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Chest x-ray reading 報告醫師 : 李士毅醫師 指導醫師 : 林榮祿醫師. Check List(1) 1.Check patient data, position, technical quality and normal anatomy. 2.Review systematically.

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Presentation on theme: "Chest x-ray reading 報告醫師 : 李士毅醫師 指導醫師 : 林榮祿醫師. Check List(1) 1.Check patient data, position, technical quality and normal anatomy. 2.Review systematically."— Presentation transcript:

1 Chest x-ray reading 報告醫師 : 李士毅醫師 指導醫師 : 林榮祿醫師

2 Check List(1) 1.Check patient data, position, technical quality and normal anatomy. 2.Review systematically oInitial survey oReview skeletal structures of shoulder girdles and chest wall oReview mediastinum: overall size and shape trachea: position margins: SVC, ascending aorta, right atrium, left subclavian artery, aortic arch, main pulmonary artery, left ventricle lines and stripes: paratracheal, paraspinal, paraesophageal (azygoesophageal), paraaortic retrosternal clear space oReview hila: normal relationships size

3 Check List(2) oReview lungs and pleura: compare lung sizes evaluate pulmonary vascular pattern: compare upper to lower lobe, right to left, normal tapering to periphery pulmonary parenchyma pleural surfaces –fissures - major and minor - if seen –compare hemidiaphragms –follow pleura around rib cage oSoft tissue including breast, companion shadow. Review abdomen for bowel gas, organ size, abnormal calcifications, free air, etc. Review soft tissues and spine of neck. Review spine and rib cage: check alignment, disc space narrowing, lytic or blastic regions, etc.

4 Check List 1.Check patient data, position, technical quality and normal anatomy. 2.Review systematically oInitial survey oReview skeletal structures of shoulder girdles and chest wall oReview mediastinum oReview hila oReview lungs and pleura oSoft tissue including breast, companion shadow

5 1. Data base 1.Name 2.Date - important for comparing prior exams - Serial image 3.Position markers - right(R) vs. left(L) 4.Type of film 5.Patients position –supine, upright, lateral, etc. 6. Technical quality

6 (erect)

7 Introduction Serial image: Doubling time –Point of disease(location/size) –Make diagnosis easily Pneumonia Edema Tumor

8 Position Chest x-ray –P-A view –A-P –A-P supine –Lateral (Lt’/Rt’) –Lateral decubitus (Lt’/Rt’) –Lordotic –Oblique(Rt’/Lt’; post/anterior)

9 Position Speical position for special purpose –A-P supine: Ambulatory limit –A-P Lateral (Lt’/Rt’): Anatomy reading –Lateral decubitus: Effusion or thickening –Lordotic: Apical lesion –Oblique: Eliminate superimposed lesion Affect read result - eg. redistritubion Phenomenon (slide 183)

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11 P-A view

12 Rt’ Lateral decubitus view Rt’ Lateral view

13 Technical quality Ideal KV exposure –Key points Apex Retrocardiac lung marking Trachea position Spine Scapula –You can't find a subtle pneumothorax if there is patient motion or the film is overexposed. 4 basic radiographic densities

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21 Technical quality Ideal KV exposure 4 basic radiographic densities –Air –Fat –Water(soft tissue) –Bone(metal)

22 Normal Anatomy Anatomy & projection –General anatomy –Lobar anatomy –Segmental anatomy The sihouette sign

23 Anatomy & projection –General anatomy Posterior process Rib(Ant/Post) Left 2/Right 4 Costothoracic ratio Central trachea Hilar: Lt>Rt Lung field: Central> Peripheral/ Peripheral clear zone Pleura: Linear Diaphragm: Right >left/ Angle/Gastric pattern Subcutaneous tissue –Lobar anatomy –Segmental anatomy Normal Anatomy

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26 Anatomy & projection –General anatomy of lateral view 1.Right diaphragm 2.Left diaphragm 3.Spine 4.Scapula 5.Axiallary fold 6.Sternum 7.Subcutaneous tissue 8.Trachea 9.Aortic arch 10.Main bronchus 11.Pulmonary artery 12.Heart 13.Retrosternal clear space 14.Retrocardiac clear space 15.Costophrenic angle 16.Costocardiac angle Normal Anatomy

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28 Anatomy & projection –General anatomy –Lobar anatomy Fissures –Def: Pleura surround by air –3 main(1 minor; 2 major) –3 accessory(Azygos; inferior & superior accessory) –If fissure do not appear a thin line? - Ans: ? –Segmental anatomy The sihouette sign Normal Anatomy

