reading chest films
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Chest Radiography Interpretation: Reading Chest Films
Chest Radiography Chest Radiography Interpretation: Interpretation: Reading Chest FilmsReading Chest Films
Lisa Chen , M.D.Assistant Clinical Professor
Pulmonary and Critical Care DivisionDepartment of Medicine
San Francisco General Hospital
Michael Gotway, MDAssociate Clinical Professor, RadiologyUniversity of California, San Francisco
Approach to the CXR:Technical Aspects
Approach to the CXR:Approach to the CXR:Technical AspectsTechnical Aspects
• Inspiratory effort9-10 posterior ribs
• Penetrationthoracic intervertebral disc space just visible
• Positioning/rotationmedial clavicle heads equidistant to spinous process
• Inspiratory effort99--10 posterior ribs10 posterior ribs
• Penetrationthoracic intervertebral disc space just visiblethoracic intervertebral disc space just visible
• Positioning/rotationmedial clavicle heads equidistant to spinous medial clavicle heads equidistant to spinous processprocess
Low Lung VolumesLow Lung Volumes
Over ExposureOver Exposure Proper ExposureProper Exposure
101010
What to EvaluateWhat to EvaluateWhat to Evaluate
• Lungs• Pleural surfaces• Cardiomediastinal contours• Bones and soft tissues• Abdomen
• Lungs• Pleural surfaces• Cardiomediastinal contours• Bones and soft tissues• Abdomen
Where to LookWhere to LookWhere to Look
• Apices• Retrocardiac areas (left and right)• Below diaphragm
• Apices• Retrocardiac areas (left and right)• Below diaphragm
Apical TBApical TB
Left Left RetrocardiacRetrocardiac OpacityOpacity
Normal Anatomy: Frontal CXRNormal Anatomy: Frontal CXRNormal Anatomy: Frontal CXR
• Heart• Aorta• Pulmonary arteries• Airways• Diaphragm/costophrenic sulci• Junction lines
• Heart• Aorta• Pulmonary arteries• Airways• Diaphragm/costophrenic sulci• Junction lines
Normal Anatomy: LateralNormal Anatomy: LateralNormal Anatomy: Lateral
• Heart• Aorta• Pulmonary arteries• Airways• Spine
• Heart• Aorta• Pulmonary arteries• Airways• Spine
AAAA
RVRV
LVLV
Chest Radiography: Basic Principles
Chest Radiography: Chest Radiography: Basic PrinciplesBasic Principles
• X-ray photon fates:completely absorbed in patienttransmitted through patient; strike filmscattered within patient; strike film
• X-ray absorption depends on:beam energy (constant)tissue density
• X-ray photon fates:completely absorbed in patientcompletely absorbed in patienttransmitted through patient; strike filmtransmitted through patient; strike filmscattered within patient; strike filmscattered within patient; strike film
• X-ray absorption depends on:beam energy (constant)beam energy (constant)tissue densitytissue density
Maximum xMaximum x--rayrayTransmissionTransmission
(least dense tissue)(least dense tissue)
Maximum xMaximum x––ray ray AbsorptionAbsorption
(densest tissue)(densest tissue)
BlackestBlackest
airair
fatfat
soft tissuesoft tissue
calciumcalcium
bonebone
xx--ray contrastray contrast
metalmetal
WhitestWhitest
• All cardiothoracic pathology and normal anatomy is visualized (or not) by 7 different densities
• How is this accomplished?differential x-ray absorption
• All cardiothoracic pathology and normal anatomy is visualized (or not) by 7 different densities
• How is this accomplished?differential xdifferential x--ray absorptionray absorption
Chest Radiography: Basic Principles
Chest Radiography: Chest Radiography: Basic PrinciplesBasic Principles
• A structure is rendered visible on a radiograph by the juxtaposition of two different densities
• A structure is rendered visible on a radiograph by the juxtaposition of two different densities
Differential X-Ray AbsorptionDifferential XDifferential X--Ray AbsorptionRay Absorption
