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Chest X-Ray Interpretation for the Internist Theresa Cuoco, MD Medical University of South Carolina February 22, 2012.

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Presentation on theme: "Chest X-Ray Interpretation for the Internist Theresa Cuoco, MD Medical University of South Carolina February 22, 2012."— Presentation transcript:

1 Chest X-Ray Interpretation for the Internist Theresa Cuoco, MD Medical University of South Carolina February 22, 2012

2 Disclaimer: I am NOT a radiologist!

3 Why do we need to know? To direct care while awaiting an “official read” Low level radiation for the patient Easily available and noninvasive Relatively inexpensive

4 Objectives Basics of technique Type of film and the “tions” Identification of structures on a “normal” CXR Alveolar vs interstitial, lobar anatomy, silhouette sign, air bronchograms, and patterns of lung disease The mediastinum, pleura, and heart Systematic approach to interpretation Cases

5 Technique PA and lateral AP Which is preferred and why? Lateral film – left side of chest against x-ray cassette Decubitus films

6 Which is which?

7 The “tions” IdentificaTION InspiraTION PenetraTION RotaTION

8 Inspiration vs Expiration Any indications for an expiratory film?

9 Penetration Heavy light exposure causes the film to be black (A) Little light exposure causes the film to be white (B) A B

10 Rotation

11 Normal Anatomy

12 The Normal Chest X-Ray

13 Alveolar vs Interstitial Alveolar = air sacs Radiolucent Blood, mucous, tumor, or edema in alveoli obscure normal anatomy: “airless lung” Interstitial = vessels, lymphatics, bronchi, and connective tissue Radiodense Interstitial disease: prominent lung markings with aerated lungs

14 Lobar Anatomy Anterior Posterior

15 Lobar Anatomy – Lateral Views RightLeft

16 The Silhouette Sign There are 4 basic radiographic densities Gas, fat, soft tissue (water), and metal (bone) Anatomic structures are recognized on x-ray by their density differences Two substances of the same density in direct contact can’t be differentiated Loss of the normal radiologic silhouette (contour) is called the “silhouette sign”

17 Localizing Lesions Where is the silhouette sign?

18 Localizing Lesions

19 A B

20 AB

21 Obscured L heart border = lingula Aortic knob obliterated = left upper lobe Right lung base w heart border seen = right lower lobe Right lung base w heart obscured = right middle lobe Descending aorta obscured = left lower lobe EXCEPTIONS: Pseudosilhouette of diaphragm in underpenetrated film Right heart border my overlap spine Heart obscures anterior left diaphragm on lateral

22 The Air Bronchogram When lung is consolidated and bronchi contain air, the dense lung delineates the air-filled bronchi Visualization of air in the intrapulmonary bronchi is called the “air bronchogram sign” Abnormal finding Can be seen in: PNA, edema, infarction Chronic lung lesions

23 NO Air Bronchograms… In pneumonia if bronchi are filled with secretions If cancer obstructs a bronchus Interstitial fibrosis Asthma/emphysema (hyperinflation)

24 What do you see?

25 Lung and Lobar Collapse When a whole lung collapses, the trachea deviates TOWARD the side of collapse (due to volume loss)

26 Fissures Formed by 2 visceral pleural layers Demarcate the boundaries of the lobes Shift of fissures is best sign of lobar collapse

27 Which lobes have collapsed? Minor fissure is elevated – RUL partially collapsed Heart has moved to right and silhouette sign of right diaphragm – indicated RLL collapse

28 Hilar Displacement The left hilum is normally slightly higher than the right Hilar depression indicates collapse of lower lobe Hilar elevation indicates collapse of upper lobe

29 Patterns of Lung Disease Pearls Pulmonary markings are more visible in interstitial disease Generalized interstitial markings = linear (reticular) Discrete/focal thickening = nodular Homogeneous or patchy consolidation = alveolar Focal consolidation < 3cm = nodule Focal consolidation > 3cm = mass Heavy calcification generally = benign

30 What is the pattern? A: Focal/linearB: Diffuse/nodularC: Alveolar

31 The Mediastinum

32 I: Anterior Mediastinum Heart Retrosternal clear space 5 T’s II: Middle Mediastinum Esophagus Arch and descending aorta Trachea III: Posterior Mediastinum Paravertebral area Lymph nodes in all 3!

33 The Pleura The posterior costophrenic angle is the deepest and only seen on the lateral film The lateral film is more sensitive for detection of small pleural effusions How much fluid can be seen on a radiograph? Erect PA: 175 mL Erect lateral: 75 mL Decubitus: >5 mL Supine: Several hundred mL

34 What do you see?

35 The Heart The horizontal width of the heart should be less than ½ the widest internal diameter of the thorax

36 Left and Right Ventricular Enlargement Left ventricular enlargement Frontal: LHB moves laterally and cardiac apex inferolaterally Lateral: LHB moves inferoposteriorly Right ventricular enlargement Frontal: RHB further right Lateral: Contacts lower half of sternum (instead of lower 3 rd )

37 Cephalization Enlargement of the upper lobe vessels “Vascular redistribution” “Kerley B” lines: interstitial edema thickening the interlobular septa causing short lines perpendicular to the pleural surface

38 Systematic approach ABCDE Airway Bones and breasts Cardiac and costophrenic Diaphragm Edges and extrathoracic Fields (lung fields and failure) ATMLL (“Are There Many Lung Lesions?”) Abdomen Thorax – bones and soft tissues Mediastinum Lungs – unilateral and bilateral

39 Cases

40 Young man with cancer

41 Young man without symptoms

42 ICU patient with fever, WBC

43 Two older women with cough

44 Dyspnea with sudden CP & fever


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