1. Interpretation of Chest Radio Graph
Transcript of 1. Interpretation of Chest Radio Graph
8/7/2019 1. Interpretation of Chest Radio Graph
http://slidepdf.com/reader/full/1-interpretation-of-chest-radio-graph 1/102
Dr. Anindita Mishra, MD
Associate Professor
Department of Radiodiagnosis
GSL Medical College
8/7/2019 1. Interpretation of Chest Radio Graph
http://slidepdf.com/reader/full/1-interpretation-of-chest-radio-graph 2/102
Introduction
Routinely obtained
Pulmonary specialist consultation
Inherent physical exam limitations
Chest x-ray limitations
Physical exam and chest x-ray provide
compliment
8/7/2019 1. Interpretation of Chest Radio Graph
http://slidepdf.com/reader/full/1-interpretation-of-chest-radio-graph 3/102
Essentials Before Getting Started
Exposure
– Overexposure
– Underexposure
Sex of Patient
– Male
– Female
8/7/2019 1. Interpretation of Chest Radio Graph
http://slidepdf.com/reader/full/1-interpretation-of-chest-radio-graph 4/102
Path of x-ray beam
– PA
– AP
Patient Position – Upright
– Supine
8/7/2019 1. Interpretation of Chest Radio Graph
http://slidepdf.com/reader/full/1-interpretation-of-chest-radio-graph 5/102
Breath
– Inspiration
– Expiration
8/7/2019 1. Interpretation of Chest Radio Graph
http://slidepdf.com/reader/full/1-interpretation-of-chest-radio-graph 6/102
Systematic Approach
Bony Framework
Soft Tissues
Lung Fields and Hila
Diaphragm and Pleural Spaces
Mediastinum and Heart
Abdomen and Neck
8/7/2019 1. Interpretation of Chest Radio Graph
http://slidepdf.com/reader/full/1-interpretation-of-chest-radio-graph 7/102
Bony Fragments
– Ribs
– Sternum
– Spine
– Shoulder girdle
– Clavicles
8/7/2019 1. Interpretation of Chest Radio Graph
http://slidepdf.com/reader/full/1-interpretation-of-chest-radio-graph 8/102
Soft Tissues
– Breast shadows
– Supraclavicular areas
– Axillae
– Tissues along side of
breasts
8/7/2019 1. Interpretation of Chest Radio Graph
http://slidepdf.com/reader/full/1-interpretation-of-chest-radio-graph 9/102
Lung Fields and Hila
– Hilum
Pulmonary arteries
Pulmonary veins
– Lungs
Linear and fine nodular
shadows of pulmonary vessels
– Blood vessels
– 40% obscured by other tissue
8/7/2019 1. Interpretation of Chest Radio Graph
http://slidepdf.com/reader/full/1-interpretation-of-chest-radio-graph 10/102
Diaphragm and
Pleural Surfaces
– Diaphragm
Dome-shaped
Costophrenic angles
– Normal pleural is not
visible
– Interlobar fissures
8/7/2019 1. Interpretation of Chest Radio Graph
http://slidepdf.com/reader/full/1-interpretation-of-chest-radio-graph 11/102
Mediastinum and Heart
Heart size on PA
Right sideInferior vena cava
Right atrium
Ascending aorta
Superior vena cava
Left side
Left ventricle
Left atrium
Pulmonary arteryAortic arch
Subclavian artery and vein
8/7/2019 1. Interpretation of Chest Radio Graph
http://slidepdf.com/reader/full/1-interpretation-of-chest-radio-graph 12/102
Abdomen and Neck
– Abdomen
Gastric bubble Air under diaphragm
–
Neck Soft tissue mass
Air bronchogram
8/7/2019 1. Interpretation of Chest Radio Graph
http://slidepdf.com/reader/full/1-interpretation-of-chest-radio-graph 13/102
Air
Water
Bone
Tissue
Tissue
8/7/2019 1. Interpretation of Chest Radio Graph
http://slidepdf.com/reader/full/1-interpretation-of-chest-radio-graph 14/102
Pitfalls to Chest X-ray
Interpretation
Poor inspiration
Over or under penetration
Rotation
Forgetting the path of the x-ray beam
8/7/2019 1. Interpretation of Chest Radio Graph
http://slidepdf.com/reader/full/1-interpretation-of-chest-radio-graph 15/102
Lung Anatomy Trachea
Carina
Right and Left
Pulmonary Bronchi
Secondary Bronchi
Tertiary Bronchi
