basics of chest x-ray afams residency orientation april 16, 2012
TRANSCRIPT
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Basics of Chest X-Ray
AFAMS Residency OrientationApril 16, 2012
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Outline
• CXR Basics• Types of CXR– PA vs. AP Films
• Obtaining Images• Systematic method to reading CXR• Common Signs• Examples
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Chest X-ray (CXR) Basics• A standard chest X-ray
consists of a – PA Image– Lateral Image– Images read together
• AP for supine patients• Lots of information
available on a CXR• Be systematic with your
reading• Always compare to prior
studies if possible
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Basics of X-Rays
• X-Rays are part of the light spectrum
• Unlike visible light, x-rays pass through the human body– Pass through lungs without much interference– Difficult to pass through bones
• Place film cassette on other side of patient and capture the shadow
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Basics of X-Ray
• Organs absorb X-rays differently and thus their shadow on the film is different– Bone: high absorption (film appears white)
– Tissue: moderate absorption (film appears grey)
– Air/Lungs: little absorption (film appears black)
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Types of CXRs
• PA and Lateral– Patient facing cassette– X-ray 6 feet away
• Supine AP– X-ray 40 inches away– Magnifies anterior
structures and pulmonary vasculature
101 cm
1.83 m
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Comparing Chest X-rays Protocols
PA• Preferred method
AP• Note heart enlarged, lung
fields not as clear
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PA Image• PA Film– Read as if patient is facing you (Patient’s left side
is on the right of the X-ray)
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Lateral Image
• Obtained with patient’s left side against the cassette.
• Minimizes heart silhouette magnification
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Assessing Film Technique
• Inspiration• Penetration• Rotation
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Inspiration
• Image should be at full inspiration– Diaphragm at level of 8-10 rib– Allows reader to see intrapulmonary structures
Poor Inspiration mimics RML Infiltrate
Same patient with proper inspiration
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Penetration• Amount of radiation required for a quality image– PA film: should barely see thoracic spine disc spaces– Lateral: spine should appear darker as move cadually
Examples of adequately penetrated images
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Penetration
Overpenetrated Underpenetrated
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Rotation• Patient should be flat against the cassette
• Rotation of the patient will alter appearance of mediastinum
• Observe rotation by comparing location of clavicular heads– Should be equal distance from spinous process of
thoracic vertebral bodies
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Rotation
Normal Rotated to the Right
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Mass vs. Infiltrate
Mass Infiltrate
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Lobes and Fissures: PA Film
A: Minor Fissure between RML and RLLB: Upper and lower boundaries of major fissures
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Lobes and Fissures: Lateral
B: Major Fissure L Lung A: Minor Fissure R LungB: Major Fissure R Lung
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CXR Anatomy
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CXR Anatomy
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How to Read an X-Ray Part 1• Patient Data (Name, history, age, sex)
• Technique (PA vs. AP, rotation, penetration, etc)
• Trachea: midline or deviated, any masses?
• Lungs: masses, infiltrates?– Costophrenic angles should be sharp (if not = effusions)– Silhouette signs, air-bronchograms, pulmonary edema
• Pulmonary vessels: enlarged?
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How to Read an X-Ray Part 2• Hilar Region: masses or lymphadenopathy
• Heart: enlarged, abnormal shape
• Pleura: effusion, thickening, calcification
• Bones: fractures or masses
• ICU Films: looks for line and tube placement
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How to Read an X-Ray Part 3
• It is best to focus on a small area of the film and then scan rather than look at the whole film at once
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Signs: Silhouette Sign
• Loss of lung/soft tissue interface caused by mass, fluid, or infiltrate in the normally air filled lung
• Commonly applied to heart, aorta, chest wall, and diaphram borders with lung
• Location of silhouette sign helps to localize pathology
Lose Right Heart and Lung border = RML
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Signs: Air Bronchogram
• Tubular outline of an airway made visible by filling of the surrounding alveoli by fluid or inflammatory exudates
• Causes– Pulmonary edema– Lung Consolidation– Severe Interstitial Disease– Neoplasm
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Signs: Solitary Pulmonary Nodule
• Can be innocuous or potentially fatal lung cancer
• Always compare to prior films for growth
• Nodules with irregular borders are suspicious
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Conclusions• Lots of information in a chest x-ray
• Always read the film in the same order– Never skip to the most prominent abnormality, you
will miss a small (but potentially important finding)
• Compare to priors if possible
• We will finish with some examples of common pathology
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Examples: Atelectasis
• Collapse or incomplete expansion of alveoli
• Causes:– Endobronchial lesions (mucous plug or tumor)– Extrinsic compression (mass, lymph node)– Peripheral compression (pleural effusion)
• Linear density on CXR
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Examples: Pulmonary Edema• Cephalization of pulmonary
vessels (arrow)
• Kerley B Lines
• Peribronchial cuffing
• “Bat Wing” Appearance
• Increased Cardiac Size (arrow)
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Examples: Pneumonia
• Airspace disease and consolidation
• CXR Findings– Airspace opacity– Lobar consolidation– Interstitial opacities
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Differentiating Atelectasis from Pneumonia
Atelectasis• Volume Loss• Associated ipsilateral shift• Linear, wedge shaped• Apex at hilum• Air bronchograms
Pneumonia• Normal or increased volume• No shift• Consolidation, air space
process • Not centered at hilum• Air bronchograms
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Examples: TB• TB can be seen as consolidation, cavitation,
fibrosis, adenopathy, or pleural effusion depending on stage of infection
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Examples: Pleural Effusions
Blunting of Costophrenic Angles
Fluid in Costophrenic Angle
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Examples: Pneumothorax (PTX)
• Air inside the thoracic cavity but outside the lung
• PTX appears as air without lung markings in least dependent area of chest
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Examples: Hemopneumothorax
Lung
Air
Fluid
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Examples: Interstitial Lung Disease
• Hazy ground glass opacification
• Volume Loss
• Linear opacities bilaterally
• “Honeycomb lung”
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Examples: COPD and Emphysema
• Diffuse hyperinflation
• Flattened diaphragms
• Increased retrosternal space
• Bullae
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Examples: Rib Fractures
• Can you find the rib fracture?
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Examples: Pericardial Effusion
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Examples: Hiatal Hernia
Gastric Bubble
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Hilar Enlargement
Enlarged Pulmonary Artery Hilar Adenopathy