Basic interpretation of cxr
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![Page 1: Basic interpretation of cxr](https://reader030.fdocuments.us/reader030/viewer/2022012823/554b1eefb4c9055d098b52c0/html5/thumbnails/1.jpg)
Basic Interpretation
of Chest
RadiographyBy Dr. Chia Kok King
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Five Radiographic Opacities
Air Fat Soft tissue BoneMetal
least opaque to most opaquemost lucent to least lucentBlack to White
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Radiographic Opacities & Contrasts
Air Air
Fat Mineral oil
Water Water
Bone Tums
Metal ???
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Film Quality
1. PA or AP view.2. Upright/Erect or Supine3. Breath : Inspiration or Expiration4. X-ray penetration : Under- or Over-5. Rotation
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PA vs AP views
PA view• Scapula is seen in
periphery of thorax• Clavicles project over
lung fields• Posterior ribs are
distinct• Position of markers
AP view• Scapulae are over
lung fields• Clavicles are above
the apex of lung fields• Position of markers• Anterior ribs are
distinct
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Inspiration vs Expiration
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Penetration With correct exposure you should barely see
the intervertebral disc through the heart
• If you see them very clearly the film is overpenetrated
• If you do not see them it is underpenetrated
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Penetration
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Rotation
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Pitfalls to Chest X-ray Interpretation
• Poor inspiration• Over or under penetration• Rotation• Forgetting the path of the x-ray beam
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Normal Chest X-ray
• Cardiac Structures– Position
• More central in younger infants and children• More on the L side in older infants and teens
– Size• CARDIO-THORACIC RATIO!• Cardiac diameter :
– normal individuals < 15.5 cm in males; <14.5 cm in females.– A change in diameter of greater than 1.5 cm between two
X-rays is significant.
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Cardio-thoracic ratio
• seen on postero-anterior (PA) view only
• >50% is considered abnormal in an adult; more than 66% in a neonate.
• Possible causes of a ratio greater than 50% include:– cardiac failure– pericardial effusion– left or right ventricular hypertrophy
*AP views make heart appear larger than it actually is.*
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Normal Chest X-ray
• 1. Soft tissue structures– Shadows, most commonly, breast
• 2. Bony structures– Count the ribs– 8 – 10 ribs should be visible on inspiration– Clavicle placement at 2-3 intercostal space (if not,
may be rotated)
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Normal Chest X-ray
• 3. Diaphragm– Contour– Rounded with sharp pointed costophrenic and
costocardiac angles– Right diaphragm is usually 1-2 cm higher
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Normal Chest X-ray
• 4. Lungs– Start at the top and compare the R and L– Trachea should be midline over the thoracic
vertebrae and air filled– Lung parenchyma becomes lighter as you go down
the lung. If not, it may indicate a lower lobe or pleural effusion
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Anatomy
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Anatomy
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Lobes
• Right upper lobe:
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• Right middle lobe:
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• Right lower lobe:
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• Left lower lobe:
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• Left upper lobe with Lingula:
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• Lingula:
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• Left upper lobe - upper division:
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Abnormal Chest X-ray• Radiopacity (whiteness) = increased density• Radiotranslucency (blackness) = decreased density
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RadiopacityAlveolar Pattern Interstitial Pattern Vascular pattern
• Fluffy, soft, poorly demarcated opacifications < 1cm in diameter
• Possible causes:1. Pulmonary
edema2. Viral pneumonia3. Pneumocystis4. Alveolar cell
carcinoma
• Consolidation of interstitial tissue
• Looks like branching lines radiating toward the periphery of the lung
• Possible causes:1. Interstitial
pneumonitis2. Pulmonary
fibrosis
• If there is an increase in size of the pulmonary arteries as they extend out into lung – pulmonary hypertension
• If there is a decrease in size, truncation, or obliteration of a pulmonary artery – embolus
• Lack of vascular marking in the periphery – pneumothorax
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• Lobar consolidation:– Alveolar space filled with
inflammatory exudate– Interstitium and
architecture remain intact
– The airway is patent– Radiologically:
• A density corresponding to a segment or lobe
• Air bronchogram, and• No significant loss of lung
volume
Consolidation
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Consolidation
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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
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• No ventilation to lobe beyond the obstruction
• Trapped air absorbed by pulmonary circulation
• Segmental/lobar density• Compensatory hyper-inflation
of normal lungs.
Atelectasis
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Congestive Heart Failure• Increased heart size:
cardiothoracic ratio >0.5 Large hila with
indistinct markings Fluid in interlobar
fissures Pleural effusions,
alveolar edema
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Congestive Heart Failure
Alveolar edema (Bat’s wings)
Kerley B lines (Interstitial edema)
Cardiomegaly Dilated prominent
upper lobe vessels Pleural effusion
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ARDS
• Congestion• Interstitial and
alveolar edema• Collapsed or
distended alveoli• Bilateral
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Pneumothorax
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Right side tension
pneumothorax
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Left Sided Pneumothorax
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Pleural effusion
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Right Side
Pleural Effusio
n
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RLL Pneumonia
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????????????
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Fracture of posterior rib #7
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A single, 3cm relatively thin-walled cavity is noted in the left midlung. This finding is most typical of squamous cell carcinoma (SCC). One-third of SCC masses show cavitation
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Right Squamou
s Cell Carcinom
a
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Right Middle and Left Upper Lobe Pneumonia
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Cavitation : cystic changes in the area of consolidation due to the bacterial destruction of lung tissue. Notice air fluid level.
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Cavitation
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Tuberculosis
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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.
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Chronic emphysema effect on the lungs
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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.
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24 hours after diuretic therapy
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Chest wall lesion: arising off the chest wall and not the lung
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Pleural effusion: Note loss of left hemidiaphragm. Fluid drained via thoracentesis
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Lung Mass
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The Enlarged Hila
Causes:
1. Adenopathies (neoplasia, infection)
2. Primary Tumor
3. Vascular
4. Sarcoidosis
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Small Pneumothorax : LUL
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Right Middle Lobe Pneumothorax: complete lobar collapse
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Post chest tube insertion and re-expansion
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Metastatic Lung Cancer: multiple nodules seen
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Tuberculosis
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Pleural Effusion
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Pulmonary Fibrosis
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Cavitating lesion
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Miliary shadowing
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5. 65 yo male admitted for sepsis. CHF or ARDS?
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12. Is the central line correctly positioned?
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13. Does ET tube need to be advance or pulled back? Arrow shows location of carina
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14. OK for R/T feeding?