Bronchioles
Alveolar Duct
Alveoli
8/7/2019 1. Interpretation of Chest Radio Graph
http://slidepdf.com/reader/full/1-interpretation-of-chest-radio-graph 16/102
Lung Anatomy
Right Lung
– Superior lobe
– Middle lobe
– Inferior lobe
Left Lung
– Superior lobe
– Inferior lobe
8/7/2019 1. Interpretation of Chest Radio Graph
http://slidepdf.com/reader/full/1-interpretation-of-chest-radio-graph 17/102
Lung Anatomy on Chest X-ray
PA View: – Extensive overlap
– Lower lobes extend high
Lateral View:
– Extent of lower lobes
8/7/2019 1. Interpretation of Chest Radio Graph
http://slidepdf.com/reader/full/1-interpretation-of-chest-radio-graph 18/102
Lung Anatomy on Chest X-ray
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
8/7/2019 1. Interpretation of Chest Radio Graph
http://slidepdf.com/reader/full/1-interpretation-of-chest-radio-graph 19/102
Lung Anatomy on Chest X-ray
The right middle lobe
is typically the smallest
of the three, andappears triangular in
shape, being narrowest
near the hilum
8/7/2019 1. Interpretation of Chest Radio Graph
http://slidepdf.com/reader/full/1-interpretation-of-chest-radio-graph 20/102
Lung Anatomy on Chest X-ray 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.
8/7/2019 1. Interpretation of Chest Radio Graph
http://slidepdf.com/reader/full/1-interpretation-of-chest-radio-graph 21/102
Lung Anatomy on Chest X-ray These lobes can be separated
from one another by twofissures.
The minor fissure separates
the RUL from the RML, andthus represents the visceral
pleural surfaces of both of
these lobes.
Oriented obliquely, the major
fissure extends posteriorly
and superiorly approximately
to the level of the fourth
vertebral body.
8/7/2019 1. Interpretation of Chest Radio Graph
http://slidepdf.com/reader/full/1-interpretation-of-chest-radio-graph 22/102
Lung Anatomy on Chest X-ray
The lobar architectureof the left lung is
slightly different than
the right.
Because there is no
defined left minor
fissure, there are only
two lobes on the left;
the left upper
8/7/2019 1. Interpretation of Chest Radio Graph
http://slidepdf.com/reader/full/1-interpretation-of-chest-radio-graph 23/102
Lung Anatomy on Chest X-ray
Left lower lobes
8/7/2019 1. Interpretation of Chest Radio Graph
http://slidepdf.com/reader/full/1-interpretation-of-chest-radio-graph 24/102
Lung Anatomy on Chest X-ray
These two lobes are
separated by a major fissure,
identical to that seen on the
right side, although often
slightly more inferior in
location.
The portion of the left lung
that corresponds
anatomically to the rightmiddle lobe is incorporated
into the left upper lobe.
8/7/2019 1. Interpretation of Chest Radio Graph
http://slidepdf.com/reader/full/1-interpretation-of-chest-radio-graph 25/102
The Normal Chest X-ray
PA View:1. Aortic arch
2. Pulmonary trunk
3. Left atrial appendage
4. Left ventricle
5. Right ventricle
6. Superior vena cava
7. Right hemidiaphragm
8. Left hemidiaphragm
9. Horizontal fissure
8/7/2019 1. Interpretation of Chest Radio Graph
http://slidepdf.com/reader/full/1-interpretation-of-chest-radio-graph 26/102
The Normal Chest X-ray
Lateral View:
1. Oblique fissure
2. Horizontal fissure
3. Thoracic spine and
retrocardiac space
4. Retrosternal space
8/7/2019 1. Interpretation of Chest Radio Graph
http://slidepdf.com/reader/full/1-interpretation-of-chest-radio-graph 27/102
The Silhouette Sign
An intra-thoracic radio-
opacity, if in anatomic
contact with a border of
heart or aorta, will obscure
that border. An intra-
thoracic lesion not
anatomically contiguous
with a border or a normal
structure will not obliterate
that border.