29 Anatomy & projection –General anatomy –Lobar anatomy Fissures –Def: Pleura surround by air –3 main(1 minor; 2 major) –3 accessory(Azygos; inferior & superior accessory) –If fissure do not appear a thin line - Pneumonia(Bulging) - Atelectasis (Deviation) - Pleural effusion (Pseudotumor) –Segmental anatomy The sihouette sign Normal Anatomy

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31 Lobar anatomy

32 Anatomy & projection The sihouette sign –Define Interface is invisible when two areas of similar radiodensity touch. –Position Normal Anatomy

33 Anatomy & projection The sihouette sign –Define –Location Heart/Asending aorta Desending aorta/Diaphragm Airbronchogram Incomplete border Normal Anatomy

34 Anatomy & projection –General anatomy –Lobar anatomy –Segmental anatomy Rt’: 1-10 Lt’ 1-10 (1+2, 7+8) Normal Anatomy

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37 6 6

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39 8 10 8

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43 Check List 1.Check patient data, position, technical quality and normal anatomy. 2.Review systematically oInitial survey oReview skeletal structures of shoulder girdles and chest wall oReview mediastinum oReview hila oReview lungs and pleura oSoft tissue including breast, companion shadow

44 Systematic review A-B-C-D-E-F-G-H or     Try interpret and understand what you see: –D.D. normal v.s. abnormal?

45 Systematic review A-B-C-D-E-F-G-H oA: Airway oB: Bone oC: CV oD: Diaphragm oE: Extra-pulmonary oF: Lung field oG: Gastric bubble oH: Hilum/Hernia

46 Systematic review     oInitial survey oReview skeletal structures of shoulder girdles and chest wall oReview mediastinum oReview hila oReview lungs and pleura: oSoft tissue including breast, companion shadow..

47 Check List 1.Check patient data, position, technical quality and normal anatomy. 2.Review systematically oInitial survey oReview skeletal structures of shoulder girdles and chest wall oReview mediastinum oReview hila oReview lungs and pleura oSoft tissue including breast, companion shadow

48 Initial survey 1.General Body Size, Shape, and Symmetry 2.Sex 3.Age(cartilage/aortic arch /asending aorta/Pulmonary trunk) Infant/ child/ young adult/ elderly person 4.Foreign objects tubes, IV lines, EKG leads, surgical drains, prosthesis non-medical objects, bullets, shrapnel, glass, etc

49 Check List 1.Check patient data, position, technical quality and normal anatomy. 2.Review systematically oInitial survey oReview skeletal structures of shoulder girdles and chest wall oReview mediastinum oReview hila oReview lungs and pleura oSoft tissue including breast, companion shadow

50 Overall size, shape, contour of each bone. –Density( mineralization) –Compare cortical thickness to medullary cavity, trabecular pattern, –Erosions, fractures, any lytic or blastic regions. Joints –Articular relationships –Joint spaces narrowed, widened –Calcification in the cartilages –Air in the joint space, abnormal fat pads Refresh gross anatomy radiology Skeletal structures

51 Neck and Cervical spines Overall(soft tissue) –amounts –calcifications, –subcutaneous emphysema Trachea –position –size Cervical spine, –alignment –note any major congenital abnormalities. Specific parts of the vertebra and disc spaces Checking –erosions –lytic or blastic lesions –disc and synovial joint narrowing –Other abnormalities.

52 Thoracic spine and Rib cage Overall alignment- spine Symmetry - rib cage Double check bone density Two reminders at this point: –Principle of general More detailed review in each section. –concentrate on the skeletal detail “Look through" the mediastinum and lungs.

53 Specific parts(Each) –Vertebra –Disc spaces height integrity of cortical margins/pedicles/lamina presence of any lytic or sclerotic areas synovial joints(normal /narrowing /sclerosis spacing ) Compare frontal & lateral projections Thoracic spine

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55 1. Posterior Rib 2. Anterior Rib Ribs

56 1. Posterior rib, 2.Ant rib Compare –Side to side, –Cortical margins, –Trabecular patterns. Note calcified anterior cartilages –may obscure or mimic underlying lung lesions.

