Chest X-Ray

Collection By

AMIR B.CHANNA FFARCS,DA (Eng)

King Khalid Univ. Hospital Riyadh KSA

Most important things when reading a CXR

Have a System Use it consistently

Know your anatomy Diff. diagnosis & Pathophysiology

Step #1:
Always, always, always Confirm the patients name & check date on film

Step #2:
Know a good CXR when you see one assess the films quality HOW ?

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

Step #3:
Read the film DO NOT JUMP TO DIAGNOSIS

My System: the Short Version:

(Use this for routine films)
A Airways B Bones & soft tissues C Cardiac silhouette D Diaphragm E Everything else the lungs

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

More Details on the Lungs:

Features to look for when characterizing parenchymal lung disease:

Over/under inflation (<8 or >9 ribs visible) suggests a restrictive 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?

Investigations
Chest Radiograph PA AP
Ill patient

Lateral
Mass localisation, cardiac chambers, hila

Expiratory

2
3

1 2 3 4 5 6

4
5

7
8

6
7

9
10

Heart size - Cardiothoracic Ratio (CTR) A+B/C

Investigations

CT
Focal masses Diffuse lung disease Pulmonary emboli

Ultrasound
Diaphragm, pleura

Magnetic Resonance
Mediastinum Lung apex

Intervention
Biopsy, Drainage

Conventional CT Slice width

Spiral CT

Bone

Water

Air

Normal Anatomy

Bone-CT Reconstruction
PA View
Clavicle

Rib Vertebral Column

Intercostal Space

Bone Anatomy
Sternum

Rib

Heart Size

Normal is <50% on PA upright radiograph

Lateral view

Cardiac Anatomy: Right Sided Chambers

Cardiac Anatomy: Left Sided Chambers

SVC

Aortic Arch

Right Descending Pulmonary Artery

Left Descending Pulmonary Atery

Scapula

Retrosternal Airspace Hilum

Lungs posteriorly should get darker as you go down more inferiorly

IVC

Pulmonary Vessels

Airway Anatomy
Trachea
Cartilage Membranous posteriorly

Carina
Bifurcation

Bronchus
Left and right Lobar (RUL,RML,LUL,LLL) Segmental (8 left, 10 right)

Trachea R + L Main Bronchi Carina

Lung Anatomy
Lobes are separated by fissures Right
Upper Lobe Middle Lobe Lower Lobe

Left
Upper Lobe (includes lingula) Lower Lobe

Pleura and Fissures

Pleura
Lubricates and prevents friction during respiration Potential Space Dont see unless abnormal

Parietal pleura: Lines chest wall, mediastinal and diaphragmatic surfaces Visceral pleura: Lines lungs, fissures

Parietal Pleura

Visceral pleura

Diaphragms

Normal: Sharp costophrenic sulcus

Which is right and left diaphragm?

Approach to Chest Radiograph: Technical Factors

Patient Identification (name and date) Markers (Left vs right) Assess for rotation (clavicles vs spinous process) Penetration (thoracic spine should be visible) Degree of Inpiration: 6th anterior or 10th posterior

Clavicles

Spinous Process

Vertebral Body Visible

6

10 11

Counting anterior ribs

Counting posterior ribs

Inspiration/Expiration Images
Expiration
Heart size appear larger Mediastinum is wider Pulmonary vasculature indistinct

4th Anterior

8th Posterior

Expiration Image

Expiration

Inspiration: Same Patient

Abnormal Cases
Bone Cardiovascular Airspace Disease including Silhouette Sign Interstitial Disease and Pulmonary Edema Atelectasis Pulmonary Nodule Pleura and Diaphragm Mediastinal Mass

Bone and Soft Tissues

Productive 1st rib changes: Can simulate nodule

Lordotic View

Better assess apices without bone over

Rib Fracture

Presenting CXR

Pancoast Tumour

MRI

Computed Tomography

Cardiovascular

Increased Cardiac Size: Can be Cardiac or Pericardial

Dilated Cardiomyopathy Pericardial Effusion

What imaging would you use to differentiate between the tw

Left Ventricular Enlargement

IVC

Enlargement of Left Ventricle

Left Ventricle

Airspace Disease and Silhouette Sign

Airspace Disease
Filling in of acini (air space) Air space (acinar) nodules Coalesce to consolidation Air bronchograms Silhouette Sign

Air Space Disease: Etiology

Water-Pulmonary Edema Pus-Infections, Non-infectious inflammatory process
Blood-Pulmonary Hemmorhage
Protein-Alveolar Proteinosis Tumour-BAC, Lymphoma

Bronchopneumonia Pattern: Airspace Nodules

Acinar Nodules

Computed Tomography

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.