8/7/2019 1. Interpretation of Chest Radio Graph
http://slidepdf.com/reader/full/1-interpretation-of-chest-radio-graph 28/102
Putting It All Together
8/7/2019 1. Interpretation of Chest Radio Graph
http://slidepdf.com/reader/full/1-interpretation-of-chest-radio-graph 29/102
8/7/2019 1. Interpretation of Chest Radio Graph
http://slidepdf.com/reader/full/1-interpretation-of-chest-radio-graph 30/102
Understanding Pathological Changes
Most disease states replace air with a
pathological process
Each tissue reacts to injury in a predictable
fashion
Lung injury or pathological states can be
either a generalized or localized process
8/7/2019 1. Interpretation of Chest Radio Graph
http://slidepdf.com/reader/full/1-interpretation-of-chest-radio-graph 31/102
Liquid Density
Liquid density Increased airdensityGeneralized Localized
Diffusealveolar
Diffuse
interstitialMixed
Vascular
InfiltrateConsolidation
Cavitation
MassCongestion
Atelectasis
Localized airwayobstruction
Diffuse airway
obstructionEmphysema
Bulla
8/7/2019 1. Interpretation of Chest Radio Graph
http://slidepdf.com/reader/full/1-interpretation-of-chest-radio-graph 32/102
Consolidation
Lobar consolidation:
– Alveolar space filledwith inflammatoryexudate
– Interstitium and
architecture remainintact
– The airway is patent
– Radiologically:
A density correspondingto a segment or lobe
Airbronchogram, and
No significant loss of lung
volume
8/7/2019 1. Interpretation of Chest Radio Graph
http://slidepdf.com/reader/full/1-interpretation-of-chest-radio-graph 33/102
Atelectasis
Loss of air
Obstructive atelectasis:
– No ventilation to the lobe
beyond obstruction
– Radiologically:
Density corresponding to a
segment or lobe
Significant loss of volume
Compensatory
hyperinflation of normal
lungs
8/7/2019 1. Interpretation of Chest Radio Graph
http://slidepdf.com/reader/full/1-interpretation-of-chest-radio-graph 34/102
Stages of Evaluating an Abnormality
1. Identification of abnormal shadows2. Localization of lesion
3. Identification of pathological process
4. Identification of etiology5. Confirmation of clinical suspension
Complex problems
Introduction of contrast medium
CT chest
MRI scan
8/7/2019 1. Interpretation of Chest Radio Graph
http://slidepdf.com/reader/full/1-interpretation-of-chest-radio-graph 35/102
Putting It Into Practice
8/7/2019 1. Interpretation of Chest Radio Graph
http://slidepdf.com/reader/full/1-interpretation-of-chest-radio-graph 36/102
Case 1
8/7/2019 1. Interpretation of Chest Radio Graph
http://slidepdf.com/reader/full/1-interpretation-of-chest-radio-graph 37/102
8/7/2019 1. Interpretation of Chest Radio Graph
http://slidepdf.com/reader/full/1-interpretation-of-chest-radio-graph 38/102
A single, 3cm relatively thin-walled cavity is noted in the left mid lung. This
finding is most typical of squamous cell carcinoma (SCC). One-third of SCC
masses show cavitation
8/7/2019 1. Interpretation of Chest Radio Graph
http://slidepdf.com/reader/full/1-interpretation-of-chest-radio-graph 39/102
Case 2
8/7/2019 1. Interpretation of Chest Radio Graph
http://slidepdf.com/reader/full/1-interpretation-of-chest-radio-graph 40/102
