cxr interpretation
TRANSCRIPT
Interpretation of Interpretation of Chest RadiographsChest Radiographs
UNC Emergency MedicineUNC Emergency MedicineMedical Student Lecture SeriesMedical Student Lecture Series
ObjectivesObjectives
►The BasicsThe Basics Approach to interpretationApproach to interpretation AnatomyAnatomy Interstital diseaseInterstital disease Alveolar diseaseAlveolar disease
►Pattern RecognitionPattern Recognition►Practice!Practice!
InterpretationInterpretation
► Use a systematic approachUse a systematic approach Use or develop one you likeUse or develop one you like
► Use the same approach every time Use the same approach every time ►Describe what you seeDescribe what you see► Form a differential based on patient Form a differential based on patient
presentation and appearance of x-raypresentation and appearance of x-ray► If you find an abnormality, don’t stop thereIf you find an abnormality, don’t stop there
Finish your systematic readingFinish your systematic reading The second lesion is often missedThe second lesion is often missed
Systematic ApproachSystematic Approach
►ABCDEABCDE►AAirway (trachea)irway (trachea)
Midline v. deviated or rotated, FB in trachea, Midline v. deviated or rotated, FB in trachea, ET tube positionET tube position
►BBones (clavices, ribs, humeri, etc)ones (clavices, ribs, humeri, etc)►CCardiomediastinal silhoutteardiomediastinal silhoutte►DDiaphragms (and the costophrenic angles) iaphragms (and the costophrenic angles) ►EEverything Else (lung fields, soft tissues, verything Else (lung fields, soft tissues,
tubes, lines, wires, devices, etc)tubes, lines, wires, devices, etc)
Normal Chest RadiographNormal Chest Radiograph
Trachea
Right main stem bronchus
Left mainstem bronchus
Pulmonary artery
Pulmonary artery
Aortic knob
Left ventricle
Right atrium
Anatomy
Left hemidiaphragm
Right costophrenicangle Stomac
h
Upper lobes
Middle lobeLingula
Lower Lobes
Anatomy
Lower lobes
Upper lobes
Right middle lobe
Lingula
Common ViewsCommon Views
PA
AP
Left Lateral
Right anterior oblique
AP supine
Right lateral decubitus
Portable CXR
PA/Lateral CXR
These are from the Same Patient
Explain the difference…..
PA APAlways get a PA film to avoid cardiac magnificationExceptions: trauma, active cardiac chest pain, unstable, unable to cooperate with procedure
Silhouette SignSilhouette Sign
► Two substances of the Two substances of the same density, in direct same density, in direct contact, cannot be contact, cannot be differentiated from differentiated from each other on x-rayeach other on x-ray
► Common locationsCommon locations Lower lobes-diaphragmsLower lobes-diaphragms Right heart border – RMLRight heart border – RML Left heart border – Left heart border –
LingulaLingula Left diaphragm – Heart Left diaphragm – Heart
(on lateral view)(on lateral view)
Air Bronchogram SignAir Bronchogram Sign
► Visualization of air in Visualization of air in the intrapulmonary the intrapulmonary bronchibronchi
► Abnormal Abnormal ► Denotes a pulmonary Denotes a pulmonary
lesion/consolidation lesion/consolidation (excludes a pleural or (excludes a pleural or mediastinal lesion)mediastinal lesion)
► Seen in pneumonia, Seen in pneumonia, pulmonary edema or pulmonary edema or pulmonary infarct pulmonary infarct
An air bronchogram within the heart shadow suggests LLL consolidation
Silhouette sign
Interstitial Lung DiseaseInterstitial Lung Disease
► The vessels (lung The vessels (lung markings) appear markings) appear more prominentmore prominent
► Alveoli are still Alveoli are still aeratedaerated
►DDx: Pulmonary DDx: Pulmonary edema, edema, inflammation, inflammation, tumor, fibrosistumor, fibrosis
Alveolar DiseaseAlveolar Disease
► Vessels are less Vessels are less visible in the area of visible in the area of diseasedisease
► Lung is not aeratedLung is not aerated►May have air May have air
bronchograms or bronchograms or silhouette signsilhouette sign
►DDx: Bacterial DDx: Bacterial pneumonia, pneumonia, pulmonary edemapulmonary edema
Let’s PracticeLet’s Practice
►What type of filmWhat type of film►Describe what you seeDescribe what you see
Consolidation, infiltrate, nodular, diffuse, Consolidation, infiltrate, nodular, diffuse, streaky, opacificationstreaky, opacification
Look for Silhouette sign and air Look for Silhouette sign and air bronchogramsbronchograms
Is it an interstitial or alveolar pattern?Is it an interstitial or alveolar pattern? Other findings…Other findings…
►Give differential or diagnosisGive differential or diagnosis
75 yo F with hx of MI now presenting with SOB, hypoxia
Pulmonary edema
Opacification of right hemithorax, obscured left hemidiaphramDDx: Massive pleural effusion, right pneumonectomy
Multiple R sided rib fractures – flail chest
Opacification of left hemithorax, air-fluid level in left upper lobe, left clavicular fractureDiagnosis: Left empyema after trauma
Air-fluid (cavitary)lesion
Same patientLateral view
Air-fluid level
48 yo M with hx of PUD presenting with abdominal pain
pneumoperitoneum
67 yo smoker with one week of cough, sob, fevers
Left lower lobe pneumonia
““Spine Sign”Spine Sign”
http://images.google.com/imgres?imgurl=http://www.residentandstaff.com/content/RSP/2006/07/img/Case_pneum_1.jpg&imgrefurl=http://www.residentandstaff.com/issues/articles/2006-07_02.asp&h=572&w=580&sz=72&hl=en&start=23&um=1&tbnid=wBsgta58mO7XPM:&tbnh=132&tbnw=134&prev=/images%3Fq%3Dleft%2Blower%2Blobe%2Batelectasis%26start%3D21%26ndsp%3D21%26um%3D1%26hl%3Den%26sa%3DN
Dx: Subcutaneous air in neck and shoulder and pneumomediastinum (left heart border)
Lack of lung markings on right, collapsed lung
Dx: Complete rightpneumothorax
Collapsed lung
Is it a tension pneumothorax?
NO!NO!
►Tension PneumothoraxTension Pneumothorax Mediastinum is shifted to Mediastinum is shifted to oppositeopposite site of site of
pneumothoraxpneumothorax►Look at trachea and bronchiLook at trachea and bronchi►Look at heartLook at heart
Your patient is unstable or in distressYour patient is unstable or in distress►Absent breath soundsAbsent breath sounds►Respiratory difficulty, hypoxiaRespiratory difficulty, hypoxia►HypotensionHypotension►Trachea shiftedTrachea shifted
Deep sulcus signDeep sulcus sign
Thank You!Thank You!
Any Questions?Any Questions?