CT Consolidation: Air Bronchograms

Silhouette Sign
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?

What Types of CXRs Are Available?

Different CXR Views:

Posterior-Anterior (PA) Anterior-Posterior (AP) Lateral Supine Oblique Expiratory Lateral Decubitus Lordotic

Routine CXR Views:

Erect or Posterior-Anterior (PA):

Standard view & most reliable technique Erect films detect air under the diaphragm

Lateral view:
Done at the same time as the PA film Helps localize infiltrates Also helps with CM, effusions & LAD

Anterior-posterior (AP):
Portable- patient is too ill to go to X-ray, usually patient is sitting upright in bed Poor quality but may be the best you can do Remember- AP films may cause the mediastinum & heart to appear larger than they are

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)

Enough Basics
Lets read some films!
**Dont feel bad if you miss some things these are not easy films**

Case #201

Patient is brought to the ED after a restrained MVAhe complains of CP and abd pain
A Portable film was obtained in the ER

CXR 201

Case #202

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 with which to make your Dx

CXR 202

CXR 202 (lat)

Case #203

35 yo with chronic cough, new onset oligoarthritis & painful nodules on his BLEs
A Portable film was obtained in the ER

CXR 203

Case #204

44 yo alcoholic presents with new onset SOB

PA & lat from the ED

CXR 204

CXR 204 (lat)

CXR 204 (decub)

These are the two CXRs of the same patient taken few seconds apart, what is evident from it

Identify the problem with this patient having this CXR, what are its anesthetic implications

Identify the problem with this patient having this CXR, what are its anesthetic implications

Identify the problems with this patient having this CXR, what are its anesthetic implications

Identify the problems with this patient having this CXR, what other investigations would you do for this patient who is scheduled for chest surgery

Identify the problems with this patient having this CXR, what are its anesthetic implications

Identify the problem with this patient having this CXR, what are its anesthetic implications & how will you manage this

Identify the problem with this patient having this VQ scan, what are its anesthetic implications & how will you manage this patient

Identify the problem with this patient having this CXR, what are its anesthetic implications & how will you manage this patient

Identify the problems with this child having this CXR, what are its anesthetic implications

Identify the problem with this patient having this CXR, what do the arrows point toward & what are its anesthetic implications

Identify the problems with this patient having this CXR, what are its anesthetic implications

Case #205

Same 44 yo alcoholic presents 1 week later with fevers & chills

PA/lat CXR performed in the ED

CXR 205

CXR 205 (lat)

Case #206

50 yo male with sinusitis, fever & progressive cough/DOE for 8 weeks

An AP film was obtained in the ED

CXR 206

Case #207

25 yo female presents with acute L sided chest pain

AP & lateral films were obtained in the ED

CXR 207

CXR 207 (lat)

Case #208

40 yo with HIV (refused HAART), presents with new SSCP

A portable film was obtained in the ED

CXR 208

Case #209

40 yo with HIV on HAART x 10 years (cd4 count 250) presents with new onset fever & night sweats

Portable film obtained in the ED

CXR 209

Case #210

60 yo with 1 week of progressive DOE followed by SOB at rest

AP film was obtained in the ED

CXR 210

CXR from 3 months prior

Case #211

70 yo presents with 6 weeks of progressive DOE, chronic n-p cough and now SOB at rest

PA & lateral films were obtained in the ED

CXR 211

CXR 211 (lat)

Case #212

55 yo with severe epigastric pain x 2 days followed by 4 hours of new onset SSCP and worsing abd pain
Portable film obtained in the ED

CXR 212

Case #213

45 yo smoker gets this pre-op CXR before an elective Nissen fundapplication Hes been having a lingering nonproductive cough x 6 weeks
This PA film was obtained

CXR 213

Case #214

40 yo previously healthy immigrant presents with new onset massive (>400cc) hemoptysis
A portable CXR was obtained in the ED

CXR 214

Case #215

40 yo previously healthy female presents with 1 day fever, cough & SOB She is admitted to the floor for dehydration but then develops hypoxemia requiring increasing O2

Serial CXRs over the next 12 hours were obtained

CXR 215A

CXR 215B

CXR 215C

End CXR 201 Happy CXR reading!