lecture 7- cxr lecture slides

7/31/2019 Lecture 7- CXR Lecture Slides

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Thoracic Imaging - Basic

pproac o es


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De artment of Radiolo

Vancouver General Hospital

Dr. Savvas NicolaouDirector of ER/Trauma Radiology

[email protected]


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Learning Objectives

Be able to evaluate technical factors required for an adequate interpretation ofa chest x-ray with respect to

Penetration Inspiration Magnification

Angulation


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Learning Objectives Continued

Be able to identify the following structures on a PA chest x-ray:

Lungs & Airways Trachea Hila Right and left mainstem bronchi Right Lobe: upper, middle, lower lobes Left Lobe: upper & lower lobes

Mediastinum Heart borders Transverse thoracic aorta Pulmonary trunk Atrial appendage Aorto- ulmonar window


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Learning Objectives Continued


Costodiaphragmatic recesses

Clavicles

Spine

Humerus Sternum


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Learning Objectives Cont d


Sternum Right ventricle Vertebral bodies


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Chest Radiography

Very Inexpensive

os common reques e exam

Easily obtained

representat on o aanatomic structure

Usually first line imaging of thechest

Excellent for emergency, lineplacement, post surgical imaging

and query abnormality


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Arrow indicatesArrow indicatesmalpositionedmalpositionedtube.tube.

Normally, the ETNormally, the ETtube should betube should beat least overat least over

of carina.of carina.


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PLAIN RADIOGRAPHY PLAIN RADIOGRAPHY

Involve passing x-rays through patient s body to expose a

Computed / Digital display

unit

X-ray Unit


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INTRODUCTION TO THE CHEST XINTRODUCTION TO THE CHEST X- -RAYRAY

Posteroanterior (PA) ViewPosteroanterior (PA) View

--

Standard view, taken on full inspirationPatient stands with anterior chest wall against the film cassette

-

Anteroposterior (AP) View Anteroposterior (AP) ViewMagnifies the cardiac and mediastinal shadows (approx. 20%)


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Basic Information

metal

fat

5 Radiographic Densitiesyou should be aware of

bone

air

Water,soft tissue metal Water, air

so ssue


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Chest xray CT


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Introduction to the Chest X-RayHow the radiograph is taken - Technique

Posteroanterior (PA) View

Standard view, taken on full inspiration Patient stands with anterior chest wall against the film cassette

X-ray beam enters from behind

Anteroposterior (AP) View

Magnifies the cardiac and mediastinal shadows (approx. 20%)


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Chest X-ray Technique

PA AP


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TECHNICAL FACTORSTECHNICAL FACTORS QAULITY QAULITY

RotationRotationSpinous processes shouldSpinous processes shouldproject midway betweenproject midway betweenmedial heads of claviclesmedial heads of clavicles

InspirationInspiration

Dome of rightDome of rightover the anterior 6over the anterior 6 ththinterspace and posteriorinterspace and posteriorri ht 10ri ht 10 thth inters aceinters ace

ExposureExposureThe lower thoracic discThe lower thoracic disc

through the cardiacthrough the cardiacsilhouettesilhouette


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Determining Adequacy of the Film

Penetration:

Disk spaces of the thoracicspine can be seen behind the

ear , u no ony e a s othe spine


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Inspiration:

Diaphragm is below ribs 8-10;9-10 ribs can be seenpos er or y

10

9


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Rotation:

Clavicles are equidistant fromthe spinous processes


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Magnification:

The heart appears larger onan AP film than on a PA film

ue o e ear e ng ur erfrom the film and casting alarger shadow

Standard chest x-rays are PA

- most often AP

PA film shown here


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Angulation3

Clavicle is over the 3 rd rib If the beam is angled towards

the head due to patientposture, the clavicle would

appear higher and structures,. ,distorted


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BASIC ANATOMYBASIC ANATOMY

TracheaTrachea

SVC Az osSVC Az os

TransversethoracicTransversethoracic

confluence

confluence Left hilumLeft hilum

Right hilumRight hilum

appendage

appendage

ventricle

ventricle

RighthemidiaphragmRighthemidiaphragm

Costophrenic

angle

Costophrenic

angle


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SternumSternum

bodiesbodies

abuttingabuttingretrosternal spaceretrosternal space

Left AtriumLeft Atrium

Posterior margin ofPosterior margin ofLT ventricleLT ventricle

Normal Lateral Chest


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MAJOR AIR WAYS


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TRANSVERSE PORTION OF THE THORACIC AORTA


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Heart Chambers


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Coronal mediastinal structures:Gross vs CXR

1

3

13

22

1. Right atrium2. Ri ht ventricle3. Left ventricle


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Coronal mediastinal structures:CXR vs CT

3

2 3

5

4

7

4

5

6

887

1. Trachea2. Superior Vena Cava

5. Right atrium6. Left ventricle

. ort c rc4. Pulmonary Trunk

. g t em ap ragm8. Costophrenic angle


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1


1

32

3

4

5

6

42

56

1. Trachea 1. Pulmonary Trunk.

3. Aortic Arch.

3. Left Ventricle


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1

3

1

24

3

4

55

1. Trachea 4. Aortopulmonary Window.

3. Aortic Arch.


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Looking at Chest Wall / Soft Tissues

Check each rib individually

Check clavicles Check for the presence or

absences of breasts

Check for presence of soft tissue

masses

Vertebra

o ec o y, pe c es, sp nous

process, disc space.


