presentation chest x rays
TRANSCRIPT
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Chest X-rays
Basic to Intermediate Interpretation
Phillip Smith, BA, RRT
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Three +ain )actors Determine the Technical ualityo the Radiograph
• Inspiration
• Penetration
•
Rotation
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Inspiration
The chest radiograph should "eo"tained ith the patient in ullinspiration to help assess
intrapulmonary a"normalities#
At ull inspiration, the diaphragm
should "e o"served at a"out the levelo the .th to /0th ri" posteriorly, or the1th to 2th ri" anteriorly#
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Penetration
3n a properly e4posed chest radiograph'
• The loer thoracic verte"rae should "e visi"le through the heart
• The "ronchovascular structures "ehind
the heart $trachea, aortic arch,pulmonary arteries, etc#& should "e seen
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5ndere4posure
In an undere4posed chest radiograph,the cardiac shado is opa6ue, ithlittle or no visi"ility o the thoracic
verte"rae#
The lungs may appear much denserand hiter, much as they mightappear ith in7ltrates present#
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3vere4posure
*ith greater e4posure o the chestradiograph, the heart "ecomes moreradiolucent and the lungs "ecome
proportionately dar%er#
In an overe4posed chest radiograph, the air-7lled lung periphery "ecomes e4tremelyradiolucent, and oten gives the appearanceo lac%ing lung tissue, as ould "e seen in acondition such as emphysema#
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Rotation
Patient rotation can "e assessed "yo"serving the clavicular heads anddetermining hether they are e6ualdistance rom the spinous processes othe thoracic verte"ral "odies#
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)our ma8or positions are utili9ed orproducing a chest radiograph'
• Posterior-anterior $PA&
• :ateral
•
Anterior-posterior $AP&
• :ateral Decu"itus
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Posterioranterior $PA&Position
• The standard position or o"taining a routineadult chest radiograph
• Patient stands upright ith the anterior chestplaced against the ront o the 7lm
• The shoulders are rotated orard enough totouch the 7lm, ensuring that the scapulae do noto"scure a portion o the lung 7elds
• 5sually ta%en ith the patient in ull inspiration
• The PA 7lm is vieed as i the patient is standingin ront o you ith his;her right side on your let
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:ateral Position
• Patient stands upright ith the let sideo the chest against the 7lm and thearms raised over the head
• Allos the vieer to see "ehind theheart and diaphragmatic dome
• Is typically used in con8unction ith a PA
vie o the same chest to help determinethe three-dimensional position o organsor a"normal densities
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Anteriorposterior $AP&Position
• 5sed hen the patient is de"ilitated,immo"ili9ed, or una"le to cooperate ith thePA procedure
•
The 7lm is placed "ehind the patient
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:ateral Decu"itus Position
• The patient lies on either the right or let siderather than in the standing position as ith aregular lateral radiograph
•
The radiograph is la"eled according to the sidethat is placed don $a let lateral decu"itusradiograph ould have the patient
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Anatomical Structures inthe Chest
• +ediastinum
• =ilum
•
:ung )ields• Diaphragmatic Domes
• Pleural Suraces
•
Bones• Sot Tissue
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+ediastinum
• The trachea should "e centrally located orslightly to the right
• The aortic arch is the 7rst conve4ity on the
let side o the mediastinum• The pulmonary artery is the ne4t conve4ity
on the let, and the "ranches should "etracea"le as it ans out through the lungs
• The lateral margin o the superior venacava lies a"ove the right heart "order
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The =eart
• To-thirds o the heart should lie on the letside o the chest, ith one-third on the right
• The heart should ta%e up less that hal o
the thoracic cavity $C;T ratio > 10?&• The let atrium and the let ventricle create
the let heart "order
• The right heart "order is created entirely "y
the right atrium $the right ventricle liesanteriorly and, thereore, does not have a"order on the PA&
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=ilum
• The hila consist primarily o thema8or "ronchi and the pulmonary
veins and arteries
• The hila are not symmetrical, "utcontain the same "asic structures oneach side
• The hila may "e at the same level,"ut the let hilum is commonlyhigher than the right
• Both hila should "e o similar si9e
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:ungs
• @ormally, there are visi"le mar%ingsthroughout the lungs due to thepulmonary arteries and veins,
continuing all the ay to the chestall
• Both lungs should "e scanned,
starting at the apices and or%ingdonard, comparing the let andright lung 7elds at the same level $as
is done ith ascultation&
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:ungs
• 3n a PA radiograph, the minor7ssure can oten "e seen as a ainthori9ontal line dividing the R+:
rom the R5:#• The ma8or 7ssures are not usually
seen on a PA vie "ecause they are