8/7/2019 1. Interpretation of Chest Radio Graph
http://slidepdf.com/reader/full/1-interpretation-of-chest-radio-graph 41/102
LUL Atelectasis: Loss of heart borders/silhouetting. Notice
over inflation on unaffected lung
8/7/2019 1. Interpretation of Chest Radio Graph
http://slidepdf.com/reader/full/1-interpretation-of-chest-radio-graph 42/102
Case 3
8/7/2019 1. Interpretation of Chest Radio Graph
http://slidepdf.com/reader/full/1-interpretation-of-chest-radio-graph 43/102
8/7/2019 1. Interpretation of Chest Radio Graph
http://slidepdf.com/reader/full/1-interpretation-of-chest-radio-graph 44/102
Right Middle and Left Upper Lobe Pneumonia
8/7/2019 1. Interpretation of Chest Radio Graph
http://slidepdf.com/reader/full/1-interpretation-of-chest-radio-graph 45/102
Case 4
8/7/2019 1. Interpretation of Chest Radio Graph
http://slidepdf.com/reader/full/1-interpretation-of-chest-radio-graph 46/102
8/7/2019 1. Interpretation of Chest Radio Graph
http://slidepdf.com/reader/full/1-interpretation-of-chest-radio-graph 47/102
Cavitation:cystic changes in the area of consolidation due to the
bacterial destruction of lung tissue. Notice air fluid level.
8/7/2019 1. Interpretation of Chest Radio Graph
http://slidepdf.com/reader/full/1-interpretation-of-chest-radio-graph 48/102
Cavitation
8/7/2019 1. Interpretation of Chest Radio Graph
http://slidepdf.com/reader/full/1-interpretation-of-chest-radio-graph 49/102
Case 5
8/7/2019 1. Interpretation of Chest Radio Graph
http://slidepdf.com/reader/full/1-interpretation-of-chest-radio-graph 50/102
8/7/2019 1. Interpretation of Chest Radio Graph
http://slidepdf.com/reader/full/1-interpretation-of-chest-radio-graph 51/102
Tuberculosis
8/7/2019 1. Interpretation of Chest Radio Graph
http://slidepdf.com/reader/full/1-interpretation-of-chest-radio-graph 52/102
Case 6
8/7/2019 1. Interpretation of Chest Radio Graph
http://slidepdf.com/reader/full/1-interpretation-of-chest-radio-graph 53/102
8/7/2019 1. Interpretation of Chest Radio Graph
http://slidepdf.com/reader/full/1-interpretation-of-chest-radio-graph 54/102
COPD: increase in heart diameter, flattening of the
diaphragm, and increase in the size of the retrosternal air
space. In addition the upper lobes will become hyperlucent due
to destruction of the lung tissue.
8/7/2019 1. Interpretation of Chest Radio Graph
http://slidepdf.com/reader/full/1-interpretation-of-chest-radio-graph 55/102
Chronic emphysema effect on the lungs
8/7/2019 1. Interpretation of Chest Radio Graph
http://slidepdf.com/reader/full/1-interpretation-of-chest-radio-graph 56/102
Case 7
8/7/2019 1. Interpretation of Chest Radio Graph
http://slidepdf.com/reader/full/1-interpretation-of-chest-radio-graph 57/102
8/7/2019 1. Interpretation of Chest Radio Graph
http://slidepdf.com/reader/full/1-interpretation-of-chest-radio-graph 58/102
Pseudotumor: fluid has filled the minor fissure creating a density
that resembles a tumor (arrow). Recall that fluid and soft tissue
are indistinguishable on plain film. Further analysis, however,
reveals a classic pleural effusion in the right pleura. Note the right
lateral gutter is blunted and the right diaphram is obscurred.
