Basic CXR Interpretation_Diagnostic Radiographs

Diagnostic Radiographs Basic CXR Interpretation

Marc Imhotep Cray, M.D.

Introduction  Review of normal chest x-ray  Administrative  Initial survey

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Review of normal chest x-ray A systematic approach to film review is most important skill to developďƒ major areas of should be viewed in a sequential order

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Review of Normal CXR (2) Sequenced Checklist: 1. Check patient name, position, technical quality 2. Soft tissue including breast, chest wall, companion shadow 3. Review soft tissues and skeletal structures of shoulder girdles and chest wall 4. Review abdomen for bowel gas, organ size, abnormal calcifications, free air, etc.

5. Review soft tissues and spine of neck

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Review of Normal CXR (3) Sequenced Checklist: 6. Review spine and rib cage: check alignment, disc space narrowing, lytic or blastic regions, etc.

7. Review mediastinum: a. overall size and shape b. trachea: position c. margins: SVC, ascending aorta, right atrium, left subclavian artery, aortic arch, main pulmonary artery, left ventricle d. lines and stripes: paratracheal, paraspinal, paraesophageal (azygoesophageal), paraaortic e. retrosternal clear space

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Review of Normal CXR (4) Sequenced Checklist: 8. Review hila: a. normal relationships b. size

9. Review lungs and pleura: a. compare lung sizes b. evaluate pulmonary vascular pattern: compare upper to lower lobe, right to left, normal tapering to periphery c. pulmonary parenchyma d. pleural surfaces • • •

fissures - major and minor - if seen compare hemidiaphragms follow pleura around rib cage 6

Administrative Get in habit of always checking following items before anything elseďƒ takes a few seconds and is an important legal safe guard as well 1. Patient's name 2. Date exam done (very important if comparing prior exams) 3. Check for position markers right vs. left, upright 7

Administrative (2) Other items to check before commencing w clinical review of film include: 1.Type of film (practice noticing if it is a plain film, CT, angio, MRI, etc.)

2.Patients position - supine, upright, lateral, decubitus 3.Technical quality of exam - learn what are acceptable limits for examďƒ Ex. You can't find a subtle pneumothorax if there is patient motion or the film is overexposed.

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Administrative (3)  A basic principle to adopt  going from general observations to specific details  sometimes a change may be so major that old saying “missing the forest for the trees” comes true o For instance, an absent breast shadow on a film of a patient after a mastectomy

 After completing your administrative housekeeping, get a general overview of film before zooming in on tiny detail

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Administrative (4)  Notice following b/c may change baseline normals you use as reference points, and you may be sensitized to look for specific findings 1.General Body Size, Shape, and Symmetry 2.Male vs. Female 3.Is this an infant, child, young adult, elderly person?

4.Survey for foreign objects - tubes, IV lines, EKG leads, surgical drains, prosthesis, etc., as well as non-medical objects, bullets, shrapnel, glass, etc.

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The Chest X-Ray

Following radiographic plates are scan-ins from: Felson, B., et al.: Principles of Chest Roentgenology. Philadelphia, W.B. Saunders Co., 1973.

Fraser, R., et al.: Diagnosis of Diseases of the Chest, 3rd edition. Philadelphia, W.B. Saunders Co., 1988.

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Discussion Outline •Densities •Techniques •Anatomy •CXR Interpretation •Common Pathologies

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Densities The big two densities are: (1) WHITE - Bone (2) BLACK - Air The others are: (3) DARK GREY- Fat (4) GREY- Soft tissue/water And if anything Man-made is on film, it is: (5) BRIGHT WHITE – Man made 13

Techniques - Projection P-A (relation of x-ray beam to patient)

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Techniques – Projection cont’d.

Lateral

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Techniques - Projection cont’d.