57 Lt/Rt SHOULDER GIRDLE

58 Check List 1.Check patient data, position, technical quality and normal anatomy. 2.Review systematically oInitial survey oReview skeletal structures of shoulder girdles and chest wall oReview mediastinum oReview hila oReview lungs and pleura oSoft tissue including breast, companion shadow

59 Mediastinum Define –Area between the lung –Water density Surrounded two air filled lungs and Intersected by the air filled trachea and major bronchi. Key is knowledge of anatomical relationships and how structures project on a radiograph. CT and MRI is helpful. Interfaces of air-soft tissue margins may be distorted by pathological lesion –Masses –otherwise

60 Mediastinum Define –Area between the lung –Water density Surrounded two air filled lungs and Intersected by the air filled trachea and major bronchi. Key is knowledge of anatomical relationships and how structures project on a radiograph. CT and MRI is helpful. Interfaces of air-soft tissue margins may be distorted by pathological lesion –Masses –otherwise

61 MEDIASTINUM

62 Mediastinum Define –Area between the lung –Water density Surrounded two air filled lungs and Intersected by the air filled trachea and major bronchi. Key is knowledge of anatomical relationships and how structures project on a radiograph. CT and MRI is helpful. Interfaces of air-soft tissue margins may be distorted by pathological lesion –Masses –otherwise

63 Anatomy

64 Project

65 Anatomy & project 1. Carina 2. Left Main Stem Bronchus 3. Descending Aorta 4. Main Pulmonary Artery 5. Aorticopulmonary Window 6. Arch of Aorta

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68 Anatomy dividing region –SUPERIOR MEDIASTINUM Begins - root of the neck and Ends - line drawn T-4 vertebrae --- sternomandible junction. –line skims the top of the aortic arch. T –Mediastinum Begins - this line End- diaphragm Further divided into three regions –Anterior –Middle –Posterior. MEDIASTINUM

69 1cm 4

70 Mediastinum Overall size and shape Trachea: position Margins Lines and stripes Retrosternal clear space

71 Mediastinum Overall size and shape Trachea- position Margins SVC- Ascending aorta Right atrium Left subclavian artery- Aortic arch Main pulmonary artery Left antrium Left ventricle Lines and stripes Retrosternal clear space

72 I II IV I II III Margins

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74 Venography 1. Right Brachiocephalic Vein 2. Superior Vena Cava 3. Left Brachiocephalic Vein

75 Axial plan of computer tomography 1.Right Brachiocepahlic Artery 2.Superior Vena Cava 3.Right Paratracheal Stripe 4.Esophagus 5.Left Subclavian Artery 6.Left Common Carotid Artery 7.Left Brachiocephalic Vein

76 1cm 4

77 Mediastinum Overall size and shape Trachea: position Margins Lines and stripes Paratracheal Paraspinal Paraesophageal (azygoesophageal) Paraaortic Retrosternal clear space

78 Edge of Superior vena cave (SVC) Seen PA(AP) view only Often only a portion Never bulge into the lung with a convex border.

79 Right Pratracheal stripe

80 Normal- < 5 mm, usually 2-3 mm. –Important marker for subtle adenopathy. Distal end - formed by azygous vein –Distended vein, stripe > 1 cm. Medial margin -soft tissue interface /right mucosal surface of trachea. Outer margin -begins medial end of clavicle/formed by plural surface of right upper lobe (RUL). Normal structures in soft tissue density between air trachea and the RUL –Right wall of the trachea –Nerves –Fat –Lymph nodes –Pleura of the RUL. Azygous vein - anteriorly to empty into the posterior surface of the SVC. Right Pratracheal stripe

81 Right paratracheal stripe(TOMOGRAM )

82 CT of Paratracheal stripe 1. Asending aorta 2. Azygous vein 3. Esophagus 4. Desending aorta 5. Pulmonary trunk

83 Left Subclavian stripe Width- normal cm. Inner margin- Air mucosal interface - mucosal surface of the trachea, Outer margin interface - Medial aspect of left upper lobe Upper- outer edge Level of the clavicle and will be able to follow it End- Bulge of the aortic arch.

84 Paraspinal stripe

85 Sometimes(+) on the frontal view Plural edge parallel to the lateral margins of the vertebral bodies. Edge > millimeters beyond the vertebral bodies Should not be lumpy or bulging.

86 Pleural mediastinal interface 1.Superior Vena Cava 2.Right Paratracheal Stripe 3.Left Subclavian Stripe

87 Azygoesophageal line or Paraesophageal line

88 On the forntal view only Formed by the right lower lobe & Mediastinum, containing –Esophagus –Azygous vein. Overlies the thoracic spine –Near the midline –Fairly straight, vertically. Bulges convex to lung –S/p mediastinal mass, eg. subcarinal lymph nodes Enlarged left atrium.