8/7/2019 1. Interpretation of Chest Radio Graph
http://slidepdf.com/reader/full/1-interpretation-of-chest-radio-graph 59/102
Case 8
8/7/2019 1. Interpretation of Chest Radio Graph
http://slidepdf.com/reader/full/1-interpretation-of-chest-radio-graph 60/102
8/7/2019 1. Interpretation of Chest Radio Graph
http://slidepdf.com/reader/full/1-interpretation-of-chest-radio-graph 61/102
Pneumonia:a large pneumonia consolidation in the right lower
lobe. Knowledge of lobar and segmental anatomy is important
in identifying the location of the infection
8/7/2019 1. Interpretation of Chest Radio Graph
http://slidepdf.com/reader/full/1-interpretation-of-chest-radio-graph 62/102
Case 9
8/7/2019 1. Interpretation of Chest Radio Graph
http://slidepdf.com/reader/full/1-interpretation-of-chest-radio-graph 63/102
8/7/2019 1. Interpretation of Chest Radio Graph
http://slidepdf.com/reader/full/1-interpretation-of-chest-radio-graph 64/102
CHF:a great deal of accentuated interstitial markings, Curly
lines, and an enlarged heart. Normally indistinct upper lobe
vessels are prominent but are also masked by interstitial edema.
8/7/2019 1. Interpretation of Chest Radio Graph
http://slidepdf.com/reader/full/1-interpretation-of-chest-radio-graph 65/102
24 hours after diuretic therapy
8/7/2019 1. Interpretation of Chest Radio Graph
http://slidepdf.com/reader/full/1-interpretation-of-chest-radio-graph 66/102
Case 10
8/7/2019 1. Interpretation of Chest Radio Graph
http://slidepdf.com/reader/full/1-interpretation-of-chest-radio-graph 67/102
8/7/2019 1. Interpretation of Chest Radio Graph
http://slidepdf.com/reader/full/1-interpretation-of-chest-radio-graph 68/102
Chest wall lesion: arising off the chest wall and not the lung
8/7/2019 1. Interpretation of Chest Radio Graph
http://slidepdf.com/reader/full/1-interpretation-of-chest-radio-graph 69/102
Case 11
8/7/2019 1. Interpretation of Chest Radio Graph
http://slidepdf.com/reader/full/1-interpretation-of-chest-radio-graph 70/102
8/7/2019 1. Interpretation of Chest Radio Graph
http://slidepdf.com/reader/full/1-interpretation-of-chest-radio-graph 71/102
Pleural effusion: Note loss of left hemidiaphragm. Fluid drained
via thoracentesis
8/7/2019 1. Interpretation of Chest Radio Graph
http://slidepdf.com/reader/full/1-interpretation-of-chest-radio-graph 72/102
Case 12
8/7/2019 1. Interpretation of Chest Radio Graph
http://slidepdf.com/reader/full/1-interpretation-of-chest-radio-graph 73/102
8/7/2019 1. Interpretation of Chest Radio Graph
http://slidepdf.com/reader/full/1-interpretation-of-chest-radio-graph 74/102
Lung Mass
8/7/2019 1. Interpretation of Chest Radio Graph
http://slidepdf.com/reader/full/1-interpretation-of-chest-radio-graph 75/102
Case 13
8/7/2019 1. Interpretation of Chest Radio Graph
http://slidepdf.com/reader/full/1-interpretation-of-chest-radio-graph 76/102
8/7/2019 1. Interpretation of Chest Radio Graph
http://slidepdf.com/reader/full/1-interpretation-of-chest-radio-graph 77/102
Small Pneumothorax: LUL
8/7/2019 1. Interpretation of Chest Radio Graph
http://slidepdf.com/reader/full/1-interpretation-of-chest-radio-graph 78/102
Case 15
8/7/2019 1. Interpretation of Chest Radio Graph
http://slidepdf.com/reader/full/1-interpretation-of-chest-radio-graph 79/102
8/7/2019 1. Interpretation of Chest Radio Graph
