1. Chest Xrays
Dr Faezeh Sakhinia
FY2

2. Aims Basics of CXR interpretation OSCE approach
Images with explanation
Quiz!!

3. Initial Approach Details: Correct patient Correct date
Correct examination (CXR)
Correct view
AP/PA
Supine/portable/lateral
On an AP CXR the heart often appears larger than it is – so you can’t really comment on the heart size in these examples.
AP: ?EMERGENCY FILM

4. Projections PA AP
LATERAL

5. Picture Quality Rotation Inspiration Picture Exposure (Penetration)
Rotation – medial clavicle ends equidistant from spinous process
Inspiration – 5-6 anterior ribs in MCL or 8-10 posterior ribs above diaphragm, poor inspiration?hyperexpanded?
Picture – straight vs oblique, entire lung fields, scapulae outside lung fields
Exposure (Penetration) – IV disc spaces, spinous processes , left hemidiaphragm visible through cardiac shadow.

6. Order of View Airway– is it deviated? Breathing – Lungs
Circulation – Heart (normal<½ cardiothoracic ratio in PA view)
Diaphragm – R>L by ~ 1 intercostal space, cardiophrenic and costophrenic angles
Extras – pneumoperitoneum? air under the skin (surgical emphysema), fractures, lines (NG,ECG, chest drains, pacemaker)
‘C3, C4, C5 keeps the diaphragm alive’

7. OSCE Approach OSCE Example:
“This is a plain chest xray of John Smith in a PA view. The film is adequately exposed and orientated.”
The main findings are:
Starting off with the airways....

8. Normal Xray

9. Pleural Effusion Meniscus Uniformly white Exudate/transudate Case:
Clinical information
Life long smoker
Weight loss and increasing shortness of breath
Diagnosis
Large left pleural effusion
Underlying bronchogenic carcinoma

10. Consolidation with Air Bronchograms
Clinical information
The patient had a high temperature and a productive cough
Diagnosis
Pneumonia - consolidation with pus
Differential diagnosis of consolidation
Pneumonia - airways full of pus
Cancer - airways full of cells
Pulmonary haemorrhage - airways full of blood
Pulmonary oedema - airways full of fluid

11. COPD
Chest xrays demonstrates very marked hyperinflation of both lungs. Over 11 posterior ribs are seen, the diaphragms are flattened and there is enlargement of the retrosternal airspace.  Pulmonary vasculature not terribly distorted, although there is some prominence of the pulmonary arteries.  

12. Pneumothorax Tension pneumothorax
This is the one not to miss. If you cannot diagnose a tension pneumothorax at medical finals you won't find an examiner who will defend you.
The left hemithorax is black due to air in the pleural cavity.
Signs of tension
The left lung is completely compressed (arrowheads).
The trachea is pushed to the right (arrow)
The heart is shifted to the contralateral side - note right heart border is pushed to the right (red line)
The left hemidiaphragm is depressed (orange line)
Remember
If you diagnose a tension pneumothorax clinically - do not request an X-ray - TREAT THE PATIENT!

13. Left Lower Lobe Collapse
The tracheal deviation seen in this chest x-ray is due to left lower lobe collapse. This has a classical appearance of a 'double left heart border,' or a 'sail sign' (orange). The second heart border (curved arrow) is due to the dense edge of the collapsed left lower lobe, which has been squashed into a triangle or sail shape.
Note that the left hemidiaphragm cannot be followed all the way to the spine. This is because the left lower lobe sits directly on top of the diaphragm, and as it no longer contains air, it is of the same soft tissue density as the diaphragm and therefore blends into it.

14. Left Upper Lobe Collapse
Note the following appearances
Trachea deviated to the left
Right heart border not visible - indicating mediastinal shift to the left
Volume loss of the left hemithorax
'Veil-like' opacification of the left hemithorax obscuring the left heart border - characteristic of left upper lobe collapse
Ovoid density at the left hilum
CT confirmed a large left hilar mass, which occluded the left upper lobe bronchus.
Note the left hemidiaphragm is still visible - indicating sparing of the left lower lobe
The left lower lobe has increased in volume to compensate for the volume loss and can be seen wrapping round the medial side of the collapsed upper lobe (red line). This is known as the 'Luftsichel' (air crescent) sign .