Silhouette SignSilhouette SignSilhouette Sign
• Loss of the expected interface normally created by juxtaposition of two structures of different density
• No boundary can be seen between two structures of similar density
• Loss of the expected interface normally created by juxtaposition of two structures of different density
• No boundary can be seen between two structures of similar density
Right Lower Lobe PneumoniaRight Lower Lobe Pneumonia
Differential X-Ray AbsorptionDifferential XDifferential X--Ray AbsorptionRay Absorption
• The absence of a normal interface may indicate disease;
• The presence of an unexpected interface may also indicate disease
• The presence of interfaces can be used to localize abnormalities
• The absence of a normal interface may indicate disease;
• The presence of an unexpected interface may also indicate disease
• The presence of interfaces can be used to localize abnormalities
Chest Radiographic Patterns of DiseaseChest Radiographic Chest Radiographic Patterns of DiseasePatterns of Disease
• Air space opacity• Interstitial opacity• Nodules and masses• Lymphadenopathy• Cysts and cavities• Lung volumes• Pleural diseases
• Air space opacity• Interstitial opacity• Nodules and masses• Lymphadenopathy• Cysts and cavities• Lung volumes• Pleural diseases
• Cardiomediastinal contour abnormalities• Bone and soft tissue abnormalities• Below the diaphragm: abdominal and
retroperitoneal disease
• Cardiomediastinal contour abnormalities• Bone and soft tissue abnormalities• Below the diaphragm: abdominal and
retroperitoneal disease
Chest Radiographic Patterns of DiseaseChest Radiographic Chest Radiographic Patterns of DiseasePatterns of Disease
Air Space OpacityAir Space OpacityAir Space Opacity
• Components:air bronchogram: air-filled bronchus surrounded by airless lungconfluent opacity extending to pleural surfacessegmental distribution
• Components:air air bronchogrambronchogram: air: air--filled bronchus filled bronchus surrounded by airless lungsurrounded by airless lungconfluent opacity extending to pleural confluent opacity extending to pleural surfacessurfacessegmental distributionsegmental distribution
Air Space Opacity: DDXAir Space Opacity: DDXAir Space Opacity: DDX
• Blood (hemorrhage)• Pus (pneumonia)• Water (edema)
hydrostatic or non-cardiogenic• Cells (tumor)• Protein/fat: alveolar proteinosis and
lipoid pneumonia
• Blood (hemorrhage)• Pus (pneumonia)• Water (edema)
hydrostatic or nonhydrostatic or non--cardiogeniccardiogenic• Cells (tumor)• Protein/fat: alveolar proteinosis and
lipoid pneumonia
LUL PneumoniaLUL Pneumonia
Interstitial OpacityInterstitial OpacityInterstitial Opacity
• Hallmarks:small, well-defined noduleslines
interlobular septal thickeningfibrosis
reticulation
• Hallmarks:small, wellsmall, well--defined nodulesdefined noduleslines lines
interlobular septal thickeninginterlobular septal thickeningfibrosisfibrosis
reticulationreticulation
Interstitial Opacity: Small NodulesInterstitial Opacity: Small Nodules
Interstitial Opacity: Interstitial Opacity: LinesLines
Interstitial Opacity: Lines & ReticulationInterstitial Opacity: Lines & Reticulation
Interstitial Opacity: DDXInterstitial Opacity: DDXInterstitial Opacity: DDX
• Idiopathic interstitial pneumonias• Infections (TB, viruses)• Edema• Hemorrhage• Non–infectious inflammatory lesions
sarcoidosis• Tumor
• Idiopathic interstitial pneumonias• Infections (TB, viruses)• Edema• Hemorrhage• Non–infectious inflammatory lesions
sarcoidosissarcoidosis• Tumor
Nodules and MassesNodules and MassesNodules and Masses
• Nodule: any pulmonary lesion represented in a radiograph by a sharply defined, discrete, nearly circular opacity 2-30 mm in diameter
• Mass: larger than 3 cm
