cxr interpretation

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Interpretation of Interpretation of Chest Radiographs Chest Radiographs UNC Emergency Medicine UNC Emergency Medicine Medical Student Lecture Medical Student Lecture Series Series

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Page 1: CXR Interpretation

Interpretation of Interpretation of Chest RadiographsChest Radiographs

UNC Emergency MedicineUNC Emergency MedicineMedical Student Lecture SeriesMedical Student Lecture Series

Page 2: CXR Interpretation

ObjectivesObjectives

►The BasicsThe Basics Approach to interpretationApproach to interpretation AnatomyAnatomy Interstital diseaseInterstital disease Alveolar diseaseAlveolar disease

►Pattern RecognitionPattern Recognition►Practice!Practice!

Page 3: CXR Interpretation

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

Page 4: CXR Interpretation

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)

Page 5: CXR Interpretation

Normal Chest RadiographNormal Chest Radiograph

Page 6: CXR Interpretation

Trachea

Right main stem bronchus

Left mainstem bronchus

Pulmonary artery

Pulmonary artery

Aortic knob

Left ventricle

Right atrium

Anatomy

Page 7: CXR Interpretation

Left hemidiaphragm

Right costophrenicangle Stomac

h

Upper lobes

Middle lobeLingula

Lower Lobes

Anatomy

Page 8: CXR Interpretation

Lower lobes

Upper lobes

Right middle lobe

Lingula

Page 9: CXR Interpretation

Common ViewsCommon Views

PA

AP

Left Lateral

Right anterior oblique

AP supine

Right lateral decubitus

Portable CXR

PA/Lateral CXR

Page 10: CXR Interpretation

These are from the Same Patient

Explain the difference…..

Page 11: CXR Interpretation

PA APAlways get a PA film to avoid cardiac magnificationExceptions: trauma, active cardiac chest pain, unstable, unable to cooperate with procedure

Page 12: CXR Interpretation

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)

Page 13: CXR Interpretation

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

Page 14: CXR Interpretation

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

Page 15: CXR Interpretation

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

Page 16: CXR Interpretation

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

Page 17: CXR Interpretation

75 yo F with hx of MI now presenting with SOB, hypoxia

Page 18: CXR Interpretation

Pulmonary edema

Page 19: CXR Interpretation
Page 20: CXR Interpretation

Opacification of right hemithorax, obscured left hemidiaphramDDx: Massive pleural effusion, right pneumonectomy

Page 21: CXR Interpretation
Page 22: CXR Interpretation

Multiple R sided rib fractures – flail chest

Page 23: CXR Interpretation
Page 24: CXR Interpretation

Opacification of left hemithorax, air-fluid level in left upper lobe, left clavicular fractureDiagnosis: Left empyema after trauma

Air-fluid (cavitary)lesion

Page 25: CXR Interpretation

Same patientLateral view

Air-fluid level

Page 26: CXR Interpretation

48 yo M with hx of PUD presenting with abdominal pain

Page 27: CXR Interpretation

pneumoperitoneum

Page 28: CXR Interpretation

67 yo smoker with one week of cough, sob, fevers

Page 29: CXR Interpretation

Left lower lobe pneumonia

Page 30: CXR Interpretation

““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

Page 31: CXR Interpretation
Page 32: CXR Interpretation

Dx: Subcutaneous air in neck and shoulder and pneumomediastinum (left heart border)

Page 33: CXR Interpretation
Page 34: CXR Interpretation

Lack of lung markings on right, collapsed lung

Dx: Complete rightpneumothorax

Collapsed lung

Is it a tension pneumothorax?

Page 35: CXR Interpretation

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

Page 36: CXR Interpretation

Deep sulcus signDeep sulcus sign

Page 37: CXR Interpretation

Thank You!Thank You!

Any Questions?Any Questions?