1. Teaching point #2
Choose and utilize a standardized way to view each radiograph
Alphabet method
BIO (Between, inside, outside the lungs)
Top down
Other
My approach: Abnormalities, right lung, left lung, compare the two lungs, trachea, mediastinum, heart, outside the lungs (including abdomen) and bones

2. Now that you have a search pattern
What structures should you normally see?
Anatomy important for lines and tubes
Trachea and carina
Aortic arch
Cavoatrial junction
Subclavian vein/artery
Internal jugular vein

3. Trachea Carina Left main bronchus Right main bronchus
In the normal chest radiograph only airways within the mediastinum are apparent

4. SVC

5. Aortic arch
Aortopulmonary recess
Main Pulmonary Artery
Cavoatrial junction

6. Cavoatrial junction Our perspective on most central lines
Is it central? Yes = good
Is it flopping around hitting the AV Valve? Yes = bad
Close to the CAJ is fine
CAJ landmarks
About 2 cm below the bulge of the right atrial appendage
About 2 vertebral bodies below the carina (better for peds)

7. Appropriately placed IJ line?
Good placement or not? Yep

8. Lobar anatomy
Lesson for today – the upper lobes aren’t just at the top of the CXR, and the lower lobes aren’t just at the bottom.

9. Right Lung: Lobes and Fissures

10. Right Upper & Right Middle Lobes
Lobar Anatomy:
Right Upper & Right Middle Lobes
RUL
RUL
RML
RML

11. Lobar Anatomy:
Right Lower Lobe
RLL
RLL

12. Lobar Anatomy:
Left Upper Lobe
LUL
LUL

13. Lobar Anatomy:
Left Lower Lobe
LLL
LLL

14. Which lobe is collapsed?

15. Which lobe has a pneumonia?

16. Pattern and Distribution
Abnormalities have two important imaging clues:
Pattern of disease
Distribution of disease location, location, location!

17. Patterns Consolidation Ground Glass
Lines (interstitial or septal thickening)
Reticulation
Peripheral Lace-like opacities
Cysts
Nodules
Tree-in-Bud or Budding Tree opacities

18. Patterns *Infiltrate is not one of these patterns* Consolidation
Ground Glass
Lines (interstitial or septal thickening)
Reticulation
Cysts
Nodules

19. We can do better
“Infiltrate”: A vague term at best, used to describe any abnormality. Avoid it!
Lung “fields”: Fields are for cows! They are lungs or lobes
“Poor inspiratory effort”: Low lung volumes is at least more appropriate
“Nonspecific”: Earn your paycheck

20. Fields are for cows 

21. Patterns Consolidation Ground Glass
Lines (interstitial or septal thickening)
Reticulation
Cysts
Nodules
Tree-in-Bud or Budding Tree opacities

22. Distribution of Disease
Focal (or multifocal) versus diffuse
Dependent distribution (varies with position!)
Upper lobe
Bronchovascular
Peripheral
Random

23. Normal versus consolidation

24. Acute Consolidation Infection Water Blood
Indeterminate White Blob (IWB)
Infection
Bacterial pneumonia
Water
Pulmonary edema
Blood
Pulmonary hemorrhage, contusion

25. Acute? Think Infection, Water, Blood

26. Normal Ground Glass

28. Acute Ground Glass Opacity
Indeterminate White Blob (IWB)
Infection
PCP, viral pneumonia
Water
Pulmonary edema
Blood
Pulmonary hemorrhage

29. 17 yo Male: Sudden Onset Dyspnea

30. Acute Ground Glass Opacity (2 Weeks of symptoms) & Upper Lobe Distribution

31. Diffuse GGO versus focal consolidation

32. Questions?

33. Teaching points
Name the 5 densities that are seen on standard radiographs
Choose and utilize a standardized way to view each radiograph
Locate the following anatomic structures:
Trachea, carina, subclavian artery and vein, SVC, cavoatrial junction
Name the 6 patterns seen on chest imaging

34. Teaching points
Name the 5 densities that are seen on standard radiographs
Air
Fat
Densities Water/tissue
Bone
Metal

35. Teaching points
Choose and utilize a standardized way to view each radiograph
Alphabet method (Airspaces, Bones, Cardiac, etc.)
BIO (Between, inside, outside the lungs)
Top down
Other

36. Teaching points Locate important anatomic structures:
SVC begins at approximately the 1st anterior rib space
Cavoatrial junction: 2 cm below the initial SVC-right atrium bump, or about 2 vertebral bodies below the carina
Carina is the branch point of the trachea, it’s usually directly identifiable
If it’s not, it should be around T6

37. Teaching Points Consolidation Ground Glass
Lines (interstitial or septal thickening)
Reticulation
Cysts
Nodules
Tree-in-Bud or Budding Tree opacities