• Nodule: any pulmonary lesion represented in a radiograph by a sharply defined, discrete, nearly circular opacity 2-30 mm in diameter
• Mass: larger than 3 cm
Nodules and MassesNodules and MassesNodules and Masses
• Qualifiers:single or multiplesizeborder definitionpresence or absence of calcificationlocation
• Qualifiers:single or multiplesingle or multiplesizesizeborder definitionborder definitionpresence or absence of calcificationpresence or absence of calcificationlocationlocation
MassMass
CalcificationCalcification
WellWell--DefinedDefined
IllIll--DefinedDefined
LymphadenopathyLymphadenopathyLymphadenopathy
• Non-specific presentations:mediastinal wideninghilar prominence
• Specific patterns:particular station enlargement
• Non-specific presentations:mediastinal wideningmediastinal wideninghilar prominencehilar prominence
• Specific patterns:particular station enlargementparticular station enlargement
Right Paratracheal Right Paratracheal LymphadenopathyLymphadenopathy
Right Hilar LANRight Hilar LAN
Right Hilar LANRight Hilar LAN
Left Hilar LANLeft Hilar LAN
Subcarinal LANSubcarinal LAN
Subcarinal LANSubcarinal LAN
*
AP Window LANAP Window LAN
Cysts & CavitiesCysts & CavitiesCysts & Cavities
• Cyst: abnormal pulmonary parenchymal space, not containing lung but filled with air and/or fluid, congenital or acquired, with a wall thickness greater than 1 mm
epithelial lining often present
• Cyst: abnormal pulmonary parenchymal space, not containing lung but filled with air and/or fluid, congenital or acquired, with a wall thickness greater than 1 mm
epithelial lining often presentepithelial lining often present
Cysts & CavitiesCysts & CavitiesCysts & Cavities
• Cavity: abnormal pulmonary parenchymal space, not containing lung but filled with air and/or fluid, caused by tissue necrosis, with a definitive wall greater than 1 mm in thickness and comprised of inflammatory and/or neoplastic elements
• Cavity: abnormal pulmonary parenchymal space, not containing lung but filled with air and/or fluid, caused by tissue necrosis, with a definitive wall greater than 1 mm in thickness and comprised of inflammatory and/or neoplastic elements
Cysts & CavitiesCysts & CavitiesCysts & Cavities
• Characterize:wall thickness at thickest portioninner liningpresence/absence of air/fluid levelnumber and location
• Characterize:wall thickness at thickest portionwall thickness at thickest portioninner lininginner liningpresence/absence of air/fluid levelpresence/absence of air/fluid levelnumber and locationnumber and location
Benign Lung Cyst : Benign Lung Cyst : PCPPCP PneumatocelePneumatocele•• Uniform wall thicknessUniform wall thickness•• 1 mm1 mm•• Smooth inner liningSmooth inner lining
Benign Cavities :Benign Cavities :CryptococcusCryptococcus
•• max wall thickness max wall thickness ≤≤4 mm4 mm•• minimally irregular inner liningminimally irregular inner lining
Indeterminate CavitiesIndeterminate Cavities
•• max wall thickness max wall thickness 55--15 mm15 mm•• mildly irregular inner liningmildly irregular inner lining
Malignant Cavities: Squamous Cell CaMalignant Cavities: Squamous Cell Ca•• max wall thickness max wall thickness ≥≥16 mm16 mm•• Irregular inner liningIrregular inner lining
Pleural Disease: Basic PatternsPleural Disease: Basic PatternsPleural Disease: Basic Patterns
• Effusionangle blunting to massivemobility
• Thickeningdistortion, no mobility
• Mass• Air• Calcification
• Effusionangle blunting to massiveangle blunting to massivemobilitymobility
• Thickeningdistortion, no mobilitydistortion, no mobility
• Mass• Air• Calcification
Pleural EffusionPleural Effusion
Pleural EffusionPleural Effusion
Subpulmonic EffusionSubpulmonic Effusion
Pleural CalcificationPleural Calcification
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