when hitting the anode at the right (i.e. current) speed.
INTRODUCTION
Thus, the radiographic appearance of thoracic structures depends mainly on their density. While areas with a high density per unit volume (e.g., cortical bone) appear light or white, areas with a lower density that are more transparent to roentgen rays (e.g., air in the alveoli) appear dark.
INTRODUCTION
FUNDAMENTAL OF CXR INTEPRETATION
• When interpreting a CXR it is important to make an assessment of whether the x-ray is of diagnostic quality.
• In order to facilitate this, first pay attention to two radiographic parameters prior to checking for pathology; namely the quality of the film and patient-dependent factors.
• A suboptimal x-ray can mask or even mimic underlying disease.
Quality assessmentIs the film correctly labelled?
What to check for?
• Does the x-ray belong to the correct patient?
Check the patient’s name on the film.
• Have the left and right side markers been labelled correctly, or does the patient really have dextrocardia?
• Lastly has the projection of the radiograph (PA vs. AP) been documented?
Assessment of exposure qualityIs the film penetrated enough?
• On a high quality radiograph, the vertebral bodies should just be visible through the heart.
• If the they are not visible, then an insufficient number of x-ray photons have passed through the patient to reach the x-ray film.
• As a result the film will look ‘whiter’ leading to potential ‘overcalling’ of pathology.
• Similarly, if the film appears too ‘black’, then too many photons have resulted in overexposure of the x-ray film.
• This ‘blackness’ results in pathology being less conspicuous and may lead to ‘undercalling’.
The effect of varied exposure on the quality of the final image
Is the film PA or AP ?
11
Why are PA Views Preferred over AP Views?
• PA view diminishes magnification, especially the heart
• PA view has better quality
AP views are indicated for:
• Patients too ill to stand1) In younger children 2) When there is doubt on a PA view about abnormalities in
hidden areas like retro-clavicular regions
PA View: Correct Standing or Sitting Position for CXR
If the patient is in
supine position, the
cardiac outline and
mediastinum is enlarged.
The scapula may be on
the lung field.
X-ray tube
X-ray cassette
AP View
ANTERIOR
POSTERIOR
14
AP: leads to false
cardiomegaly
PA: same patient heart no
longer magnified
AP VIEW vs PA VIEW
The technician should always specify if the view is not PA view;
this should be marked on the film, either at the bottom of the film or on the side
PA VIEW IS THE PREFERRED VIEW
15
PA View left-anterior oblique right-anterior oblique
D1 D2 D3
D3> D1>D2
The Diameter of the Cardiac Shadow Changes
with the Incidence of the X-Ray Beam
The cardiomediastinal contour is
significantly magnified on this AP
film. This needs to be appreciated and
not overcalled.
On the PA film, taken only an hour
later, the mediastinum appears
normal.
Patient-dependent factorsAsessment of patient rotation
• Identifying patient rotation is important.
• Patient rotation may result in the normal thoracic anatomy becoming distorted; cardiomediastinalstructures, lung parenchyma and the bones and soft tissues may all appear more, or less, conspicuous.
• To the uninitiated, failure to appreciate this could easily lead to ‘overcalling’ pathology.
A well centred x-ray. Medial ends of clavicles are equidistant from
the spinous process
This patient is rotated to the left. Note the spinous process is
close to the right clavicle and the left lung is ‘blacker’ than
the right, due to the rotation.
Assessment of adequacy of inspiratory effort
• Ensuring the patient has made an adequate inspiratory effort is important in the initial assessment of the CXR.
• It is ascertained by counting either the number of visible anterior or posterior ribs.
• If six complete anterior or ten posterior ribs are visible then the patient has taken an adequate inspiratory effort.
• Conversely, fewer than six anterior ribs implies a poor inspiratory effort and more than six anterior ribs implies hyper-expanded lungs.
Six complete anterior ribs (and ten posterior ribs) are clearly visible.
An example of poor inspiratory effort.
Only four complete anterior
ribs are visible. This results in several
spurious findings: cardiomegaly,
a mass at the aortic arch and patchy
opacification in both lower zones
Same patient following an adequate
inspiratory effort. The CXR now
appears normal
NotesIf a poor inspiratory effort is made or if the CXR is taken in expiration, then several potentially spurious findings can result:
• apparent cardiomegaly
• apparent hilar abnormalities
• apparent mediastinal contour abnormalities
• the lung parenchyma tends to appear of increased density, i.e. ‘white lung’.
