Chest Radiography Reading
Transcript of Chest Radiography Reading
-
7/29/2019 Chest Radiography Reading
1/56
Chest RadiographyInterpretation:Reading Chest Films
Lisa Chen , M.D.
Assistant Clinical Professor
Pulmonary and Critical Care Division
Department of MedicineSan Francisco General Hospital
Michael Gotway, MD
Associate Clinical Professor, Radiology
University of California, San Francisco
-
7/29/2019 Chest Radiography Reading
2/56
Approach to the CXR:
Technical Aspects
Inspiratory effort
9-10 posterior ribs
Penetration
thoracic intervertebral disc space just visible Positioning/rotation
medial clavicle heads equidistant to spinous
process
-
7/29/2019 Chest Radiography Reading
3/56
Low Lung Volumes
-
7/29/2019 Chest Radiography Reading
4/56
Over Exposure Proper Exposure
-
7/29/2019 Chest Radiography Reading
5/56
10
-
7/29/2019 Chest Radiography Reading
6/56
-
7/29/2019 Chest Radiography Reading
7/56
What to Evaluate
Lungs
Pleural surfaces Cardiomediastinal contours
Bones and soft tissues
Abdomen
-
7/29/2019 Chest Radiography Reading
8/56
Where to Look
Apices
Retrocardiac areas (left and right)
Below diaphragm
-
7/29/2019 Chest Radiography Reading
9/56
Apical TB
-
7/29/2019 Chest Radiography Reading
10/56
Left Retrocardiac Opacity
-
7/29/2019 Chest Radiography Reading
11/56
Normal Anatomy: Frontal CXR
Heart
Aorta Pulmonary arteries
Airways
Diaphragm/costophrenic sulci
Junction lines
-
7/29/2019 Chest Radiography Reading
12/56
-
7/29/2019 Chest Radiography Reading
13/56
Normal Anatomy: Lateral
Heart
Aorta
Pulmonary arteries
Airways
Spine
-
7/29/2019 Chest Radiography Reading
14/56
AA
RV
LV
-
7/29/2019 Chest Radiography Reading
15/56
Chest Radiography:
Basic Principles
X-ray photon fates:
completely absorbed in patient
transmitted through patient; strike film
scattered within patient; strike film
X-ray absorption depends on: beam energy (constant)
tissue density
-
7/29/2019 Chest Radiography Reading
16/56
Maximum x-rayTransmission
(least dense tissue)
Maximum xrayAbsorption
(densest tissue)
Blackest
air
fat
soft tissue
calcium
bone
x-ray contrast
metal
Whitest
-
7/29/2019 Chest Radiography Reading
17/56
All cardiothoracic pathology andnormal anatomy is visualized (or not)
by 7 different densities
How is this accomplished? differential x-ray absorption
Chest Radiography:
Basic Principles
-
7/29/2019 Chest Radiography Reading
18/56
A structure is rendered visible on a
radiograph by the juxtaposition of two
different densities
Differential X-Ray Absorption
-
7/29/2019 Chest Radiography Reading
19/56
Silhouette Sign
Loss of the expected interface
normally created by juxtaposition oftwo structures of different density
No boundary can be seen betweentwo structures of similar density
-
7/29/2019 Chest Radiography Reading
20/56
Right Lower Lobe Pneumonia
-
7/29/2019 Chest Radiography Reading
21/56
Differential X-Ray Absorption
The absence of a normal interface
may indicate disease;
The presence of an unexpected
interface may also indicate disease The presence of interfaces can be
used to localize abnormalities
-
7/29/2019 Chest Radiography Reading
22/56
Chest RadiographicPatterns of Disease
Air space opacity
Interstitial opacity
Nodules and masses
Lymphadenopathy
Cysts and cavities
Lung volumes
Pleural diseases
-
7/29/2019 Chest Radiography Reading
23/56
Cardiomediastinal contour abnormalities
Bone and soft tissue abnormalities
Below the diaphragm: abdominal and
retroperitoneal disease
Chest RadiographicPatterns of Disease
-
7/29/2019 Chest Radiography Reading
24/56
Air Space Opacity
Components:
air bronchogram: air-filled bronchus
surrounded by airless lung
confluent opacity extending to pleural
surfaces
segmental distribution
-
7/29/2019 Chest Radiography Reading
25/56
Air Space Opacity: DDX
Blood (hemorrhage)
Pus (pneumonia)
Water (edema)
hydrostatic or non-cardiogenic
Cells (tumor) Protein/fat: alveolar proteinosis and
