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M C Alraies1 Chest Radiography Interpretation M Chadi Alraies, MD Chief Medical Resident Case Western Reserve University SVCH.

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Presentation on theme: "M C Alraies1 Chest Radiography Interpretation M Chadi Alraies, MD Chief Medical Resident Case Western Reserve University SVCH."— Presentation transcript:

1 M C Alraies1 Chest Radiography Interpretation M Chadi Alraies, MD Chief Medical Resident Case Western Reserve University SVCH

2 Reading CXR’s Have a structured method! Have a structured method! Be consistent with that method Be consistent with that method Don’t take short cuts Don’t take short cuts LOOK AT ALL YOUR PATIENTS XRAYS YOURSELF (and with your resident of course!) LOOK AT ALL YOUR PATIENTS XRAYS YOURSELF (and with your resident of course!) PRACTICE…PRACTICE… PRACTICE PRACTICE…PRACTICE… PRACTICE

3 What is a Chest Radiograph? SHADOW

4 Start at the beginning Identification! Identification! Correct patient Correct patient Correct date and time Correct date and time Correct examination Correct examination Are old films available? Are old films available? DO THIS EVERYTIME – It buys you time and is vitally important. DO THIS EVERYTIME – It buys you time and is vitally important.

5 Approach to the CXR: Technical Aspects Projection – PA or AP Projection – PA or AP Position – Upright or Supine (Supine folks are sick) Position – Upright or Supine (Supine folks are sick) Inspiratory effort Inspiratory effort 9-10 posterior ribs 9-10 posterior ribs Penetration Penetration thoracic intervertebral disc space just visible thoracic intervertebral disc space just visible Positioning/rotation Positioning/rotation medial clavicle heads equidistant to spinous process medial clavicle heads equidistant to spinous process

6 Projection

7 Portable (AP or Antero- posterior) FILM

8 PA (Postero-anterior) FILM

9 Projection PAAP

10 Low Lung Volumes

11 Over Exposure Proper Exposure

12 99

13

14 Mental Break

15 Anatomy RML RUL

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17

18 RUL (Right Upper Lung)

19 RML (Right Middle Lung)

20 RLL (Right Lower Lung)

21 Right Sided Fissures

22 LUL (Left Upper Lung)

23 LLL (Left Lower Lung)

24 Left Side Fissure LUL LLL

25 What to Evaluate Lungs Lungs Pleural surfaces Pleural surfaces Cardiomediastinal contours Cardiomediastinal contours Bones and soft tissues Bones and soft tissues Abdomen Abdomen

26 Where to Look Apices Apices Retrocardiac areas (left and right) Retrocardiac areas (left and right) Below diaphragm Below diaphragm

27 Apical TB

28 Left Retrocardiac Opacity

29 Normal Anatomy: Frontal CXR Heart Heart Aorta Aorta Pulmonary arteries Pulmonary arteries Airways Airways Diaphragm/costophrenic sulci Diaphragm/costophrenic sulci

30

31 Normal Anatomy: Lateral Heart Heart Aorta Aorta Pulmonary arteries Pulmonary arteries Airways Airways Spine Spine

32 Maximum x-ray Transmission (least dense tissue) Maximum x–ray Absorption (densest tissue) Blackestairfat soft tissue calciumbone x-ray contrast metalWhitest

33 A structure is rendered visible on a radiograph by the juxtaposition of two different densities A structure is rendered visible on a radiograph by the juxtaposition of two different densities Chest Radiography: Basic Principles

34 Silhouette Sign Loss of the expected interface normally created by juxtaposition of two structures of different density Loss of the expected interface normally created by juxtaposition of two structures of different density No boundary can be seen between two structures of similar density No boundary can be seen between two structures of similar density

35 Right Lower Lobe Pneumonia

36 Differential X-Ray Absorption The absence of a normal interface may indicate disease; The absence of a normal interface may indicate disease; The presence of an unexpected interface may also indicate disease The presence of an unexpected interface may also indicate disease The presence of interfaces can be used to localize abnormalities The presence of interfaces can be used to localize abnormalities

37 Chest Radiographic Patterns of Disease Air space opacity Air space opacity Interstitial opacity Interstitial opacity Nodules and masses Nodules and masses Lymphadenopathy Lymphadenopathy Cysts and cavities Cysts and cavities Lung volumes Lung volumes Pleural diseases Pleural diseases

38 LUL Pneumonia

39 Air Space Opacity Components: Components: air bronchogram: air-filled bronchus surrounded by airless lung air bronchogram: air-filled bronchus surrounded by airless lung confluent opacity extending to pleural surfaces confluent opacity extending to pleural surfaces segmental distribution segmental distribution

40 Air Space Opacity: DDX Blood (hemorrhage) Blood (hemorrhage) Pus (pneumonia) Pus (pneumonia) Water (edema) Water (edema) hydrostatic or non-cardiogenic hydrostatic or non-cardiogenic Cells (tumor) Cells (tumor) Protein/fat: alveolar proteinosis and lipoid pneumonia Protein/fat: alveolar proteinosis and lipoid pneumonia

