Chest X-Ray Review

Why order a CXR? SYMPTOMS: Bad or persistent cough Chest pain Chest injury Coughing up blood Fever Shortness of breath S/P fall

Why order a CXR? Pleural effusion Lung cancer Pneumothorax Hemothorax Pulmonary embolus Trauma Monitoring chest drainage TB Lung cancer Chest pain (MI?) Hypertension Screening Pneumonia COPD Asthma

Normal Chest X-Ray Compare symmetry Review organs (bones, lungs, heart) in sequence Left to Right then… Top to Bottom Random free search Normal Chest X-Ray Recognition of abnormal first requires knowledge of normal. Over diagnosis of normal variation may be more serious than omission & may lead to needless & harmful therapy.

Chest X-Ray Findings Is heart enlarged or normal? Signs of heart failure and fluid overload? Does patient have pneumonia or collapsed lung? Is there evidence of emphysema? Are there findings of an aortic aneurysm? Is there fluid in the sac that surrounds the lung? Is there free air under the diaphragm? Is there a tumor in the lung that could represent cancer?

The Normal Chest X-Ray Systematically evaluate chest wall, mediastinum, lungs, pleural space, heart, large arteries, ribs & diaphragm. Also evaluate neck, axilla, thyroid gland & abdomen What does air under diaphragm signify? What is best position for this diagnosis?

The Normal Chest X-Ray You can recognize air, water & bone density on chest x-ray Lung fields appear dark because of air. 99% of the lung is air.

The Normal Chest X-Ray The pulmonary vasculature, interstitial space, constitutes 1% of the lung Gives a lacy lung pattern. Most disease states replace air with a pathological process which usually is a liquid density and appears white.

Poor Quality CXR Supine position Semi-upright position Decreases lung volume, increased heart size Basilar infiltrates & interstitial spaces accentuated Increases venous return to the heart Semi-upright position Enlarges normal structures Changes air-fluid levels Failure to hold breath Lung structures & diaphragm blurred Expiration film Increased heart size

What is wrong with this lung tissue??? Missed Diagnoses 10% of all x-ray interpretations have errors Nothing!! But the clavicle is fractured! What is wrong with this lung tissue??? Especially if there are multiple problems, don’t focus on the most obvious abnormality!

Systematic CXR Interpretation IDENTIFICATION Correct patient Correct date & time Correct examination Right vs. Left side Comparison film TECHNIQUE Complete exam? All views Entire anatomical area included? Projection Is the film AP or PA? The width of heart & mediastinum larger on AP film Position

Systematic CXR Interpretation TECHNIQUE, cont. Inspiration Normal, erect, inspiratory CXR shows 9.5-10.5 ribs. Less inspiration appears diffusely denser Diaphragms elevated causing heart & mediastinum to appear enlarged TECHNIQUE, cont. Penetration Over-penetrated dark films can obscure subtle pathologies Under-penetrated white films may given impression of diffuse increased density

Systematic CXR Interpretation Order of exam is important. Start with "less significant" Tendency to stop looking as soon as find pathology Identify atelectasis behind heart shadow! Don’t notice tip of ET tube is in right main stem bronchus, causing the atelectasis!

Systematic CXR Interpretation TECHNIQUE, cont. Rotation Determined by distance between spinous process & medial clavicle Affects heart size & shape, aortic tortuosity, mediastinal widening, density of lung fields

Systematic CXR Interpretation Extraneous material Contrast Lines, tubes, clips All properly located? Soft tissues Asymmetry Calcifications Diaphragms & Below Free air Dilated bowel Abnormal position INTERPRETATION Bones Fracture, dislocation Mineralization Lung fields Asymmetry Consolidation Nodules, lesions Heart Size & shape Cardiothoracic ratio

Systematic CXR Interpretation Pulmonary vascularity Taper at periphery Narrow toward upper lobes with erect film Asymmetry Interstitial markings Very fine If indistinct, prominent suspect edema, fibrosis INTERPRETATION Mediastinum Width Masses Contour Hila Asymmetry Vessel aneurysm Trachea & carina

CONSOLIDATION Alveolar space filled with inflammatory exudate WBC, bacteria, plasma, and debris

Congestive Heart Failure Increased heart size: cardiothoracic ratio >0.5 Large hila with indistinct markings Fluid in interlobar fissures Pleural effusions, alveolar edema

ARDS Congestion Interstitial and alveolar edema Collapsed or distended alveoli Bilateral

SARCOIDOSIS Granulomatous Inflammation Bilateral & symmetrical hilar & mediastinal LAD Generalized fibrosis

ATELECTASIS No ventilation to lobe beyond the obstruction Trapped air absorbed by pulmonary circulation Segmental/lobar density Compensatory hyper-inflation of normal lungs.

TENSION PNEUMOTHORAX

PLEURAL EFFUSION

COPD

Let’s See How Much You Paid Attention

Right Lower Lobe Pneumonia

ET tube in right mainstem bronchus

Right side tension pneumothorax

Fracture of posterior rib #7

Right Side Pleural Effusion

Left Sided Pneumothorax

Right Squamous Cell Carcinoma

GOOD LUCK