89 CT of the Azygoesophageal line 1. Esophagus 2. Azygous Vein 3. Descending Aorta

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91 Lateral view of tracheal wall Posterior tracheal < 4mm

92 Overall size/ shape on PA & lateral views –Decide if it is normal & age. Look for –Obvious masses –Calcifications –Double check for foreign projects Tubes Electrical leads Pacemaker Artificial valves MEDIASTINUM

93 Evidence of –Mediastinal shift Entire or Section of it. Look trachea/major bronchus –Size –Position –Intraluminal masses MEDIASTINUM

94 SUPERIOR MEDIASTINUM - PA Overall width for normal size, Look for –Masses –Calcifications –Free air. Detailed search for subtle distortion of –several major pleural mediastinal interfaces. Not all of the following structures are seen on every film –Try to find them

95 Mediastinum Define –Area between the lung –Water density Surrounded two air filled lungs and Intersected by the air filled trachea and major bronchi. Key is knowledge of anatomical relationships and how structures project on a radiograph. CT and MRI is helpful. Interfaces of air-soft tissue margins may be distorted by pathological lesion –Masses –otherwise

96 HEART 1 Edge of superior vena cava 2. Right atrium 3. Aortic arch 4. Edge of main pulmonary artery 5. Left atrial appendage 6. Left ventricle

97 Superimposed on the frontal view. The major structure is the heart. Pericardium and heart is inseparable on plain film views. Review the heart for overall size and shape. Rough yardstick - cardiac-thoracic ratio –Widest diameter of the heart /widest width of the thoracic cage( inner aspect of rib to rib). –> 50% Check –Calcifications –Pneumopericardium –Pneumomediastinum –Sutures –Prosthetic valves etc., You may have overlooked on the general survey of the entire mediastinum.

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101 1. Trachea 2. Right Ventricle 3. Left Ventricle 4. Left Atrium 5. Right Pulmonary Artery Lateral view of heart

102 Aorta

103 Try tracking –Root –Distal descending aorta. Young adult - hidden in the mediastinum Older - swing to the right to cast a soft tissue bulge. Arch- always be seen –make sure left to distal trachea –Pushes trachea slightly to the right actually. Check aortic calcifications and size. Left lateral border of descending aorta –abuts the left lung (column of dots on the pt's. left, on the annotated image). Lateral view- aorta is usually not seen.

104 Pulmonary artery 1. Carina 2. Left Main Stem Bronchus 3. Descending Aorta 4. Main Pulmonary Artery 5. Aorticopulmonary Window 6. Arch of Aorta

105 Main pulmonary artery –Straight or –Convex (most commonly in young females). "middle mogul" - when convex –Upper "mogul" - aortic knob –Lower mogul - left ventricle. Left pulmonary artery- branching of main pulmonary artery Right pulmonary artery- –Proximal- not seen, ( buried in the mediastinum) –Branches can see ( as the right hilum)

106 Blood vesseles in the lung

107 Pulmonary arteries, Lateral view 1. Trachea 2. Right Ventricle 3. Left Ventricle 4. Region of left Atrium 5. Right Pulmonary Artery 6. Left Pulmonary Artery 6

108 Pulmonary artery Right pulmonary artery –Ovoid branching structure- easily seen, –Just anterior to the air column of the trachea and main bronchi. Left pulmonary artery –Never seen as clearly as the right –Unless markedly enlarged. –Curved shadow, similar to the aorta –just behind the air column

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110 Aorticopulmonary window (AP WINDOW)

111 Double check area - for subtle mediastinal masses. Between –Aortic arch –Left pulmonary artery –Residual portion Ligamentum arteriosum left recurrent laryngeal nerve Should concave or straight border. –Mediastinal mass(+) Lung pushed laterally  border becomes convex.

112 MISCELLANEOUS Lateral view –Adult anterior mediastinum cephalad to the heart Lung-air density, not soft tissue density. –Infants and young children Thymus fills this area. Check posterior sternal margin –Small masses: internal thoracic lymph node enlargement.

113 Check List 8.Review hila: –normal relationships –size 9.Review lungs and pleura: –compare lung sizes –evaluate pulmonary vascular pattern: compare upper to lower lobe, right to left, normal tapering to periphery –pulmonary parenchyma –pleural surfaces fissures - major and minor - if seen compare hemidiaphragms follow pleura around rib cage

114 Frontal view of the hila

115 Frontal view, hilar shadows most –left pulmonary arteries. –right pulmonary arteries. Bronchi(with the arteries) –Radiolucent. Pulmonary veins –Not clearly seen they are behind the widest parts of the heart, inferior to the hila, where they converge into the left atrium. Left pulmonary artery always more superior > right,  left hilum higher. Calcified lymph nodes may be visible within the hilar shadows. Frontal view of the hila