• Needless to say any of these factors can lead to CXR misinterpretation.
REVIEW OF IMPORTANT ANATOMY
Heart and mediastinum
• The cardiothoracic ratio should be less than 0.5 i.e. A/B<0.5.
• A cardiothoracic ratio of greater than 0.5 (in a good quality film)suggests cardiomegaly.
Assessment of cardiomediastinal contour
Assessment of hylar regions
Both hilar should be concave. This results from the superior pulmonary
vein crossing the lower lobe pulmonary artery. The point of intersectionis known as the hilar point (HP)
Assessment of trachea• The trachea is placed usually just to the
right of the midline, but can bepathologically pushed or pulled to either side, providing indirect supportfor an underlying abnormality.
• The right wall of the trachea should be clearly seen as the so-called right para-tracheal stripe.
• The para-tracheal stripe is visible by virtue of the silhouette sign: air within the tracheal lumen and adjacent right lung apex outline the soft tissue-density tracheal wall.
• Loss or thickening of the para-tracheal stripe intimates adjacent pathology.
Evaluation of mediastinal compartments
It is useful to consider the
contents of the mediastinum as belonging to three compartments:
• Anterior mediastinum: anterior to the pericardium and trachea.
• Middle mediastinum: between the anterior and posterior mediastinum.
• Posterior mediastinum: posterior to the pericardial surface
Lung and Pleura
• There are two layers of pleura: the parietal pleura and the visceral pleura.
• The parietal pleura lines the thoracic cage and the visceral pleura surrounds the lung.
• Both of these layers come together to form reflections which separate the individual lobes. These pleural reflections are known as fissures.
Right lung
• Upper lobe
• Middle lobe
• Lower lobe.
Left lung
• Upper lobe; this contains the lingula
• Lower lobe.
Lobar and pleural anatomy –
frontal view
Lobar and pleural anatomy –
left lateral view.Lobar and pleural anatomy –
Right lateral view.
DiaphragmsAssessment of diaphragms
The right hemidiaphragm is ‘higher’ than the left. Both
costophrenic angles are sharply outlined
DiaphragmsAssessment of diaphragms
The outlines of both hemidiaphragms should be clearly
visible
DiaphragmsAssessment of diaphragms
Assess for diaphragmatic flattening. The distance
between A and B should be at least 1.5 cm
Bones and soft tissuesAssessment of bones and soft tisssues
Remember to scrutinise every rib, (from the anterior to posterior),
the clavicles vetebrae and the shoulders
Bones and soft tissuesAssessment of bones and soft tisssues
The ‘hidden’ areas Lateral View is important
38
Lateral View
39
AO
PA
RV
LA
LV
40
Heart and
Mediastinum
Vessels
Ascending
Aorta
Superior
Vena Cava
Right Pulmonary
Artery
Right
Ventricle
Descending
Aorta
Courtesy of Dr Jeanbourquin France
A brief look at the lateral CXRImportant anatomy relating to the lateral CXR
Key points
There should be a
decrease in density from
superior to inferior in the
posterior mediastinum.
The retrosternal airspace
should be of the same
density as the retrocardiac
airspace
42
Retro sternal clear space
Retro cardiac clear space
The “Clear Spaces”
43
The “Clear Spaces”
Retro tracheal
space
Courtesy of Dr Jeanbourquin France
44
The retro sternal space
is filled with a massNormal lateral view
45
Anterior opacity in the mediastinum
(red arrow on the PA view)
Filling of the retrosternal space on the lateral view
46
Retro cardiac clear
space
The “Clear Spaces”
47Normal CXR Retro-cardiac opacity
Diaphragms
The right hemidiaphragm is usually ‘higher’ than the left. The outline of
the right can be seen extending from the posterior to anterior chest
wall. The outline of the left hemidiaphragm stops at the posterior heart
border. Air in the gastric fundus is seen below the left hemidiaphragm.
