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1 Principles of Chest X-Ray Interpretation Dr Rod Taylor Consultant Respiratory Physician Dr Rod Taylor Consultant Respiratory Physician.

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Presentation on theme: "1 Principles of Chest X-Ray Interpretation Dr Rod Taylor Consultant Respiratory Physician Dr Rod Taylor Consultant Respiratory Physician."— Presentation transcript:

1 1 Principles of Chest X-Ray Interpretation Dr Rod Taylor Consultant Respiratory Physician Dr Rod Taylor Consultant Respiratory Physician

2 2 Different from us….

3 3 Only Two Choices Hmmn! There are far too many white bits! Hmmn! There are far too many white bits! That’s funny - this one’s got too many black bits!

4 4

5 5 Chest X-ray PP = important radiological principle

6 6 The Normal CXR Vertebral spines equidistant Horizontal fissure Costophrenic angle Cardiophrenic angle Left hilum Descending aorta Right diaphragm

7 7 It’s All Relative… 1 Stupid humans… PP

8 8 Why Does It Show Up? Because there is something of a different radiological density next to it. Four main densities: Because there is something of a different radiological density next to it. Four main densities: P

9 9 Étienne de Silhouette The silhouette sign If a structure shows up, there must be adjacent to it something of a different radiological density. If a structure does not show up, there must be adjacent to it something of a similar radiological density. The silhouette sign If a structure shows up, there must be adjacent to it something of a different radiological density. If a structure does not show up, there must be adjacent to it something of a similar radiological density. Controller-General of Finances during the Seven Years War (1754 – 63)

10 10 Silhouetted Hills This hill shows up This one doesn’t

11 11 Rotation PA

12 12 The Lobes Front Back

13 13 Lateral View (Right) Horizontal fissure Upper Lobe Lower Lobe Oblique fissure Apical segment of lower lobe Vertebral bodies appear to darken Middle Lobe Heart

14 14 Lateral View (Left) Oblique fissure Upper Lobe Lower Lobe Lingula No fissure (normally) Heart

15 15 Naming of Segments Apical Anterior Posterior Medial Lateral

16 16 Don’t Forget…. The bones Gas under the diaphragm Has this patient had a chest x-ray? Oh, good, then I can start!

17 17 It’s All Relative… 2 Normal CXR Too White? Too White? Too Black? Too Black? PP Look for collateral evidence Look for collateral evidence

18 18 What Do You See? The most obvious abnormality is likely to be the primary event. Other, more subtle, changes are likely to be secondary to this. The most obvious abnormality is likely to be the primary event. Other, more subtle, changes are likely to be secondary to this. PP

19 19

20 20 The Man in the Street Dryclough Lane Er, there’s a white bit on the right… at the top… um… which comes… ooh, about halfway down… with a sharp, um, line, at the bottom…

21 21 Right Upper Lobe Consolidation

22 22 The ‘Pair of Scissors Sign’ If you could cut along a line seen on a CXR with a pair of scissors - think of a pleural boundary or fissure. If you could cut along a line seen on a CXR with a pair of scissors - think of a pleural boundary or fissure. PP

23 23 Interlobar Effusion

24 24

25 25 Right Upper Lobe Collapse Horizontal fissure is pulled up, producing a sharply-defined RUZ opacity. Trachea is pulled to the right. Right hilum is pulled upwards. Right hemidiaphragm may be pulled up. Horizontal fissure is pulled up, producing a sharply-defined RUZ opacity. Trachea is pulled to the right. Right hilum is pulled upwards. Right hemidiaphragm may be pulled up.

