interpretation of chest imaging1

8/12/2019 Interpretation of Chest Imaging1

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Mukbil Hourani M.D.

AUBMCDiagnostic Radiology

Introduction to CXRand

Chest CT


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Objectives

Technique Learn the difference

between PA vs. AP CXR Learn the utility of a

lateral decubitus CXR

Anatomy Learn the basic anatomy of

the fissures of the lungs,heart borders, bronchi, andvasculature that can beseen on a chest x-ray and

CT Interpretation Develop a consistent

technique Learn the silhouette sign

Pathology Learn the concept of

atelectasis and the abilityto recognize it on a chestx-ray

Appreciate the appearanceof pulmonary edema Appreciate the difference

findings of atelectasis andpneumonia

Recognize pleural effusions

and pneumothorax Recognize the signs of

COPD Pulmonary nodules & masses Others.


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PA View


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Lateral View


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Ribs and Diaphragm


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Postero-anterior or Antero-posterior

PA AP


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Inspiration

-The patient should be examined in full inspiration.

-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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Right and Left Upper Lobes

Right Middle Lobe

Right and Left Lower Lobes

Left Upper Lobe

Major Fissure

Left Lower Lobe

Right Upper Lobe

Minor or Horizontal

Fissure

Right Middle Lobe

Major Fissure

Right Lower Lobe


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Right Lung containing:

RUL: Apical Segment

RUL: Posterior Segment

RUL: Anterior Segment

RML: Lateral Segment RML: Medial Segment

RLL: Anterior Basal Segment

Left Lung containing:

LUL: Apical Posterior Segment

LUL: Anterior Segment LUL: Lingula Superior Segment

LUL: Lingula Inferior Segment

LLL: Anteromedial Segment


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CT Anatomy


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CT Anatomy


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CT Anatomy


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CT Anatomy


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CT Anatomy


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Pulmonary Vasculature


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Fissures


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Lobes and Fissures


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Lobes and Fissures


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How to Read a Chest X-Ray

Patient Data (name history #, age, sex, old films) Routine Technique: AP/PA, supine or erect Trachea: midline or deviated, caliber, mass Lungs: abnormal shadowing or lucency Pulmonary vessels: vascular enlargement Hila: masses, lymphadenopathy Heart: thorax: heart width > 2:1 ? Cardiac configuration? Mediastinal contour: width? mass? Course of aorta Pleura: effusion, thickening, calcification Bones: lesions or fractures

Soft tissues: dont miss a mastectomy ICU Films: identify tubes first and look for pneumothorax


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Looking for Abnormalities

Do a directed search of the chest film

rather than simply gazing at the film


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Silhouette Sign

One of the most usefulsigns in chest radiology

Described by Dr. BenFelson

The silhouette sign is inessence elimination ofthe silhouette or loss oflung (air)/soft tissueinterface caused by amass or fluid in the

normally air filled lung.

If an intrathoracic opacityis in anatomic contact withthe heart border, then theopacity will obscure thatborder.

The sign is commonlyapplied to the heart, aorta,chest wall, and diaphragm.

The location of thisabnormality can help to

determine the locationanatomically.


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Which lobe is it?


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Silhouette Sign

For the heart, the silhouettesign can be caused by an opacityin the RML, lingula, anteriorsegment of the upper lobe, and

anterior portion of the pleuralcavity.

This contrasts with an opacity inthe posterior pleural cavity,posterior mediastinum, or lower

lobes which cause an overlap andnot an obliteration of the heartborder.


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Silhouette Sign


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Silhouette Sign


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Air Bronchogram

Is a tubular outline of anairway made visible byfilling of the surroundingalveoli by fluid orinflammatory exudates

Six causes of airbronchograms are; lung consolidation, pulmonary edema, nonobstructive pulmonary

atelectasis, severe interstitial disease, neoplasm, and normal expiration.


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Atelectasis

Collapse or incompleteexpansion of the lung orpart of the lung

Often caused by anendobronchial lesion,

such as mucus plug ortumor

Extrinsic compressioncentrally by a mass suchas lymph nodes or

peripheral compressionby pleural effusion

Atelectasis is almostalways associated with alinear increased densityon chest x-ray

Indirect signs of volume

loss include vascularcrowding or fissural,tracheal, or mediastinalshift, towards thecollapse.

Segmental andsubsegmental collapsemay show linear,curvilinear, wedgeshaped opacities. This ismost often associatedwith post-op patients


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LLL Collapse


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RUL Collapse


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RML Collapse


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Pulmonary Edema

Two basic types ofpulmonary edema. cardogenic edema caused

by increased hydrostaticpulmonary capillary

pressure. noncardogenic pulmonary

edema, and is caused byeither altered capillarymembrane permeability

or decreased plasmaoncotic pressure.

NOT CARDIAC Near-drowning, Oxygen therapy, Transfusion or trauma,

CNS disorder, ARDS, aspiration, oraltitude sickness,

Renal disorder orresuscitation,

Drugs, Inhaled toxins, Allergic alveolitis, Contrast or contusion.


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Pulmonary Edema


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Pulmonary Edema

June 2, 2009 June 4, 2009


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Congestive Heart Failure

Congestive heart failure (CHF) is one of themost common abnormalities evaluated byCXR.

The earliest CXR finding of CHF iscardiomegaly, detected as an increasedcardiothoracic ratio (>50%).

In the pulmonary vasculature of the normalchest, the lower zone pulmonary veins arelarger than the upper zone veins due togravity.


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CHF


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Kerley B lines

Horizontal lines less than 2cm long, commonly found in the lower zone periphery. These

lines are the thickened, edematous interlobular septa.