41 Interstitial Opacity: Small Nodules

42 Interstitial Opacity: Lines

43 Interstitial Opacity: Lines & Reticulation

44 Interstitial Opacity Hallmarks: Hallmarks: small, well-defined nodules small, well-defined nodules lines lines interlobular septal thickening interlobular septal thickening fibrosis fibrosis reticulation reticulation

45 Interstitial Opacity: DDX Idiopathic interstitial pneumonias Idiopathic interstitial pneumonias Infections (TB, viruses) Infections (TB, viruses) Edema Edema Hemorrhage Hemorrhage Non–infectious inflammatory lesions Non–infectious inflammatory lesions sarcoidosis sarcoidosis Tumor Tumor

46 Mass Calcification Well-Defined Ill-Defined

47 Nodules and Masses Nodule: any pulmonary lesion represented in a radiograph by a sharply defined, discrete, nearly circular opacity 2-30 mm in diameter Nodule: any pulmonary lesion represented in a radiograph by a sharply defined, discrete, nearly circular opacity 2-30 mm in diameter Mass: larger than 3 cm Mass: larger than 3 cm

48 Nodules and Masses Qualifiers: Qualifiers: single or multiple single or multiple size size border definition border definition presence or absence of calcification presence or absence of calcification location location

49 Right Paratracheal Lymphadenopathy

50 Right Hilar LAN

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52 Left Hilar LAN

53

54 Subcarinal LAN *

55 AP Window LAN

56 Lymphadenopathy Non-specific presentations: Non-specific presentations: mediastinal widening mediastinal widening hilar prominence hilar prominence Specific patterns: Specific patterns: particular station enlargement particular station enlargement

57

58 Cysts & Cavities Cyst: abnormal pulmonary parenchymal space, not containing lung but filled with air and/or fluid, congenital or acquired, with a wall thickness greater than 1 mm Cyst: abnormal pulmonary parenchymal space, not containing lung but filled with air and/or fluid, congenital or acquired, with a wall thickness greater than 1 mm epithelial lining often present epithelial lining often present

59 Cysts & Cavities Cavity: abnormal pulmonary parenchymal space, not containing lung but filled with air and/or fluid, caused by tissue necrosis, with a definitive wall greater than 1 mm in thickness and comprised of inflammatory and/or neoplastic elements Cavity: abnormal pulmonary parenchymal space, not containing lung but filled with air and/or fluid, caused by tissue necrosis, with a definitive wall greater than 1 mm in thickness and comprised of inflammatory and/or neoplastic elements

60 Benign Lung Cyst : PCP Pneumatocele Uniform wall thickness Uniform wall thickness 1 mm 1 mm Smooth inner lining Smooth inner lining

61 Benign Cavities : Cryptococcus max wall thickness  4 mm max wall thickness  4 mm minimally irregular inner lining minimally irregular inner lining

62 Indeterminate Cavities max wall thickness 5-15 mm max wall thickness 5-15 mm mildly irregular inner lining mildly irregular inner lining

63 Malignant Cavities: Squamous Cell Ca max wall thickness  16 mm max wall thickness  16 mm Irregular inner lining Irregular inner lining

64 Cysts & Cavities Characterize: Characterize: wall thickness at thickest portion wall thickness at thickest portion inner lining inner lining presence/absence of air/fluid level presence/absence of air/fluid level number and location number and location

65 Pleural Effusion

66

67 Pleural Calcification

68 Pleural Disease: Basic Patterns Effusion Effusion angle blunting to massive angle blunting to massive mobility mobility Thickening Thickening distortion, no mobility distortion, no mobility Mass Mass Air Air Calcification Calcification

69 Thoracic Aorta Aneurysm

70 Chest breast implants

71 u Rib fx’s u Mediast. OK u Pulmonary contusion u Subcu air u Chest tube u NG tube

72 MVC victim

73 Deep Right Mainstem Intubation Carina Tip of ET tube

74 Tip of ET Pneumomediastinum

75 wide mediastinum wide mediastinum obliteration of aortic knob obliteration of aortic knob Rt mainstem shift up and right Rt mainstem shift up and right NG deviate to right NG deviate to right pleural cap pleural cap Major Vessel Injury Potential X ray findings

76 Pneumothoraces

77

78 Expiration reduces lung volume, making a small pneumo easier to see

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87 Irregular linear opacities are present in both lungs, especially in the periphery and the bases of the lungs. The heart is slightly enlarged, but this is not related to the pulmonary abnormalities in this case.

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90 Hodgkin’s Disease

91 Ao SVC Mediastinal Hematoma

92 Chest tube NG shift to Rt. Tracheal deviation to Rt. ET tube Obliterated aortic knob First rib fx

93 ET NG Rt. Subclavian Art. Lt. Internal Carotid Artery Lt. Subclavian Artery Aortic Rupture

94 Tension Pneumothorax on CT Rt.Lt. Mediastinum Ao Tension Pneumo

95 Hemothoraces

96 Hemothorax SupineUpright

97 Hemopneumothorax

98

99 Indistinct diaphragm

100 Elevated, irregular hemidiaphragm

101 Close-up Rib fxs Clavicle fx Chest tube Suspicious Indistinct, elevated diaphragm

102 Crushed right chest

103 After ventilated with PEEP


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