Lateral Decubitus

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“The A-B-C-D Sequence” Assessment  Assess quality of film using mnemonic PIER:  Position: Is this a supine AP film? PA? Lateral?  Inspiration: Count posterior ribs. You should see 8–9 ribs with a good inspiratory effort  Exposure: Well-exposed films have good lung detail and show a detailed outline of spinal column. Overpenetration leads to a dark film with more spinal detail. Underpenetrated films are whiter with little spinal detail.  Rotation: Space between medial clavicle and margin of adjacent vertebrae should be roughly equal on each side.

 Also look for indwelling lines or objects (eg, endotracheal tube, feeding tube, airway obstruction) that may reveal clues to pathology in film 17

Penetration (Exposure)

Underpenetrated

Overpenetrated 18

Inspiration/Expiration

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Rotation

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Rotation cont’d.

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Anatomy

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Anatomy

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Anatomy

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Lobes Right upper lobe:

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Lobes cont’d.

Right middle lobe:

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Lobes cont’d.

Right lower lobe:

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Lobes cont’d.

Left lower lobe:

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Lobes cont’d.

Left upper lobe with Lingula:

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Lobes cont’d.

Lingula:

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Lobes cont’d.

Left upper lobe - upper division:

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Heart Right border: Edge of (r) Atrium 2. Left border: (l) Ventricle + Atrium 3. Posterior border: Left Ventricle 4. Anterior border: Right Ventricle 32

Heart cont’d

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Heart cont’d.

Valves

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Mediastinum

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Hilum Made of: 1. Pulmonary Art. + Veins 2. The Bronchi Left Hilus higher (max 1-2, 5 cm) Identical: size, shape, density

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Ribs

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Lateral CXR

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Lateral CXR cont’d.

Tracheoesophageal Stripe

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Lateral CXR cont’d.

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CXR Interpretation

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Technical Details • Type • Orientation • Rotation • Inspiration/expiration • Penetration To be studied along side Reading Chest X-Ray Notes.pdf (“The A-B-C-D Sequence”) 42

Lungs: •Lungs • Density • Symmetry • Lesions

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Heart Size:

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Heart • Size of heart • Size of individual chambers of heart • Size of pulmonary vessels • Evidence of stents, clips, wires and valves • Outline of aorta and IVC and SVC

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Mediastinum:

• Width • Contour • AP window • Size • Location

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Review areas: • • • • • • •

Apices Behind the heart CP angles Below diaphragm Soft tissues ( breast, surgical emphysema) Ribs & clavicle Vertebrae

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Identify the lesion → localize lesion → describe lesion → give a DDx Never stop looking, carry on w your systematic approach!!

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Pathology Following radiographic plates are scan-ins from: Felson, B., et al.: Principles of Chest Roentgenology. Philadelphia, W.B. Saunders Co., 1973.

Fraser, R., et al.: Diagnosis of Diseases of the Chest, 3rd edition.

Philadelphia, W.B. Saunders Co., 1988.

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RUL pneumonia

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RML pneumonia

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RLL pneumonia

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LUL pneumonia

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LLL pneumonia

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• Consolidation on CT

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Hilar mass

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The Enlarged Hila • Causes: 1. Adenopathies (neoplasia, infection) 2. Primary Tumor 3. Vascular 4. Sarcoidosis 57

• Multiple Masses 58

Hilar Lymphadenopathy - BL 59

Hilar Lymphadenopathy - BL

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Pleural Effusion 61

Pulmonary Fibrosis

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Heart failure

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Pneumothorax

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RUL collapse 65

LLL collapse 66

Air under diaphragm

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Emphysema

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Cavitating lesion

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Hiatus hernia

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Miliary shadowing

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Chest Tube, NG Tube, Pulm. artery cath.

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See next slide for links to tools and resources for further study.

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Further study: IVMS CXR Video Education Cloud folder Reading Chest X-Ray Notes.pdf (“The A-B-C-D Sequence”) eBook Eng P, Cheah KF. Interpreting Chest X-Rays: 100 Illustrated Cases.

Cambridge: Cambridge University, 2005.

Radiology Online Study Resources: RadiologyEducation.com, curated by Michael P. D'Alessandro, M.D. http://www.radiologyeducation.com/

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