interpretation chest radio graph

8/3/2019 Interpretation Chest Radio Graph

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Chest X-ray Interpretation for the

Clinician

Karen LaframboiseAssociate Professor of MedicineDivision of Respirology, Critical Careand Sleep MedicineUniversity of Saskatchewan


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Chest X-ray Interpretation

Objectives:

1) To review basic anatomy seen on the plainchest x-ray.

2) Discuss an approach to common chest x-raypresentations seen in common lung diseases.

3) Discuss uncommon chest x-ray presentationsin lung diseases (common and uncommon).

4) Discuss an approach to chest x-rayinterpretation in the critically ill patient.


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CXR Interpretation for the Clinician

Pearls of Wisdom

Previous/prior CXRs areinvaluable in aiding theinterpretation, if possiblehave them available whenlooking at the current CXR.

The knowledge of thepatients history andphysical findings by the

reader is very helpful. The hardest CXR to read?

Normal CXR!

Read 100s of CXRs. Readthe CXR of every patientyou see! Never accept thereading of Normal CXRwithout viewing it yourself!

Dont read theradiologists report beforelooking at the CXR. Look at

each one as a test. Describe to yourself what

you see before thinking ofthe differential diagnosis.


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Begin ~ 6 away and then move closer

Dont stop with the first abnormality you see

Directed systematic visual approach

Non-mnemonic way to review whole CXR: Lung parenchyma and airways

Mediastinum Chest wall including; ribs, diaphragms, pleura,

vertebrae, all extrathoracic structures.

If ICU/CCU patient, lines and tubes first.

Reading a CXR


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Approach to the CXR:

Technical Aspects Name of patient, date

Type of film and position markers: PA vs AP/ Rightvs Left

Patients position: Upright or erect/ semi erect/supine/ lateral etc.

Technical Quality: Penetration/exposure

Lung volumes

Foreign objects: lines, tubes, drains, ECG leads.Non-medical objects; bullets, glass, etc.


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Approach to the CXR:

Technical Aspects Positioning/Rotation:

- medial clavicle heads equidistant to thespinous process

Lung volumes: 6 ribs anteriorly (5 to 7), 9 to 10posteriorly

Penetration/Exposure:

- thoracic intervertebral disc space just visible

(looking through the heart)


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Chest Xray Technical Aspects

PA film minimizes magnification of the cardiacsilhouette/shadow.

AP view magnifies the clavicles, sternum andmediastinal structures (heart, aorta, pulmonaryvessels.

Supine position widens the heart and

mediastinum and changes the normalphysiology of the pulmonary blood flow.


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Penetration


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Thoracic Imaging Strategies

Approach to image interpretationWhat is the expected normal and variant

anatomy?

Is something absent?

Is there some additional structure present?Look at the bones and soft tissues

Look at the heart and mediastinum

Look at the lungs and pleura

Look at the airways

Look at the diaphragms and upper abdomen


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Normal PA and Lateral Film


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Look at the bones

123

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5

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9

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11The location of an abnormalshadow can be described by itsproximity to a particular rib orinterspace

Identify the 1st rib by its anterior

junction with the manubrium thencount down the posterior ribs

12

Examine scapulae, humeri,

shoulder joints, clavicles, ribs and

spine for symmetry


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Survey the

soft tissues

Breast tissues (ifapplicable)

SkinSupraclavicular areas

Axillae

Subcutaneous fatMuscles Which film is that of a woman?


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Notice the asymmetry ofthe left breast shadowrelative to the right and thesurgical clips in the left

axilla

Diagnosis: Leftbreast cancertreated withlumpectomy andaxillary nodedissection

What happened

to this patient?


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Subcutaneous emphysema and

pneumomediastinum

Notice the air within theright lateral soft tissuesand in the

supraclavicular region.There are also linearstreaks of air outliningthe mediastinalstructures.


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Whats wrong with this

radiograph?Notice the absenceof both clavicles.The heart and aorticarch are also on theright side (situsinversus), a

congenital variant.


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Normal Anatomy: Frontal CXR

Heart

Aorta

Pulmonary arteries

Airways

Diaphragm/costophrenic sulci

Junction lines


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Normal Anatomy: Lateral

Heart

Aorta

Pulmonary arteries

Airways

Spine


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Heart and Mediastinum

Three bumps on left side (PA view):aorta, main pulmonary artery and LV

if more think of adenopathy or LA enlargement

Superior mediastinum (at level of aortic knob) 100 cc

homogeneous opacification of theposterior costophrenic angle

Superior concave meniscus

If lateral normal, a clinically significant

effusion is excluded


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Pleural Effusion

PA film

May see > 175 cc, usually 200

400ccObliteration of

costophrenic/cardiophrenic

anglesMeniscus convex toward the

lung


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Pleural Effusion

Supine:

Seen when > 500 cc

Opacification of lateral costophrenic

angles Generalized density/haziness to

hemithorax

obscured diaphragm contour

Will still see well-defined vessels if mild-moderate in size (not in consolidation oratelectasis)


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Lines and Tubes

Endotracheal tube should sit a minimum of 2cm above the carina.

Mid-trachea, T46, below the clavicles.

With flexion and extension the ETT can move2 to 3 cm.


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http://www.med.virginia.edu/med-ed/mmdb/high/r/rad00101.jpg


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Diffuse Parenchymal Lung Disease OrInterstitial Lung Diseases


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Interstitial Lung Diseases

Idiopathic

Interstitialpneumonias

Connective

Tissue Diseases

Occupationaland

EnvironmentalExposures

Drug-Induced

Lung Injury

OtherSystemic

Disorders


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Diff se L ng Disease


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Diffuse Lung Disease

Infection: > than 40 causes

Drugs: > 50 causes

Air space/edema:cardiogenic or non-

cardiogenic: > 30 or morecauses

Inflammatory: Sarcoidosis,HypereosinophilicSyndromes, vasculitides

CTD: ~ 10 causes

Occupational/hypersensitivity pneumonitis: > 50 causes

Pulmonary hemorrhage:Good Pastures, idiopathichemosiderosis, others

Interstitial pneumonias:DIP/RB-ILD, NSIP, AIP, LIP, UIP,

IIP, COP

Malignancy/lymphoproliferative disorders

Miscellaneous: Pulmonary

alveolar proteinosis, LAM,LCH (Histiocytosis X), CF,alveolar microlithiasis,tuberous sclerosis, etc.


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CXR Interpretation Summary


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CXR Interpretation Summary

Practice and repetition. Speak with yourRadiologist.

Prior CXRs are very useful!

Plain CXR is the starting point, findings on theCXR will direct you towards further imaging.

Some diseases have certain CXR patterns, butthis is not written in stone!

Always keep the patient clinical presentingfeatures in mind when coming up with yourdifferential diagnosis.


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interpretation chest radio graph

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