"eing vieed o"li6uely#
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Diaphragm
• The let dome is normally slightly loer thanthe right due to elevation "y the liver, located
under the right hemidiaphragm#• The costophrenic recesses are ormed "y the
hemidiaphragms and the chest all#
• 3n the PA radiograph, the costophrenic recess
is seen only on each side here an angle isormed "y the lateral chest all and the domeo each hemidiaphragm $costophrenic angle
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Pleura
• The pleura and pleural spaces illonly "e visi"le hen there is ana"normality present
• Common a"normalities seen iththe pleura include pleuralthic%ening, or uid or air in thepleural space#
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Sot Tissue
Thic% sot tissue may o"scure underlyingstructures'
• Thic% sot tissue due to o"esity may
o"scure some underlying structures suchas lung mar%ings
• Breast tissue may o"scure thecostophrenic angles
:ucencies ithin sot tissue may representgas $as o"served ith su"cutaneous air&
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Bones
The "ones visi"le in the chest radiograph include'
• Ri"s
• Clavicles
•
Scapulae• erte"rae
• Pro4imal humeri
The "ones are useul as mar%ers to assess patientrotation, ade6uacy o inspiration, and 4-raypenetration#
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Descri"ing A"normal )indings on aChest Radiograph
• *hen addressing an a"normal 7nding ona chest radiograph, only a description ohat is seen, rather than a diagnosis,
should "e presented $a chest radiographalone is not diagnostic, "ut is only onepiece o descriptive inormation used toormulate a diagnosis&
• Descriptive ords such as shados,density, or patchiness, should "e used todiscuss the 7ndings
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Common A"normal )indings on Chest Radiographs
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Silhouette Sign
• The loss o the lung;sot tissueinterace due to the presence o uidin the normally air-7lled lung
• I an intrathoracic opacity is inanatomic contact ith a "order, thenthe opacity ill o"scure that "order
• Commonly seen ith the "orders othe heart, aorta, chest all, anddiaphragm
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Air Bronchogram
A tu"ular outline o an airay made visi"le due tothe 7lling o the surrounding alveoli "y uid orinammatory e4udates
Conditions in hich air "ronchograms are seen'
• :ung consolidation
• Pulmonary edema
• @on-o"structive pulmonary atelectasis
• Interstitial disease
• @eoplasm
• @ormal e4piration
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Consolidation
The lung is said to "e consolidated henthe alveoli and small airays are 7lledith dense material#
This dense material may consist o'
• Pus $pneumonia&
•
)luid $pulmonary edema&• Blood $pulmonary hemorrhage&
• Cells $cancer&
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Atelectasis
• Almost alays associated ith alinear increased density due to
volume loss
• Indirect indications o volume lossinclude vascular croding ormediastinal shit toard the collapse
• Possi"le o"servance o hilarelevation ith an upper lo"ecollapse, or a hilar depression ith a
loer lo"e collapse
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Pneumonia
Typical 7ndings on the chestradiograph include'
• Airspace opacity
• :o"ar consolidation
• Interstitial opacities
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Pleural !usion
3n an upright 7lm, an e!usion ill cause "lunting onthe lateral costophrenic sulcus and, i large enough, onthe posterior costophrenic sulcus#
• Appro4imately 00 ml o uid are needed to detect an
e!usion in a PA 7lm, hile appro4imately E1 ml ouid ould "e visi"le in the lateral vie
In the AP 7lm, an e!usion ill appear as a graded ha9ethat is denser at the "ase
A lateral decu"itus 7lm is helpul in con7rming ane!usion as the uid ill collect on the dependent side
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Pneumothora4
• Appears in the chest radiograph asair ithout lung mar%ings
• In a PA 7lm it is usually seen in the
apices since the air rises to the leastdependent part o the chest
• The air is typically ound peripheral
to the hite line o the visceralpleura
• Best demonstrated "y an e4piration
7lm
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Pulmonary dema
There are to "asic types o pulmonaryedema'
• Cardiogenic pulmonary edema caused
"y increased hydrostatic pulmonarycapillary pressure
• @oncardiogenic pulmonary edema
caused "y either altered capillarymem"rane permea"ility or decreasedplasma oncotic pressure
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Congestive =eart )ailure
Common eatures o"served on thechest radiograph o a C=) patientinclude'
• Cardiomegaly $cardiothoracic ratioF 10?&
• Cephali9ation o the pulmonary veins
• Appearance o Gerley B lines
• Alveolar edema oten present in aclassis perihilar "at ing pattern o
density
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mphysema
Common eatures seen on the chestradiograph include'
• =yperination ith attening o the
diaphragms
• Increased retrosternal space
• Bullae
• nlargement o PA;R $corpulmonale&
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:ung +ass
A lung mass ill typically present as alesion ith sharp margins and ahomogenous appearance, in contrastto the di!use appearance o an
in7ltrate#
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uestionsH