15. Right Lower Lobe Collapse
This chest x-ray shows tracheal deviation to the right. There is no pleural effusion on the left, and there is overall volume loss of the right hemithorax, compared with the left. The mediastinum is therefore PULLED to the right.
Bronchoscopy showed a cancer occluding the right lower lobe bronchus. The x-ray shows right lower lobe collapse (ringed). Although the mass itself is not seen clearly, collapse of a lung lobe in an adult should raise the suspicion of a malignant process.

16. Right Upper Lobe Collapse
There is volume loss of the right upper lobe. The right upper zone has become dense due to lobar collapse. The volume loss has displaced the trachea which is PULLED to the right, and the horizontal fissure (arrow) has been PULLED upwards
Right upper lobe collapse is hardly ever caused by plugging of mucous or foreign bodies. The presence of right upper lobe collapse in an adult should therefore immediately raise the suspicion of an underlying malignant process occluding the right main bronchus.

17. Lung Cancer
'cannon ball lesions’ : Lesions of 2-3cm diameter usually 

18. Heart failure Signs of heart failure Cardiomegaly CTR = 18/30
Upper zone vessel enlargement (1) - a sign of pulmonary venous hypertension
Pulmonary oedema (2) - bilateral increased lung markings (classically peri-hilar and shaped like bats wings - more widespread in this case)
Septal (Kerley B) lines (3) - See next picture
Pleural effusions (4)
Clinical information
Worsening exercise tolerance
Chronic uncontrolled hypertension
Rapid onset of shortness of breath
Atrial fibrillation
Diagnosis
Left ventricular failure with pulmonary oedema
Septal lines (Kerley B lines)
Costophrenic angle
Horizontal lines reaching the lung edge
Septal lines - a specific sign of pulmonary oedema
Differential diagnosis
Occasionally conditions that cause lymphatic obstruction may cause septal lines - such as sarcoidosis or lymphangitis carcinomatosa

19. QUIZ!!! Easy......Odd!

20. Consolidation & Collapse (pneumonia)

21. Pneumothorax (COPD)

22. Mastectomy

23. Dextocardia with Situs Inversus
Be careful it could be a mistake with labelling On clinical examination the apex beat was found on the RIGHT, confirming dextrocardia.

24. Valve Replacements
The aortic valve is above the red line and the mitral valve lies below it.

25. Nipple Ring!

26. If you can answer these...a career in radiology is for you!!!

27. Pneumonectomy Pneumonectomy
The trachea, hila and mediastinum are deviated to the left. Are they PUSHED or PULLED?
This patient has had a pneumonectomy (removal of the left lung) to treat a lung cancer. Note the left main bronchus is abruptly cut off (arrowhead). The left hemithorax is filled by the heart and great vessels which have moved to the fill the space vacated by the removed lung. The right lung has expanded to fill the space vacated by the heart.

28. Surgical Emphysema Secondary
to Chest Drain
Drain/surgical emphysema
Surgical emphysema (subcutaneous trapped air) is a complication of chest drain insertion, or sometimes of the pneumothorax itself.
Surgical emphysema can form because of poor technique during drain insertion or because of displacement of the drain such that a side hole near the end of the drain lies within the subcutaneous tissues.
Surgical emphysema has the clinical characteristic of feeling like 'rice crispies' or 'bubble wrap' on palpation.

29. Asbestos Related Pleural Plaques
Bilateral well defined irregular shadows that are as dense as the bones
Peripheral pleural thickening
Clinical information
Chronic mild shortness of breath
Retired dock worker with clear history of asbestos exposure
Diagnosis
Bilateral calcified asbestos related pleural plaques

30. Quiz Done...and Relax!!!

31. Summary

32. Thank You!!