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ANTERIOR


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POSTERIOR


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Chest Wall: Ribs

Posterior Ribs

More apparent on PA

Posterior Ribs

More apparent on PAfilm

Up to 10 visible on

film

Up to 10 visible onPPPP

PP

Anterior RibsAnterior RibsAA

PA film

PA film AA

AA

Ch t W ll C ti RibCh t W ll C ti Rib


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Chest Wall: Counting RibsChest Wall: Counting Ribs

Posterior Ribs

-more apparent on PA film

Posterior Ribs

-more apparent on PA film PP-up o v s e on uinspiration-up o v s e on uinspiration

Anterior Ribs Anterior Ribs-less visible on PA film-less visible on PA film


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Chest Wall: Counting Ribs

Posterior Ribs

-more a aren on PA

Posterior Ribs

-more a aren on PAfilm

-up to 10 visible on full

film

-up to 10 visible on full PPPP

inspirationinspiration PP

Anterior Ribs Anterior Ribs A A

- ess v s e on m- ess v s e on m A A A A

P t i Rib


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Posterior Ribs

22

33

44

55

66

77

88

99

1010

Diaphragm


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Diaphragm

,namely the lateral and posterior costophrenic angles (arrows).

Right hemidiaphragm normally about 2cm higher than left.

L

R

Coronal mediastinal structures:


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211

2

1. Right hemidiaphragm.


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Pleura


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Pleura

Pleura extends to the:

8th rib in themidclavicular line

10th rib in the midaxillaryline , and to the

12th rib posterior

Pneumothorax - Air in Pleural Space


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p

pleura


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Mediastinum


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The mediastinum is the space

between the spine at the back,

,

lungs at the sidesMiddle

It is divided into the anterior,

middle and posterior mediastinum

Anterior Posterior

Lateral film helpful but usually will

need a CT scan for furtherinvestigation


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A

Thymic mass in anteriormediastinum

Hila


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Comprised of lobar bronchi,

central/lobar pulmonary arteries,

veins, lymph nodes

The left hilum is slightly higher

than the right in normal

,

masses or enlarged lymph

nodes

HILUM


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Coronal mediastinal structures:CXR CT


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CXR vs CT

2

34

34

1. Trachea2. Aortic Arch

.4. Left hilum

Coronal mediastinal structures:CXR vs CT


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CXR vs CT

1 4

2 3

4

2

56

5 6

1. Trachea2. Right Main Bronchus

1. Aortic Arch2. Right Hilum

3. Left Main Bronchus 3. Left Hilum



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Gross vs CXR

1

2

4

1

4

1. Trachea2. Aortic Arch

. g t um4. Left hilum



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Gross vs CXR

1

4

2

6

31 4

2

35

6

1. Trachea2. Ri ht Main Bronchus

4. Aortic Arch5. Ri ht Hilum

3. Left Main Bronchus 6. Left Hilum


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u y y

Axial (transverse) mediastinal structures: Gross vs CT


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a (t a sve se) ed ast a st uctu es: G oss vs C

213

3

5

5

6

12

4 6

1. Right Major (oblique) fissure.

3. Right Upper Lobe4. Right Lower lobe

1 2

3 5

.6. Left lower lobe

Cross Sectional CT Imaging of Lungs


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3

4

57

3

4

5

7

1 2

6 8 68

1. Right Major (oblique) fissure. e t ma or o que ssure

3. Right minor (horizontal) fissure4. Right Upper Lobe

. g t ower o e7. Left Upper lobe8. Left lower lobe

5. g t e o e


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Coronal Saggital

Transverse

Coronal CT Imaging of Lungs


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g g g

23

4 7

12

3

7

8

6 8

1. Right Major (oblique) fissure2. Left major (oblique) fissure3. Ri ht minor horizontal fissure

5. Right Middle lobe6. Right Lower lobe7. Left U er lobe

4. Right Upper Lobe 8. Left lower lobe

The Right Lung


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The Right Lung


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Major fissure

The Right Lung


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Minor fissure

(Horizontal Fissure)

The Right Upper Lobe


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RUL

Right Middle Lobe


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RMLRML

Right Lower Lobe


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RLL

RLL

The Left Lung


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Left Lower and Upper Lobes


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LUL

LLL

LLL

Normal Lateral Chest


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Sagittal mediastinal structures:Gross vs CXR


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1

32

1

3

75

4

6

4

7

5

1. Sternum2. Right Pulmonary Artery

5. Right Ventricle6. Inferior Vena Cava

.4. Left Atrium

.

LOOKING AT THELOOKING AT THE LUNGSLUNGS


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RadiographicRadiographica earance isa earance iscomprised of gas filledcomprised of gas filledalveoli (black) andalveoli (black) and

(white)(white)

Bronchi dont normallyBronchi dont normallycontribute radiographiccontribute radiographicdensitydensity

by their tapering andby their tapering andbranching patternbranching pattern

NORMAL PULMONARY EDEMA


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lecture 7- cxr lecture slides

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