Step Details• Identification, time
1. the X-ray
2. the clinical information
• Check technical factors – quality of film, patient dependent
factors, AP/PA
• Examination
1. trachea and root of the neck
2. lung fields
3. silhouette sign
4. mediastinum and heart
5. fissures
6. hila
7. diaphragm and below the diaphragm
8. bones and soft tissues
9. artefacts
10. abnormal densities
• Diagnosis –
REMEMBER
• DIAGNOSIS
DIA : MELALUI / THROUGH
GNOSIS : PROSES BERPIKIR / LOGIC THINKING
Trachea and Bronchus
Trachea
Main right
bronchus
Main left
bronchus
Trachea
Right upper
lobe bronchus
Left upper
Lobe bronchus
Right Bronchography
(this examination, with opacification of bronchi by iodine contrast fluid, is no longer performed)
Left Bronchography
Minor Fissure
Right View
Large Oblique
Fissure
Left View
Left
Fissure
The fissure are
sometimes
visible on the
lateral view
On the PA view
only minor
fissure is
sometimes
visible
Sections of
the Lungs
Bronchial Syndromes
Different Radiological Syndromes
• Atelectasis
• Bronchiectasis
Atelectasis
• Atelectasis is the consequence of an obstruction of
the bronchus by an intrinsic or extrinsic element.
• The air in the alveolar system progressively
disappears and the lung retracts.
This retraction can involve a segment, a lobe or the
entire lung.
Main Etiology of Atelectasis
• Bronchial Cancer:
• TB (bronchial TB or extrinsic compression by TB adenopathy)
• Extrinsic compression by adenopathy or malignant tumor
• Foreign body (in children, remember peas or small toys which are not radio-opaque)
Less frequent:
• Asthma
• Chronic bronchitis
• Viral or bacterial pneumonia
• Atelectasis after thoracic or abdominal surgery or trauma
The X-ray image mimics
consolidation but it is characterized by:
• Systematised (close to a fissure)
• Loss of volume
• Homogeneity
• Absence of air bronchogram
• Variable size: segment, lobe or entire lung
•ATELECTASIS
Right
Superior
Lobe
Atelectasis
by Cancer
• Right scapula pain
• Worsening condition
• Smoker (40 pack/year)
• AFB sputum negative
Bronchiectasis
Bronchiectasis is a disease characterised by dilatation
and irreversible destruction of the bronchial tree
Barker A. N Engl J Med 2002;346:1383-1393
Etiology of Bronchiectasis
Localised• TB, bacterial or viral infection, especially in children
(measles, whooping cough)
• Foreign body
• Bronchus stenosis, extrinsic compression (adenopathy)
Diffuse• TB, bacterial or viral infection, especially in children
(measles, whooping cough)
• Cystic Fibrosis• Other congenital diseases: Situs inversus, immotile
cilia syndrome• Disglobulinemy, chronic immune deficit, chronic auto-
immune affections
• Repeated infections
• Hemoptysis
• Significant and sometimes purulent sputum, (AFB negative)
•Bronchiectasis, Clinical Features:
Bronchiectasis Radiological Features:
• Round or cylindric opacities
• Sometimes with an air-fluid level if active infection
• Localised in one lobe or in a segment, or diffuse
Bronchiectasis
Bronchography (opacification of bronchi by iodine contrast fluid) is no more used
CT is not the gold standard to confirm the diagnosis of bronchiectasis
Bronchiectasis
Rail Picture: Cylindric Bronchiectasis
Lung field
PNEUMONIA
Lobar consolidation appears as extensive opacification of part or whole of a lobe. An air bronchogram is often seen in the consolidation. The lobar pneumonia is often demarcated by a fissure; the horizontal fissure separates the opacification from the middle lobe.
Dikutip dari Silbernagi, Lang. Color Atlas of Pathophysiology. 2000
TUBERCULOSIS
Young Tibetan Refugee, Worsening Condition,
Sputum and Fever, AFB positive
As in the
previous slide,
close to cavity
there are
infiltrates and
nodules, which
are highly
suggestive of
TB
Woman with Cough and
Recurrent Hemoptysis
Right Upper Lobe Pneumonia with two Cavities
and Draining Bronchus, AFB positive
SEL DATIA
LANGHANS
Pematangan lesi TB paru
Dartos V. The path of anti-tuberculosis drug: from blood to lesions to mycobacterial cell. Nat Rev
Microbiol. 2014
CONGESTIVE LUNG OEDEM
Chest X-ray showing alveolar oedema: airspace opacification
in the perihilar regions A producing a bat’s wing appearance.