26 26 Fissure extends medial to hilum Diaphragm disappears Vertebrae get whiter Diaphragm indistinct Diaphragm indistinct

27 27 Right Lower Lobe

28 28 Right Lower Lobe Collapse

29 29 Horizontal fissure Oblique fissure

30 30

31 31

32 32 Horizontal fissure

33 33 Middle Lobe Collapse

34 34

35 35

36 36 Right M & LL Collapse Oblique fissure Horizontal fissure

37 37

38 38 Displaced oblique fissure Elevated left diaphragm Overinflated lower lobe Overinflated lower lobe Tongue of collapsed upper lobe

39 39 Left Upper Lobe Collapse Overinflated left lower lobe

40 40 Consolidation Collapse

41 41 What is it?

42 42

43 43 “Radiological Homeostasis” If a structure is displaced on a CXR, then something else will happen to compensate for that displacement. Example: collapse of one lobe  overinflation of another If a structure is displaced on a CXR, then something else will happen to compensate for that displacement. Example: collapse of one lobe  overinflation of another PP

44 44 If a Structure is Displaced Pushed out of place Pulled out of place Look for collateral evidence Look for collateral evidence PP

45 45 Left heart border indistinct

46 46 Left heart border visible Oblique fissure Diaphragm indistinct Diaphragm indistinct

47 47 Diaphragm indistinct Descending aorta indistinct Triangular opacity

48 48 Collapsed Left Lower Lobe Descending aorta Diaphragm visible

49 49

50 50 Left Lower Lobe Collapse

51 51 Collapsed left lower lobe Collapsed right lower lobe

52 52 Left main bronchus ends abruptly Left main bronchus ends abruptly

53 53 Total Lung Collapse

54 54

55 55 Pleural Effusion Davis, Gardner & Qvist 1963, BMJ

56 56 Basic Principles

57 57 INTERLUDE

58 58 Bronchial Tree

59 59 Bronchial Tree RUL LUL ML Apical lower Apical lower Apical lower Apical lower Basal lower Basal lower Basal lower Basal lower Upper division Upper division Lingula

60 60 Anaesthetist’s Eye View Middle lobe Middle lobe trachea RL Basal lower Basal lower Lingula Left upper division Left upper division Apical lower Apical lower Right upper Right upper Apical lower Apical lower

61 61 Use Your Imagination!

62 62 Aspiration and Gravity

63 63 Apical Segment Anterior Posterior Apical segment Apical segment

64 64 Air Bronchogram Two requirements: 1. The bronchus must contain air. 2. The surrounding lung must not. Two requirements: 1. The bronchus must contain air. 2. The surrounding lung must not. PP Contrast bronchogram Contrast bronchogram Air bronchogram

65 65 Resolution Nodules Fibrosis Ground glass

66 66 Ground Glass Shadowing Can still see the vessels and airways Can still see the vessels and airways

67 67 Consolidation Ground glass shadowing Ground glass shadowing Consolidation Obscures the vessels and airways Obscures the vessels and airways

68 68 Pixels and Voxels Pixel Voxel

69 69 Volume Averaging When a pixel contains more than one type of tissue, it shows the average density of the voxel. 1. One big object, only partially within the voxel 2. Lots of small objects, all within the voxel When a pixel contains more than one type of tissue, it shows the average density of the voxel. 1. One big object, only partially within the voxel 2. Lots of small objects, all within the voxel

70 70 Partial Voluming

71 71 Partial Voluming Aortic arch

72 72 Partial Voluming (1)

73 73 Partial Voluming

74 74 Partial Voluming (2) Ground glass shadowing Ground glass shadowing

75 75 Volume-averaged mixture Volume-averaged mixture Individual ingredients

76 76 Ground Glass ‘Micro-fibrosis’ Normal Bronchiectatic

77 77 Traction Bronchiectasis Dilated bronchus Dilated bronchus Fibrosis

78 78 Pulmonary Fibrosis

79 79 Tree in Bud Sign Plugging and thickening of bronchioles Plugging and thickening of bronchioles

80 80 Basic Principles

81 81 (Sigh) If only everything was as simple as interpreting chest x-rays… (Sigh) If only everything was as simple as interpreting chest x-rays…


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