1. X-Rays Kunal D Patel Research Fellow IMM

2. The 12-Steps 1: Name 2: Date 3: Old films 4: What type of view(s) 5: Penetration 6: Inspiration 7: Rotation 8: Angulation 9: Soft tissues / bony structures 10: Mediastinum 11: Diaphragms 12: Lung Fields Quality Control Findings } } Pre-read }

3. Densities and Techniques?

4. Densities The big two densities are: (1) WHITE - Bone (2) BLACK - Air The others are: (3) DARK GREY- Fat (4) GREY- Soft tissue/water And if anything Man-made is on the film, it is: (5) BRIGHT WHITE - Man-made

5. Technique/ Orientation First determine is the film a PA or AP view. PA- the x-rays penetrate through the back of the patient on to the film AP-the x-rays penetrate through the front of the patient on to the film. (heart larger) All x-rays in the PICU are portable and are AP view

6. P-A (relation of x-ray beam to patient)

7. Lateral

8. Lateral Decubitus

9. 3 views: AP, oblique and lateral

10. Rotation

12. Quality Inspiration and penetration! Was film taken under full inspiration? Should be able to count 9- 10 posterior ribs Heart shadow should not be hidden by the diaphragm 1 2 3 4 5 6 7 8 9 10

13. Under penetration? if under penetrated you will not be able to see the thoracic vertebrae.

14. Angulation Clavicle should lay over 3rd rib 1 2 3

15. Sometimes handy to use PIER Position: Typically, upright PA and lateral. Sick patients will have the fuzzier supine AP (because the film is slid under their chest as they are lying down). Inspiration: Count the visible ribs. Lung fields should extend to about the 10th or 11th rib. Exposure: If the film is penetrated enough, you should be able to make out the spinous processes "inside" the vertebrae. If the film is underexposed/too white, you won't be able to see them. If the film is overexposed/too black, bony details will be lost. Rotation: Evaluate the clavicals. They should appear symmetric and equal in length. Now systematically work through the x-ray.

16. Findings! Start with soft tissues and bony structures Check for Symmetry Deformities Fractures Masses Calcifications Lytic lesions

17. Remember your lung anatomy! 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

18. The right middle lobe is typically the smallest of the three, and appears triangular in shape, being narrowest near the hilum

19. 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.

23. The Heart, mediastinum and hilum Size Shape Silhouette-margins should be sharp Evidence of stents, clips, wires and valves Diameter (>1/2 thoracic diameter is enlarged heart) Hilum: Size and shape of aorta, any enlarged vessels? Remember: AP views make heart appear larger than it actually is.

24. 1.R Atrium 2.R Ventricle 3. Apex of L Ventricle 4.Superior Vena Cava 5.Inferior Vena Cava 6. Tricuspid Valve 7.Pulmonary Valve 8.Pulmonary Trunk 9. R PA 10. L PA

26. Lung Fields Apices Top to bottom: lobes, fissures etc Diaphragm: right should be higher than left Bottom: Costophrenic angles Gastric bubble?

27. Lung Fields: Using Structures / Silhouettes Upper right heart border / ascending aorta (anterior RUL) Right heart border (medial RML) Anterior hemidiaphragms (anterior lower lobes) Upper left heart border (anterior LUL) Left heart border (lingula; anterior) Aortic knob (Apical portion of LUL )

28. Reviewing these areas Heart Size Shape Silhouette-margins should be sharp Evidence of stents, clips, wires and valves Diameter (>1/2 thoracic diameter is enlarged heart) Mediastinum Width? Contour? Lung fields Apices Lobes and fissures USE SILHOUETTES CP angles Diaphragm Gastric bubble NOTE normal pleura are NOT visible

29. The 12-Steps 1: Name 2: Date 3: Old films 4: What type of view(s) 5: Penetration 6: Inspiration 7: Rotation 8: Angulation 9: Soft tissues / bony structures 10: Mediastinum 11: Diaphragms 12: Lung Fields Quality Control Findings } } Pre-read }

30. Summarise as well! "The trachea is central, the mediastinum is not displaced. The mediastinal contours and hila seem normal. The lungs seem clear, with no pneumothorax. There is no free air under the diaphragm. The bones and soft tissues seem normal."

31. Next Pathological findings and examples!