Both costophrenic recesses are blunted B , indicating small
effusions.B
A
B
Silbernagl S, Lang F. Color Atlas of Pathophysiology.Thieme
Stuttgart.New York. 2000
Ware L. New England J Med 2005.
PLEURAL DISEASE
Pneumothorax on right hemithorax with avascular hyperluscent
94
Pleural effusion: Defined as fluid between visceral
and parietal membranes
lung
visceral serous
membrane
parietal serous
membrane
95
Effusion in pleural cavity
- Opacity not limited by fissure
- No air bronchogram
- Moves with change of position
The upper limit is curved with
a upperr concavity ascending
from the mediastinum to the
lateral thoracic wall
96
Small quantity (0.5 to 0.7 L)
97
Medium quantity
98
Substantial pleural effusion (1.5 to 2.5 L)
99
Right Sided Pleural Effusion
May push against the mediastinum on the opposite side
100
Pleural
effusion
Left sided
atelectasis
Mediastinum
pull
Pushing back
101
Pleural syndrome
Overlap of all the hemithorax
The mediastinum is pushed away
from the side of the pathology
The diaphragm is pressed down
Abundant effusion
102
Left pleural effusion and left atelectasis (pleural effusion associated with retraction)
Note that a pleural effusion is not retractile,
unless there is associated atelectasis
103
The supine position provides a different perspective on a pleural effusion
104
Effusion in fissure
PA view:
Effusion in the
small and in
the big fissure
Lateral view:
Opacities with
shuttle form
105
Effusion in the small fissure
106
Loculated pleural effusion
107
Scan view of the previous case
DISCUSSION
A 70-year-old chronic smoker for 50 years presented with
exertional shortness of breath for 1 year. His exercise
tolerance was limited to 1 flight of stairs.
Physical examination showed he was tachypnoeic with
central cyanosis.
Examination of respiratory system revealed use of accessory
muscles of respiration and hyperinflated chest on both sides.
Air entry was globally decreased in both lungs.
(1) What abnormality can you identify on CXR ?
(2) What is the clinical diagnosis ?
ANSWER
(1) What abnormality can you identify on CXR ?
- Hyperinflated, hyperlucent lungs
- Flat diaphragm
(2) What is the clinical diagnosis ?
• Frontal chest radiograph showing bilateral hyperlucent, hyperinflated lungs of chronic obstructive airway disease. There is some minor fibrosis in the right upper zone from previous TB.
Sibernagl S, Florian L. Color Atlas of Pathophysiology. Thieme Stuttgart-New York.
2000
KERJA PERNAFASAN OTOT DIAFRAGMA
KERJA PERNAFASAN OTOT INTERKOSTA
PRE TEST
CASE 1
• A 35-year-old man presented with fever and productive cough for 3 days. He was febrile, hypoxic and physical examination showed focal decrease in air entry and coarse crepitations over the right lower chest.Laboratory investigations revealed leukocytosis and a CXR was performed
1. A. What abnormalities do you see on this CXR ?
B. What is the most likely diagnosis ?
CASE 2
A 65-year-old man presented to the Accident and
Emergency Department with crushing chest pain and shortness of breath and a CXR was performed
CASE 2
(1) What are the chest radiograph findings ?
(2) What is the diagnosis?
CASE 3
• A 45-year-old woman with poorly controlled diabetes mellitus, presented with productive cough for 1 month. She also noticed low grade fever, night sweating and weight loss during this period.
Examination of the chest showed a dull percussion note, decreased air entry and coarse crepitations in the right upper zone.
Laboratory investigations revealed raised ESR, normal white cell count and a CXR was performed.
CASE 3
(1) What radiological abnormalities can you identify ?
(2) What is the radiological diagnosis ?
