how read chest xr 2
TRANSCRIPT
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HOW READ CHEST XR -2
ANAS SAHLE ,MD
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Technical Quality
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Is the film centered? Rotation
Is it PA or AP film ? Positioning
Is it exposed properly ? Penetration
Is it a good inspiration film? Inspiration
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RPPI
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observing the clavicular headsdetermining whether they are equal distance from the spinous process of the thoracic vertebral bodies
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Is the film centered? Rotation
Is it PA or AP film ? Positioning
Is it exposed properly ? Penetration
Is it a good inspiration film? Inspiration
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RPPI
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If the scapulae no longer overlie the lung fields then the film is PA
If the scapulae overlie the lung fields then the film is AP
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Is the film centered? Rotation
Is it PA or AP film ? Positioning
Is it exposed properly ? Penetration
Is it a good inspiration film? Inspiration
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RPPI
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Normal Penetrated PA film
An overpenetrated PA film
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Normal Penetrated PA film underpenetrated PA film
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Is the film centered? Rotation
Is it PA or AP film ? Positioning
Is it exposed properly ? Penetration
Is it a good inspiration film? Inspiration
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RPPI
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The diaphragm should be found at about the level of the 8th - 10th posterior rib or 5th - 6th anterior rib on good inspiration
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look at the lungs
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Scan both lungs
starting at the apices and working down
comparing left with right at the same level
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Compare and contrast vascular markings in upper vs. lower lung fields in PA view
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List conditions, where vascular markings are prominent in upper lung fields
• Mitral stenosis • Congestive heart failure • Alpha one antitrypsin deficiency
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Compare and contrast vascular markings in outer third vs. inner two thirds of lungs
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increased markings in outer third of lung fields?
• In:1. Left to right shunts (ASD, VSD, PDA)
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increased pulmonary flow
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increased markings in outer third of lung fields?
• In :2. Interstitial disease3. Lymphangitic malignant spread4. CHF with increased lymphatic flow
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Fissures
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Localizing lesions
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The position of lesioncan be described in terms ofzones
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To accurately localize a lesion on chest X ray you need to look at both the PA and lateral films
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First look at thePA film
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The upper zone lies above the anterior border of the 2nd rib
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The middle zone lies between the right anterior borders of the 2nd and 4th ribs
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The lower zone lies between the right anterior border of the 4th rib and the diaphragm
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It does not give any information about the
lobes of the lung
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Look at the borders of the lesion
• If the lesion is next to a dense (white) structure then the border between the lesion and that structure will be lost
This is calledthe silhouette sign
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Now look at thelateral film
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Lateral Positioning
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A brief look at 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 retrocardiacairspace.
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Identify the oblique fissure
• (pass obliquely downwards from the T4/T5 vertebrae through the hilum ending at the anterior third of the diaphragm)
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Identify the horizontal fissure
• (pass horizontally from the midpoint of the hilum to the anterior chest wall)
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If the lesion lies posterior to the oblique fissure it must lie within the lower lobe
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If the lesion lies anterior to the oblique fissure it may be in the upper or middle lobe
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If the lesion is below the horizontal fissure it is in the middle lobe
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If the lesion is above the horizontal fissure it is in the upper lobe
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There is no middle lobe on the left
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CASE-1
This elderly male had recent onset of streaky
hemoptysis?.
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POSITION •AP CXR
QUALITY •Poor Technical Quality
LESION •homogeneous density in the right upper zone , elevation of the transverse fissure
MEDIASTINAL •Central trachea and mediasteinal
ANGELS •Free costo-phrenic angels
OTHER •NO
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S sign
• homogeneous density in the right upper zone• elevation of the transverse fissure
( Instead of the transverse fissure being straight)
• there is a bulge at the medial end giving it an inverted S shape.
• Golden described this sign and the explanation for it is that the upper lobe
collapse is due to a right hilar mass which accounts for the medial bulge
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Atelectasis Right Upper LobeHomogenous density right upper lung field.
Mediastinal shift to right.
Loss of silhouette of ascending aorta.
Movement of oblique and transverse fissures.
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Case-2
This middle-aged female complained of :•Hemoptysis•loss ofweight two months’ duration.
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POSITION •PA CXR
QUALITY •Poor Technical Quality•(poor penetration).
LESION •hazy, veil-like opacification•in the left upper zone,obscured aortic arc,from hilar to peripheral
MEDIASTINAL •Central trachea and mediasteinal
ANGELS •Obscured left costo-phrenic angels•Elevate left hemidiaphragm
OTHER •NO
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Illustration
• The CXR shows evidence of left upper lobe collapse. • There is a hazy, veil-like opacification in the left upper lobe, which does not have a sharp
inferior margin unlike right upper lobe collapse.• This is because there is usually no left transverse
fissure and the lobe collapses anteriorly.. • There is also volume loss in the left hemithorax as
evidenced by an elevated left hemidiaphragm and crowding of the left upper ribs.
• Sometimes the trachea may also be deviated to the same side and the aortic knuckle may be obscured by the collapse
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Mediastinal shift to left.
Density left upper lung field.
Loss of aortic knob and left hilar silhouettes.
Atelectasis Left Upper Lobe
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A: Forward movement of oblique fissureC: Atelectatic LULB: Herniated right lung
Atelectasis Left Upper Lobe
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Bowing sign
•LUL atelectasis or following resection
•The oblique fissure bows forwards
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Bowing sign
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CASE-3
• 50-year-old female with a past history of tuberculosis had
• chronic cough over the past year.
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POSITION •PA CXR
QUALITY •GOOD Technical Quality
LESION •No•Left lung smaller than right
MEDIASTINAL •Left deviation trachea and mediasteinal
ANGELS •Obscured left costo-phrenic angels•Elevate left hemidiaphragm
OTHER •NO
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Inhomogeneous cardiac density.
Triangular retrocardiac density.
Left hilum pulled down.
AtelectasisLeft Lower Lobe
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•Lateral left diaphragm not visible•Increased density over lower spine
Left Lower Lobe Atelectasis
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