Causes include; pulmonary edema, lymphangitis carcinomatosa and malignant lymphoma,

viral and mycoplasmal pneumonia, interstital pulmonary fibrosis, pneumoconiosis,

sarcoidosis, chronic CHF


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Atelactasis vs. Pneumonia

Atelectasis Pneumonia

Volume LossAssociated Ipsilateral Shift

Linear, Wedge-Shaped

Apex at Hilum

Normal or Increased VolumeNo Shift, or if Present Then

Contralateral

Consolidation, Air Space

Process

Not Centered at Hilum

Air bronchograms can occur in both.


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indistinct borders, air bronchograms, and silhouetting of the

right heart border.

LLL P i


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LLL Pneumonia


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? P i


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? Pneumonia


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Lung abscess

A

F


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Pleural Effusion

Upright film, will cause blunting on

the lateral and iflarge enough, theposterior costophrenic

sulci. A large effusion canlead to a mediastinalshift away from theeffusion and opacifythe hemithorax.

Approximately 200 mlof fluid are needed todetect an effusion.


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Pl l Eff i


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Pleural Effusion

P i di l Eff i


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Pericardial Effusion

An enlarged heart shadow thatis often globular shaped(transverse diameter isdisproportionately increased).

Serial films can be helpful in

the diagnosis especially if rapidchanges in the size of the heartshadow are observed.

Approximately 400-500 ml offluid must be in the pericardiumto lead to a detectable change

in the size of the heart shadowon PA CXR. Pericardial effusion can be

definitively diagnosed witheither echocardiography or CT

P i di l Eff i


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Pericardial Effusion
http://www.learningradiology.com/caseofweek/caseoftheweekpix2007-1/cow274lg.jpghttp://www.learningradiology.com/caseofweek/caseoftheweekpix2007-1/cow274lg.jpg


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COPD

COPD / E h


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COPD / Emphysema

C l ifi d G l


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Calcified Granuloma


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T b Li & C th t


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Tubes, Lines & Catheters

P th


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Pneumothorax

A tension PTX; air enters

the pleural cavity and istrapped during expirationusually by some type ofball valve mechanism. Thisleads to increasing intra-thoracic pressure.Eventually the pressurebuildup is large enough tocollapse the lung and shiftthe mediastinum.

Defined as air inside thethoracic cavity butoutside the lung.


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Mass vs Infiltrate


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Mass vs. Infiltrate


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Mass Location Intraparench mal s ple ral s e traple ral


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Mass Location; Intraparenchymal vs. pleural vs. extrapleural

Sub centemetric Nodules


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Sub-centemetric Nodules


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Solitary Pulmonary Nodule
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Solitary Pulmonary Nodule

A common finding on achest x-ray. Most nodules are benign Nodules are diagnosed

as benign if they Show little or no growth

for 2 years Calcification

Central, laminated ordiffuse pattern indicatesa granuloma

Eccentric calcification canbe seen in a carcinoma orin a cancer that hasengulfed a granuloma.
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Hiatal Hernia
http://www.ajronline.org/content/vol183/issue2/images/large/08_03_0124_02A.jpeg


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Hiatal Hernia


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CT Calcium Score & CT Coronary Angiography


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CT Calcium Score & CT Coronary Angiography


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Aortic Aneurysm


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Aortic Aneurysm

CAD


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CAD

New Developments


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New Developments


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- This is a chest x-ray of anadult female patient.

- The silhouette of the rightupper Mediastinum is lost

and the consolidation isconfined inferiorly by thehorizontal fissure.

- Within the consolidation airbronchograms are evident.

- There is consolidation of theright upper lobe


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- In a patient of age 56, the presence of anupper lobe collapse should alert one to thepossibility of an endobronchial neoplasm.

- An endobronchial malignancy may be theunderlying cause for an upper lobe collapse oran upper lobe pneumonia which fails to resolvewith treatment.

- referral for bronchoscopy is advised


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Air Bronchogram


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Air Bronchogram

Air bronchograms are dueto the air within bronchisurrounded byconsolidated lung. Thesesmaller bronchi are not

normally delineated fromthe lung, but due toconsolidation a contrastdifference occurs. Theyare not always present,but when they are they

suggest consolidation(usually infection) in thelung.


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A = Right Main Stem BronchusB = Right Upper Lobe BronchusB1 = Apical Segmental BronchusB2 = Anterior Segmental BronchusB3 = Posterior Segmental Bronchus

C = Bronchus IntermediusD = Right Middle Lobe Bronchus

D4 = Lateral Segmental BronchusD5 = Medial Segmental Bronchus

E = Right Lower Lobe BronchusE6 = Superior Segmental Bronchus

E7 = Medial Basal Segmental BronchusE8 = Anterior Basal Segmental BronchusE9 = Lateral Basal Segmental BronchusE10 = Posterior Basal Segmental Bronchus

F = Left Main Stem BronchusG = Left Upper Lobe Bronchus

G1, G2 = Apicoposterior Segmental BronchusG3 = Anterior Segmental Bronchus

H = Lingular BronchusH4 = Superior Lingular Segmental BronchusH5 = Inferior Lingular Segmental Bronchus

I = Left Lower Lobe BronchusI6 = Superior Segmental BronchusI7 = Medial Basal Segmental BronchusI8 = Anterior Basal Segmental BronchusI9 = Lateral Basal Segmental BronchusI10 = Posterior Basal Segmental Bronchus

Lobes and Fissures


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Lobes and Fissures

interpretation of chest imaging1

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