CASE 4
A 53-year-old non-smoker presented with fever, dyspnoea and productive cough for 3 days. A
physical examination of the respiratory system revealed decreased air entry over the right chest
where the percussion note was stony dull in nature. Laboratory investigations showed leukocytosis,
sputum culture grew Staphylococcus pneumonia and a CXR was performed
CASE 4
(1) What radiological abnormality can you identify ?
(2) What is the radiological diagnosis ?
CASE 5
• A 23-year-old man with good past health, presented with sudden onset left sided chest pain and shortness of breath. The pain was sharp in nature and more severe on inspiration. Physical examination showed decreased air entry in the left upper chest which was hyperresonant on percussion. Laboratory investigations were essentially normal. A CXR was performed for further evaluation
(1) What radiological abnormality can you identify ?
(2) What is the most likely diagnosis ?
POST TEST
CASE 1
• A 35-year-old man presented with fever and productive cough for 3 days. He was febrile, hypoxic and physical examination showed focal decrease in air entry and coarse crepitations over the right lower chest.Laboratory investigations revealed leukocytosis and a CXR was performed
1. A. What abnormalities do you see on this CXR ?
B. What is the most likely diagnosis ?
ANSWER
1. A. Area of increased opacity with ill-defined borders
Faint air bronchogram within the area of opacification
2. Pneumonia.
CASE 2
A 65-year-old man presented to the Accident and
Emergency Department with crushing chest pain and shortness of breath and a CXR was performed
CASE 2
(1) What are the chest radiograph findings ?
(2) What is the diagnosis?
CASE 2
(1) What are the chest radiograph fi ndings ?
- Cardiomegaly
- Upper lobe venous diversion
- Septal lines (Kerley B lines) best seen in the right lower zone
- Sharply outlined haziness in the right upper zone with no evidence of an air bronchogram suggestive of fluid in the right horizontal fissure
(2) What is the diagnosis?
Congestive cardiac failure.
CASE 3
• A 45-year-old woman with poorly controlled diabetes mellitus, presented with productive cough for 1 month. She also noticed low grade fever, night sweating and weight loss during this period.
Examination of the chest showed a dull percussion note, decreased air entry and coarse crepitations in the right upper zone.
Laboratory investigations revealed raised ESR, normal white cell count and a CXR was performed.
CASE 3
(1) What radiological abnormalities can you identify ?
(2) What is the radiological diagnosis ?
CASE 3 - ANSWER
(1) What radiological abnormalities can you identify ?
- Multiple areas of air-space opacification in the right lung also involving the apex
- Cavitation and air-fluid level within the opacified areas
Blunting of right CP angle due to exudative effusion
(2) What is the radiological diagnosis ?
Frontal chest radiograph showing air-space opacification in the right lung with cavitating lesions (arrows) due to caseous necrosis in tuberculosis.
CASE 4
A 53-year-old non-smoker presented with fever, dyspnoea and productive cough for 3 days. A physical examination of the respiratory system revealed decreased air entry over the right chest where the percussion note was stony dull in nature. Laboratory investigations showed leukocytosis,
sputum culture grew Staphylococcus pneumonia and a CXR was performed
CASE 4
(1) What radiological abnormality can you identify ?
(2) What is the radiological diagnosis ?
ANSWER
(1) What radiological abnormality can you identify ?
- Complete opacification of the right mid and lower zoneseffacing the right heart border and right hemidiaphragm
- Blunting of the right costophrenic angle
- No evidence of mediastinal shift
(2) What is the radiological diagnosis ?
Erect chest radiograph showing large right pleural effusion opacifying the right mid and lower zone
CASE 5
• A 23-year-old man with good past health, presented with sudden onset left sided chest pain and shortness of breath. The pain was sharp in nature and more severe on inspiration. Physical examination showed decreased air entry in the left upper chest which was hyperresonant on percussion. Laboratory investigations were essentially normal.
• A CXR was performed for further evaluation
(1) What radiological abnormality can you identify ?
(2) What is the most likely diagnosis ?
(1) What radiological abnormality can you identify ?
- Hyperlucent zone devoid of vascular marking in periphery of left hemithorax.
- Shift of midline to the right.
(2) What is the most likely diagnosis ?
Large left pneumothorax with mediastinal shift to the right. Note the collapsed left lung (arrows) and thehyperlucent left hemithorax.
TERIMA KASIH