116 Lateral view of the hila 1. Trachea 2. Lower lobe bronchi (left and right superimposed) 3. Right Pulmonary Artery

117 Check List 8.Review hila: –normal relationships –size 9.Review lungs and pleura: –compare lung sizes –evaluate pulmonary vascular pattern compare upper to lower lobe, right to left, normal tapering to periphery –pulmonary parenchyma –pleural surfaces fissures - major and minor - if seen compare hemidiaphragms follow pleura around rib cage

118 Lung size

119 Compare overall size of one lung bilateral, Also a double check on your earlier look at the rib cage size. Look for major areas of abnormal lucency/or density Train your eyes to look through the heart and upper abdomen to lung posterior to these areas. Lung

120 Blood vesseles in the lung

121 Distribution- side to side –Compare right/left upper lobes and lower lobes for roughly equal. Distribution- upper to a lower –Vessel in the same middle zone of the lung. Upright person- pressure differential –lower lobe vessel wider (i.e., larger) –If same size or reversed in size, Redistribution of flow has occurred. Phenomenon does not apply, if the person is semi-recumbent or supine. Blood vesseles in the lung

122 Blood vesseles of lung

123 PARENCHYMA

124 Large abnormalities/small lesion –Masses –Infiltrates –calcifications Compare- side to side at a time. Now ignore the bone but lung. 3 areas easily overlooked: –Behind the calcified anterior first rib cartilage, –Behind the heart –Behind the diaphragm PARENCHYMA

125 LATERAL VIEW OF THE LUNG Lateral view –Help to look Posterior costophrenic recess Anterior mediastinum.

126 Pleura PA view –Minor fissue thickness and location Lateral view –minor fissures –major fissures (even if you do not see them in their entirety which you rarely will).

127 AP VIEW OF THE PLEURA Follow the pleural surface around the lung periphery making the following observations. On the frontal view, the apex of the hemidiaphragms should be in the mid third of each hemithorax with the right hemidiaphragm usually cm higher than the left. The costophrenic angles laterally should be sharp. The lung should abut right up against the inner margins of the rib cage. If the pleural space is widened by fluid or mass, the lung will be pushed away by soft tissue density. Also check for pleural calcifications, and presence of pneumothorax.

128 LATERAL VIEW OF THE PLEURA Lateral view –,follow the pleura into the posterior costophrenic recess –along the inner aspect of the posterior ribs, if possible. Recheck Posterior sternal margin.

129 Soft tissues 1.Overall 2.Following –Calcifications –Bony defect –Soft tissue companion shadow for the clavicle Supraclavicular LAP

130 Lt/Rt CHEST WALL Overall thickness, subcutaneous emphysema, calcification. Muscle-fat planes (sharp, distinct; dots).

131 BREAST TISSUE Symmetry ( Normal variation – Standing(PA view) + unequal pressure against the film holder) Notice lung density changes (lung area +/- soft tissue of the breast )

132 ABDOMEN Highly variable look for following –Gastric and bowel gas Amount/ location( normal? ) –Organ size liver, spleen, kidneys –Free peritoneal air Position will change location of free air. –Calcifications and masses can they be localized to a specific structure.

133 Final Notes

134 This completes an introduction into the beginnings of chest review. Be aware there are many more detailed observations to learn in the future. Go through the sections until you understand the anatomy, and then start practicing a continuous review looking at a full frontal and lateral view. When you have developed a review system that works for you (remember the order here is only a guide) go to the next section that has the check off list type of review. Many people find it helpful to talk their way through the film, the eye-brain-mouth loop does work. Finally look at films on a variety of normal people of all ages, sizes, and both sexes to develop a data base of normal references. Practice the review sequence that works best for you until it is automatic, and then you can concentrate on the diagnostic findings.

135 Check List (1) 1.Check patient name, position, technical quality. 2.Initial survey 3.Soft tissue including breast, chest wall, companion shadow. Review soft tissues and skeletal structures of shoulder girdles and chest wall. Review abdomen for bowel gas, organ size, abnormal calcifications, free air, etc. Review soft tissues and spine of neck. Review spine and rib cage: check alignment, disc space narrowing, lytic or blastic regions, etc. 4.Review mediastinum: –overall size and shape –trachea: position –margins: SVC, ascending aorta, right atrium, left subclavian artery, aortic arch, main pulmonary artery, left ventricle –lines and stripes: paratracheal, paraspinal, paraesophageal (azygoesophageal), paraaortic –retrosternal clear space

136 Check List (2) 8.Review hila: –normal relationships –size 9.Review lungs and pleura: –compare lung sizes –evaluate pulmonary vascular pattern: compare upper to lower lobe, right to left, normal tapering to periphery –pulmonary parenchyma –pleural surfaces fissures - major and minor - if seen compare hemidiaphragms follow pleura around rib cage


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