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Chest X-ray Interpretation Dr C. Lokubalasooriya.

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Presentation on theme: "Chest X-ray Interpretation Dr C. Lokubalasooriya."— Presentation transcript:

1 Chest X-ray Interpretation Dr C. Lokubalasooriya

2 Introduction Single most common basic examination Low cost examination More information

3  X-rays were first discovered accidentally by Wilhelm Conrad Röntgen in  X-rays are waves of electromagnetic energy that have a shorter wavelength than normal light  He discovered that these new invisible rays could pass through most objects that casted shadows including human tissue but not human bones and metals.  Within a year of the discovery many scientists replicated the experiment Röntgen performed and began using it in clinical settings  In 1901 Röntgen won the first Nobel Prize in Physics

4 Essentials Before Getting Started Identification Exposure – Overexposure – Underexposure Sex of Patient – Male – Female

5 Essentials Before Getting Started Path of x-ray beam – PA – AP Patient Position – Upright – Supine

6 Essentials Before Getting Started Breath – Inspiration – Expiration

7 Systematic Approach Bony Framework Soft Tissues Lung Fields and Hila Diaphragm and Pleural Spaces Mediastinum and Heart Abdomen and Neck

8 Systematic Approach Bony Fragments – Ribs – Sternum – Spine – Shoulder girdle – Clavicles

9 Systematic Approach Soft Tissues – Breast shadows – Supraclavicular areas – Axillae – Tissues along side of breasts

10 Systematic Approach Lung Fields and Hila – Hilum Pulmonary arteries Pulmonary veins – Lungs Linear and fine nodular shadows of pulmonary vessels – Blood vessels – 40% obscured by other tissue

11 Systematic Approach Diaphragm and Pleural Surfaces – Diaphragm Dome-shaped Costophrenic angles – Normal pleural is not visible – Interlobar fissures

12 Systematic Approach Mediastinum and Heart – Heart size on PA – Right side Inferior vena cava Right atrium Ascending aorta Superior vena cava

13 Systematic Approach Mediastinum and Heart – Left side Left ventricle Left atrium Pulmonary artery Aortic arch Subclavian artery and vein

14 Systematic Approach Abdomen and Neck – Abdomen Gastric bubble Air under diaphragm – Neck Soft tissue mass calcifications

15 Pitfalls to Chest X-ray Interpretation Poor inspiration Over or under penetration Rotation Forgetting the path of the x-ray beam

16 Lung Anatomy Trachea Carina Right and Left Pulmonary Bronchi Secondary Bronchi Tertiary Bronchi Bronchioles Alveolar Duct Alveoli

17 Lung Anatomy Right Lung – Superior lobe – Middle lobe – Inferior lobe Left Lung – Superior lobe – Inferior lobe

18 Lung Anatomy on Chest X-ray PA View: – Extensive overlap – Lower lobes extend high Lateral View: – Extent of lower lobes

19 Lung Anatomy on Chest X-ray The right upper lobe (RUL) occupies the upper 1/3 of the right lung. Posteriorly, the RUL is adjacent to the first three to five ribs. Anteriorly, the RUL extends inferiorly as far as the 4th right anterior rib

20 Lung Anatomy on Chest X-ray The right middle lobe is typically the smallest of the three, and appears triangular in shape, being narrowest near the hilum

21 Lung Anatomy on Chest X-ray The right lower lobe is the largest of all three lobes, separated from the others by the major fissure. Posteriorly, the RLL extend as far superiorly as the 6th thoracic vertebral body, and extends inferiorly to the diaphragm. Review of the lateral plain film surprisingly shows the superior extent of the RLL.

22 Lung Anatomy on Chest X-ray The lobar architecture of the left lung is slightly different than the right. Because there is no defined left minor fissure, there are only two lobes on the left; the left upper

23 Lung Anatomy on Chest X-ray Left lower lobes

24 The Normal Chest X-ray PA View: 1. Aortic arch 2. Pulmonary trunk 3. Left atrial appendage 4. Left ventricle 5. Right ventricle 6. Superior vena cava 7. Right hemidiaphragm 8. Left hemidiaphragm 9. Horizontal fissure

25 The Normal Chest X-ray Lateral View: 1. Oblique fissure 2. Horizontal fissure 3. Thoracic spine and retrocardiac space 4. Retrosternal space

26 The Silhouette Sign An intra-thoracic radio- opacity, if in anatomic contact with a border of heart or aorta, will obscure that border. An intra- thoracic lesion not anatomically contiguous with a border or a normal structure will not obliterate that border.

27 Putting It All Together

28

29 Understanding Pathological Changes Most disease states replace air with a pathological process Each tissue reacts to injury in a predictable fashion Lung injury or pathological states can be either a generalized or localized process

30 Liquid Density Liquid densityIncreased air density GeneralizedLocalized Diffuse alveolar Diffuse interstitial Mixed Vascular Infiltrate Consolidation Cavitation Mass Congestion Atelectasis Localized airway obstruction Diffuse airway obstruction Emphysema Bulla

31 Stages of Evaluating an Abnormality 1. Identification of abnormal shadows 2.Localization of lesion 3.Identification of pathological process 4.Identification of etiology 5.Confirmation of clinical suspension Complex problems Introduction of contrast medium CT chest MRI scan

32 Putting It Into Practice

33 Case 1

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35 A single, 3cm relatively thin-walled cavity is noted in the left midlung. This finding is most typical of squamous cell carcinoma (SCC). One-third of SCC masses show cavitation

36 Case 2

37

38 LUL Atelectasis: Loss of heart borders/silhouetting. Notice over inflation on unaffected lung

39 Case 3

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41 Right Middle and Left Upper Lobe Pneumonia

42 Case 4

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44 Cavitation:cystic changes in the area of consolidation due to the bacterial destruction of lung tissue. Notice air fluid level.

45 Cavitation

46 Case 5

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48 Tuberculosis: bilateral upper lobe consolidations

49 Case 6

50

51 Bronchial Harmatoma: popcorn calcifications with defined margins

52 Case 7

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54 Nipple shadow: bilateral symmetrical lower zone opacity.

55 Case 8

56

57 Extra medullary haemopoasis: enlarged paravertebral soft tissues D/D neurofibroma

58 Case 9

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60 Dextracardia : gastric air bubble seen under right hemi diaphram.

61 Case 10

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63 Chest wall lesion: arising off the chest wall and not the lung

64 Case 11

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66 Pleural effusion: Note loss of left hemidiaphragm. Fluid drained via thoracentesis

67 Case 12

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69 Lung Mass

70 Case 13

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72 Small Pneumothorax: LUL

73 Case 14

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75 Right Middle Lobe Pneumothorax: complete lobar collapse

76 Case 15

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78 Metastatic Lung Cancer: multiple nodules seen

79 Case 16

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81 Mycetoma: left upper zone intracavitatory lesion

82 Case 17

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84 Perihilar mass: Hodgkin’s disease

85 Case 18

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87 Widened Mediastinum with illdefined aortic outline: Aortic Dissection

88 Case 19

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90 Achalasia cardia: dilated oesophagus.

91 Case 20

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93 Pneumo mediatinum : the lucent line adjascent to the pericardium continues in the diaphramatic surface:

94 Case 21

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96 Sarcoidosis : bilateral symmetrical hilar LNs

97 Case 22

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99 Cystic bronchiectasis : bilateral multiple cystic air spaces with fluid level

100 Case 23

101

102 Gas under diaphram : lucent gas shadow under the diaphram

103 Questions?

104


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