http://slidepdf.com/reader/full/1-interpretation-of-chest-radio-graph 80/102
Right Middle Lobe Pneumothorax: complete lobar collapse
8/7/2019 1. Interpretation of Chest Radio Graph
http://slidepdf.com/reader/full/1-interpretation-of-chest-radio-graph 81/102
Post chest tube insertion and re-expansion
8/7/2019 1. Interpretation of Chest Radio Graph
http://slidepdf.com/reader/full/1-interpretation-of-chest-radio-graph 82/102
Case 16
8/7/2019 1. Interpretation of Chest Radio Graph
http://slidepdf.com/reader/full/1-interpretation-of-chest-radio-graph 83/102
8/7/2019 1. Interpretation of Chest Radio Graph
http://slidepdf.com/reader/full/1-interpretation-of-chest-radio-graph 84/102
Metastatic Lung Cancer: multiple nodules seen
8/7/2019 1. Interpretation of Chest Radio Graph
http://slidepdf.com/reader/full/1-interpretation-of-chest-radio-graph 85/102
Case 17
8/7/2019 1. Interpretation of Chest Radio Graph
http://slidepdf.com/reader/full/1-interpretation-of-chest-radio-graph 86/102
8/7/2019 1. Interpretation of Chest Radio Graph
http://slidepdf.com/reader/full/1-interpretation-of-chest-radio-graph 87/102
Right upper lower lobe pulmonary nodule
8/7/2019 1. Interpretation of Chest Radio Graph
http://slidepdf.com/reader/full/1-interpretation-of-chest-radio-graph 88/102
Case 18
8/7/2019 1. Interpretation of Chest Radio Graph
http://slidepdf.com/reader/full/1-interpretation-of-chest-radio-graph 89/102
8/7/2019 1. Interpretation of Chest Radio Graph
http://slidepdf.com/reader/full/1-interpretation-of-chest-radio-graph 90/102
Tuberculosis
8/7/2019 1. Interpretation of Chest Radio Graph
http://slidepdf.com/reader/full/1-interpretation-of-chest-radio-graph 91/102
Case 19
8/7/2019 1. Interpretation of Chest Radio Graph
http://slidepdf.com/reader/full/1-interpretation-of-chest-radio-graph 92/102
8/7/2019 1. Interpretation of Chest Radio Graph
http://slidepdf.com/reader/full/1-interpretation-of-chest-radio-graph 93/102
Perihilar mass: Hodgkin’s disease
8/7/2019 1. Interpretation of Chest Radio Graph
http://slidepdf.com/reader/full/1-interpretation-of-chest-radio-graph 94/102
Case 20
8/7/2019 1. Interpretation of Chest Radio Graph
http://slidepdf.com/reader/full/1-interpretation-of-chest-radio-graph 95/102
8/7/2019 1. Interpretation of Chest Radio Graph
http://slidepdf.com/reader/full/1-interpretation-of-chest-radio-graph 96/102
Widened Mediastinum: Aortic Dissection
8/7/2019 1. Interpretation of Chest Radio Graph
http://slidepdf.com/reader/full/1-interpretation-of-chest-radio-graph 97/102
Case 21
8/7/2019 1. Interpretation of Chest Radio Graph
http://slidepdf.com/reader/full/1-interpretation-of-chest-radio-graph 98/102
8/7/2019 1. Interpretation of Chest Radio Graph
http://slidepdf.com/reader/full/1-interpretation-of-chest-radio-graph 99/102
Pulmonary artery stenosis with cardiomegally likely secondary
to stenosis.
8/7/2019 1. Interpretation of Chest Radio Graph
http://slidepdf.com/reader/full/1-interpretation-of-chest-radio-graph 100/102
Questions?
8/7/2019 1. Interpretation of Chest Radio Graph
http://slidepdf.com/reader/full/1-interpretation-of-chest-radio-graph 101/102
Acknowledgement
ARNP Bucky Boaz – Chest X-Ray
radiography
8/7/2019 1. Interpretation of Chest Radio Graph
http://slidepdf.com/reader/full/1-interpretation-of-chest-radio-graph 102/102
Thank You