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Reading Chest Radiographs. Basics Anterior-Posterior vs. Posterior-Anterior AP exaggerates cardiac size PA requires pt to stand Look at the whole radiograph.

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Presentation on theme: "Reading Chest Radiographs. Basics Anterior-Posterior vs. Posterior-Anterior AP exaggerates cardiac size PA requires pt to stand Look at the whole radiograph."— Presentation transcript:

1 Reading Chest Radiographs

2 Basics Anterior-Posterior vs. Posterior-Anterior AP exaggerates cardiac size PA requires pt to stand Look at the whole radiograph Learn a system - do it the same EVERY time

3 System A-B-C-D-E-F A - Airway/lung fields B - Bones/soft tissue C - Cardiac/mediastinum D - Diaphragm E - Examine Technique F - Foreign bodies

4 Lung Parenchyma Classify disease into 3 categories Airspace: alveolar filling fluffy, opacities, air-bronchograms Interstitial: lines and small dots reticulonodular, reticular, nodular Nodule: single or multiple, vary in size, w/ or w/o cavitation/calcification, smooth or irregular

5 Consolidation Filling or loss of air spaces Pus - Pneumonia Fluid - Pulmonary edema Blood - infarct, hemorrhage Foreign body - aspiration Tumor - bronchoalveolar carcinoma Volume loss - atelectasis

6 RML atelectasis

7 Consolidation Radiographic signs Opacity, air bronchograms, silhouetting Silhouette sign: intrathoracic lesion touching border of heart, aorta, diaphragm obliterating that border Helps to identify location of consolidation

8 Left Heart Silhouette sign

9 Consolidation Silhouette sign: What structure is silhouetted on PA? R heart = RML L heart = lingula Aorta, diaphragm = Lower lobe Lateral view: which diaphragm is silhouetted? Fissure sign: abrupt margin Increased density of vert. just above diaphragm on lateral

10 Collapse Atelectasis - volume loss Extrinsic compression (effusion, tumor, etc) Airway obstruction Extraluminal - tumor, LAD Intraluminal - tumor, foreign body Lobar collapse: mediatstinal shift to affected side, displacement of hilum/fissures, fewer vessels on affected side

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14 Interstitial Pattern Acute process: Pneumonia - viral, fungal, Tb, PCP Edema - CHF, Renal failure w/ overload Drug/Transfusion reaction Chronic: many etiologies Normal/low lung volumes

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17 Interstitial Pattern Upper lobe predominant Tb, pneumoconioses, fibrosis from ankylosing spondylitis Mid lung predominant sarcoid, berylliosis, allergic alveolitis, eosinophilic granulomatosis Lower lung predominant IPF, lymphangitic tumor spread, CVD fibrosis, chronic edema, drug rxn

18 Interstitial Pattern Large Lung volumes: indicates air trapping Cystic fibrosis Eosinophilic granulomatosis Lymhangioleiomyomatosis Tuberous sclerosis

19 Pulmonary Nodule(s) Solitary Nodule: many etiologies Primary lung tumor, mets, granuloma, septic emboli, pulmonary AVM, hamartoma, Wegener’s vasculitis, bronchiectasis, fungal infection, etc Important features Change over time: growing is worrisome Calcification: eccentric is worrisome Size: > 3cm more worrisome

20 Pulmonary Nodule(s) Multiple Nodules Metastatic until proven otherwise septic/bland emboli vasculitides, CVD pneumoconioses Eosinophilic granulomatosis Fungi, viral, Tb PNA Wegener’s Lymphoma

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23 Cardiac Anatomy Frontal view Right atrium SVC Aortic knob Left atrial appendage Left ventricle Lateral view Right atrium/Ventricle Left ventricle Left atrium Aortic arch Main Pulm. Artery Descending Thoracic Aorta

24 Cardiac Anatomy On frontal CXR - 45% or less than largest diameter from inner aspect of rib to rib laterally Right heart border - mostly RA Left Border - Aortic arch, MPA, LAA, LV

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26 Right Atrium - Right border >4cm from center of spine Right Ventricle - fills retrosternal space >1/3 distance between diaphragm & sternomanubrial joint Left Atrium - subcarinal angle >90 degrees, posterior deviation of left main stem bronchus Left Ventricle - LV reaches spine prior to diaphragm Atrial/Ventricular Hypertropy

27 Pulmonary Vasculature Many potential patterns to help narrow differential for cardiac disease 3 you need to know Normal - lower lobe vessels larger due to gravity, taper smoothly to periphery, interlobar arterial size (11-16mm M, 9- 14mm F)

28 Pulmonary Vasculature Pulmonary venous hypertension: upper lobe vessels larger “cephalization” result of hypoxic vasoconstriction; dependent edema LV failure (ASCHD, valvular), atrial myxoma, PVOD Pulmonary arterial hypertension: “pruning” or rapid tapering of peripheral vessels from large central arteries Chronic venous HTN, COPD, Chronic PE, vasculitides, Primary PHTN, L-to-R shunt

29 Kerley A line

30 Mediastinum Several compartments Anterior: ant. = sternum, post. = pericardium Middle: ant. = pericardium, post. = trachea Posterior: ant. = trachea, post. = ribs Don’t miss a widened mediastinum = could be an aortic aneurysm

31 Mediastinum Masses by compartment Anterior: “4T’s” Teratoma Thymoma Terrible tumor (lymphoma, mets) Thyroid - goiter Middle: Aortic aneurysm

32 Mediastinum Lymph nodes - Lymphoma/Mets Pericardial/bronchogenic cyst Posterior: Aneurysm Lymph nodes Neurogenic tumors - ganglion tumor Spine - osteophyte Esophagus - paraesophageal hernia Substernal Thyroid

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35 Pleural Abnormalities Effusions: fluid cc to blunt CP angle on frontal 150cc posterior to blunt CP angle on lateral Free flowing or not?: obtain bilateral decubital films Subpulmonic: lateral peaking of diaphragm, loss lung parenchyma below diaphragm

36 Pleural Abnormalities Pneumothorax: air in pleural space Apical or “deep sulcus” Tension: flattened ipsilateral lung on mediastinum Masses Angle w/ chest wall is obtuse Center of Mass Well defined margin only on 1 side

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39 Pleural Abnormalities Thickening Focal: unilateral usually from infection/hemorrhage Plaque from asbestosis - near diaphragms Diffuse: unilateral Smooth: Old Tb, empyem, hemothorax, mesothelioma, mets, lymphoma Nodular: same except Tb


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