lipoid pneumonia
-
7/29/2019 Chest Radiography Reading
26/56
LUL Pneumonia
-
7/29/2019 Chest Radiography Reading
27/56
Interstitial Opacity
Hallmarks:
small, well-defined nodules lines
interlobular septal thickening
fibrosis
reticulation
I i i l O i S ll N d l
-
7/29/2019 Chest Radiography Reading
28/56
Interstitial Opacity: Small Nodules
I t titi l O it
-
7/29/2019 Chest Radiography Reading
29/56
Interstitial Opacity:Lines
I t titi l O it Li & R ti l ti
-
7/29/2019 Chest Radiography Reading
30/56
Interstitial Opacity: Lines & Reticulation
-
7/29/2019 Chest Radiography Reading
31/56
Interstitial Opacity: DDX
Idiopathic interstitial pneumonias
Infections (TB, viruses) Edema
Hemorrhage
Noninfectious inflammatory lesions
sarcoidosis
Tumor
-
7/29/2019 Chest Radiography Reading
32/56
Nodules and Masses
Nodule: any pulmonary lesion
represented in a radiograph by a sharplydefined, discrete, nearly circular opacity
2-30 mm in diameter
Mass: larger than 3 cm
-
7/29/2019 Chest Radiography Reading
33/56
Nodules and Masses
Qualifiers:
single or multiple size
border definition
presence or absence of calcification
location
Well Defined
-
7/29/2019 Chest Radiography Reading
34/56
Mass
Calcification
Well-Defined
Ill-Defined
-
7/29/2019 Chest Radiography Reading
35/56
Lymphadenopathy
Non-specific presentations:
mediastinal widening
hilar prominence
Specific patterns:
particular station enlargement
-
7/29/2019 Chest Radiography Reading
36/56
-
7/29/2019 Chest Radiography Reading
37/56
Right Paratracheal
-
7/29/2019 Chest Radiography Reading
38/56
Right ParatrachealLymphadenopathy
Right Hilar LAN
-
7/29/2019 Chest Radiography Reading
39/56
Right Hilar LAN
Right Hilar LAN
-
7/29/2019 Chest Radiography Reading
40/56
Right Hilar LAN
Left Hilar LAN
-
7/29/2019 Chest Radiography Reading
41/56
Left Hilar LAN
Subcarinal LAN
-
7/29/2019 Chest Radiography Reading
42/56
Subcarinal LAN
Subcarinal LAN
-
7/29/2019 Chest Radiography Reading
43/56
Subcarinal LAN
*
AP Window LAN
-
7/29/2019 Chest Radiography Reading
44/56
AP Window LAN
-
7/29/2019 Chest Radiography Reading
45/56
Cysts & Cavities
Cyst: abnormal pulmonary
parenchymal space, not containinglung but filled with air and/or fluid,
congenital or acquired, with a wall
thickness greater than 1 mm epithelial lining often present
-
7/29/2019 Chest Radiography Reading
46/56
Cysts & Cavities
Cavity: abnormal pulmonary
parenchymal space, not containing
lung but filled with air and/or fluid,
caused by tissue necrosis, with a
definitive wall greater than 1 mm in
thickness and comprised of
inflammatory and/or neoplastic
elements
-
7/29/2019 Chest Radiography Reading
47/56
Cysts & Cavities
Characterize:
wall thickness at thickest portion
inner lining
presence/absence of air/fluid level
number and location
Benign Lung Cyst : PCP Pneumatocele
-
7/29/2019 Chest Radiography Reading
48/56
Benign Lung Cyst : PCPPneumatocele
Uniform wall thickness
1 mm Smooth inner lining
Benign Cavities :
-
7/29/2019 Chest Radiography Reading
49/56
Benign Cavities :Cryptococcus
max wall thickness 4 mm minimally irregular inner lining
Indeterminate Cavities
-
7/29/2019 Chest Radiography Reading
50/56
Indeterminate Cavities
max wall thickness 5-15 mm
mildly irregular inner lining
-
7/29/2019 Chest Radiography Reading
51/56
Malignant Cavities: Squamous Cell Ca
max wall thickness 16 mm Irregular inner lining
-
7/29/2019 Chest Radiography Reading
52/56
Pleural Disease: Basic Patterns
Effusion
angle blunting to massive
mobility Thickening
distortion, no mobility
Mass Air
Calcification
Pleural Effusion
-
7/29/2019 Chest Radiography Reading
53/56
Pleural Effusion
Pleural Effusion
-
7/29/2019 Chest Radiography Reading
54/56
Pleural Effusion
Subpulmonic Effusion
-
7/29/2019 Chest Radiography Reading
55/56
Subpulmonic Effusion
Pleural Calcification
-
7/29/2019 Chest Radiography Reading
56/56
Pleural Calcification