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Thoracic Imaging.

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Presentation on theme: "Thoracic Imaging."— Presentation transcript:

1 Thoracic Imaging

2 Thoracic Imaging Chest x-ray Computerised tomography Ultrasound
Magnetic resonance imaging New advances MRI not widely used but can show malignancy especially We will look at actual films in the tutorials/practicals

3 Background Chest X-ray
Most common radiological investigation – 40% of all investigations Standard component of a pulmonary examination Systematic review is vital in interpretation of chest x-rays Up to 40% off all radiological investigations are chest x-rays 60% are carried out in the ICU, Sensitivity; 50% of critically ill patients in Icu will have abnormal chest x-ray A systematic review is vital when interpretating x-rays however what order is not critical and you will come across varying orders

4 Limitations of a chest x-ray
2 dimensional image of a 3 dimensional structure X-ray findings may lag behind other clinical features Normal x-ray does not rule out pathology Dependent on good quality image A chest x-ray forms a piece in the pulmonary examination, should refer to previous x-rays if available and if possible put in context of the other pulmonary findings

5 Chest x-ray views/types
Posteroanterior - PA Anteroposterior - AP Lateral Decubitus

6 Views PA Standard, radiology dept X-rays posterior to anterior
Standing position PA Standard investigation carried out in the x-ray dept Cassette anterior to chest, x-rays shot post-ant from 2 metres away, shoulders abducted to remove scapula Carried out in standing therefore better inspiration

7

8 Normal PA

9 Lung Anatomy (1) aortic arch (2) pulmonary trunk
(3) left atrial appendage (4) left ventricle (5) right atrium (6) superior vena cava (7 & 8) diaphragm (9) transverse fissure Transverse fissure – 6th rib laterally Does not estend beyond pulm artery medially Visible in 50%

10 Views AP Cassette placed behind patient X-rays anterior to posterior
Sitting in chair, semi-erect in bed, supine AP marked on film Heart enlarged, poorer inspiration AP Cassette placed behind the patient, portable machine Patient could be sitting in a chair, semi erect in bed, supine in bed. NOTE the patient position will affect the CXR Marked AP on film Heart enlarged often poorer expansion

11 Normal AP

12 Views Lateral Localises, shows posterior to heart
Side of interest placed against film Decubitus PA on side Small pleural effusions Lateral Helps to localise disease Side of interest placed against film Identifies posterior to the heart and costophrenic recesses Decubitus PA with patient on side Small pleural effusions

13 vertebrae Heart Norm lateral

14 Lung Anatomy (1) oblique fissure (2) transverse fissure
(3) retrocardiac space (4) retrosternal space Oblique fissure from t4 posteriorly Propeller shaped Differentiation between sides- left is more vertical, has more posterior junction with the diaphragm= does not intersect transverse fissure Left diaphragm is lower and possesses stomach bubble by 2.5cm in 94% population

15 BASICS Air shows as black solid structures white Too white Too black
Too large In the wrong place (Corral et al 1997)

16 Chest x-ray viewing guide
Correct CXR Name Date of birth Date Left and right, marker/stomach How to view Check patient and x-ray details Left or right, markers placed on by radiographer, stomach on left. Heart not always on left

17 Normal PA Stomach

18 Patient Position PA, AP, lateral or decubitus view
Rotation – Sternal end clavicles equal from vertebral body If AP what position Quality IF AP will have poorer inspiration and larger heart If patient supine will not see pleural effusions very well

19 Exposure How dark or light a film is
Should see vertebral bodies through heart AP will show KV/MAS

20 Soft Tissues Breast shadows Piercing Air in tissues
Tissue folds in obese Medical equipment Breast shadows – mastectomy! Medical equipment, lines (CVP, ICD), endotracheal tube, NG tube, metal implants, pacemakers

21 Breast shadows

22 Surgical emphysema

23 surgical emphysema

24 Heart valve Pacemaker

25 ECG ICD ETT

26 Bony Structures Ribs Scapulae Clavicles Vertebrae
Ribs fractures, osteoporosis. Ribs even Scoliosis Scapulae need to be identified so do not confuse when looking at lung fields

27 #Clavicle

28 #ribs

29 Trachea Deviated Carina Artificial airway
Trachea – can be pushed or pulled Air filled sacs keep trachea in middle

30 ETT #Ribs ICD

31 Mediastinum Deviated Hilar shadows Aortic arch
Hilar shadows, pulmonary vasculature and lymph nodes, right side is slightly further out and the left is usually higher by 2 cm, with COPD will get upper lobe diversion Aortic arch may be calcified

32 Mediastinum - Heart Size No larger than half width of chest Position
Two thirds on the left Borders Clear Heart Size, is usually half the width of the chest, is increased with AP picture, and in cardiac disease. Will look smaller if lungs hyperinflated and larger if very poor inspiration Positioned two thirds to the left unless have dextrocardia

33 Diaphragm Shape Height: right –6rib ant, left – 7 ant
Cardiophrenic angle Costophrenic angle Shape Domed, flattened with hyperinflation more domed with poor inspiration or paralysis, gas in stomach Height Right 6 rib ant, left 7 rib anter in 95% of population Left lower because of weigh of heart Bear in mind structures below as stomach can push up occasionally liver can push up, ascites will push up Angles Clear if cardiophrenic poor collapse, if costophrenic blurred pleural effusion

34 Lung Fields Black with lung markings Other opacity indicated pathology
Fissures Zones Air bronchograms Consolidation Lung markings of vessels, absent if a Pneumothorax Pulmonary oedema - bilateral Fissures Right horizontal, present in 80% of PA’s Third thoracic spine, goes down and anteriorly Fluid present? Moved? Oblique on lateral only Zones Upper, above 2nd rib ant Middle, 2-4 rib ant Lower, below forth rib Opacity increased with fluid, consolidation, malignancy

35 normal

36 Right upper lobe collapse

37 Right Lower lobe collapse

38 Pneumothorax

39 Pneumothorax

40 Consolidation

41 Pleural effusion

42 Pleural effusion

43 Right pneumonia

44 Air bronchogram

45 Emphysema

46 Other imaging Computerised tomography Transverse images, cross section
Localises masses High radiation dose

47 Other imaging cont Ultrasound Useful for pleural effusions
Good images of heart and valves Loculated pleural effusion

48 Other imaging cont MRI Malignancy Vascular Congenital abnormalities
Tuberculosis May be useful if other imaging not possible

49 New advances Patient archive communication system Film free radiology
Computer use Image enhancement PACS Images stored and generated on computer, allows multiple viewings at once, images can be enhanced, reduces storage and film losses. Useful for teaching as can view radiological reports

50


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