UNIT-2 IMAGING CHEST [RESPIRATORY]. CHEST.pdf · 2020-04-05 · Scapula rotated out of the lung...

CHEST [RESPIRATORY] IMAGING

UNIT-2

NUSU-ME-RAD-UNIT-2-CHEST 1

2. OBJECTIVES OF UNIT 2-CHEST

List the routine and ancillary views of chest radiography

Indicate the quality characteristics of a routine film

Describe the use of each of the imaging modalities in chest pathology

Follow a sequence of reading a chest x-ray Diagnose pneumothorax, pleural effusion,

bone injury, pneumonia, tuberculosis, lobar collapse, emphysema and mediastinal and lung masses


3. PLAIN FILMS

POSTERO-ANTERIOR (PA): is the routine view, the film is in front of the patient, nearer to the heart to reduce magnification.

ANTEROPOSTERIOR (AP): film behind, tube in front of patient Used only if patient cannot sit or stand for PA All portable CXRs are obtained in this view

for bed-ridden patients.


:PA4. THE ROUTINE VIEW -

NUSU-ME-RAD-UNIT-2-CHEST

Film is anterior, XR tube is 60 inches behind

Green dot is the centre of the XR beam

4

5.THE AP VIEW


Film is behind, tube is in front of patient.

Used if the patient cannot sit or stand for PA, or posterior ribs are to be shown.

All portable CXRs are obtained in this view


5

6.THE LATERAL VIEW


Film is on the intended (left or right) side, tube 60” on the other side


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7. ANCILLARY VIEWS: LOROTIC


Apical (lordotic) view

XRs angled on apices of both upper lobes, to move the clavicles away from apices to detect doubtful apical or thoracic inlet pathology.

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8. APICAL VIEW: Note right cervical rib

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9. ANCILLARY VIEW: DECUBITUS


Decubitus views Obtained with patient

positioned on left or right side, and the tube in front of or behind the patient, film is opposite to the tube, beam is horizpntal Hepls assess free versus loculated effusions.

Small amounts of fluid (<200 ml) may not be seen in costophrenic depth.

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10.XR ROUTINE FILM QUALITY CRITEREA

Documentation: Institution, name of patient, date, R or L. mark

Position for PA: sternoclavicular joints equidistant from midline (spinous processes).Scapula rotated out of the lung fields. Extends from V7 and includes costophrenic angles.

Beam direction: casts sternoclavicular joint opposite rib 4 or 5 posteriorly.

Exposure: vertebral column (not individual vertebrae) seen behind the heart.

Full inspiration- right cupola between 9-11 ribs posteriorly


11.NORMAL ROUTINE (PA) VIEW SHOWING ADEQUATE TECHNIQUE


A routine PA view should include the transverse processes of C7 vertebra, diaphragm and costophrenic angles.

2. UNDEREXPOSED FILM1


NORMAL Exposure: vertebral column (not individual vertebrae) seen behind the heart.

13. BRONCHOGRAM: frontal and lateral


14. COMPUTED TOMOGRAPHY (CT)

Helps stage ca lung, by evaluating extent of neoplasm through detection of focal invasion and involvement of the hilar and mediastinal LNs

Confirms and better characterizes suspected masses detected on plain films.

Definitely analyses mediastinal widening seen on plain films.


15.CHEST -CT

Often characterizes nonspecific infiltrates seen on plain films into specific categories; ie, neoplasm, infection, etc.

Better defines cavitary and cystic changes as to wall thickness and cavity contents.


16. CHEST -CT Better characterizes chest wall and pleural

masses. Quantifies pleural effusion, and better defines

areas of loculation: may detect cause of the effusion.

Thin section CTs can often definitely characterize chronic interstitial lung disease and bronchiectasis.


17. CHEST -CT

Thoracic aortic pathology such as dissecting aneurysm is well demonstrated and categorized.

Displays changes in acute chest trauma, including assessment of bronchial tears.

Better evaluates degree of emphysema Can be used for patients in ventillators,

who show nonspecific infiltrates in portable plain films.

CT-guided biopsy or fine needle aspiration.


: lung window [Identify: 18.CHEST CTgreen arrows: 1,2]


1

2

:19. CT CHEST: bone window

NUSU-ME-RAD-UNIT-2-CHEST19

A

B C

D E

Anatomical structures at five levels: (A) mid-tracheal, (B) above bifurcation, (C) at bifurcation, (D) at hila, and (E) across heart

chambers

20. CT CHEST; Bone window: Retrosternal note tracheal narrowing (black arrow) and : goiter

calcifica-tions (white arrows).


showing left : 21. CT-CHEST: bone windowhilar mass and pleural effusion (BRONCHIAL CA- arrow)


showing : 22. CT-CHEST: bone windowlung collapse (arrows) due to pleural effusion


1

23

4

5

Identify: 1,2,3,4,5,6,7

6

7

: 23. CT-CHEST: Bone windowCT-GUIDED LUNG BIOPSY


24. MAGNETIC RESONANCE IMAGING (MRI)

Used as a problem-solving tools if CT is inconclusive.

Can be helpful in assessing aortic dissection in multiple planes (coronal, sagittal, and axial)

Can detect, if CT can’t, small hilar LN enlargement

May better characterize chest wall and soft tissue disease.


Identify 1,2,3,4,5,625.MRI CHEST-


1

2

34 5

6

26.Ultrasound

To localize pleural effusion for US-guided thoracocentesis.

For peripheral masses and for US-guided biopsy or aspiration.


showing pleural effusion, 27. ULTRASOUND partial lung collape (arrows). Note liver (L)


L

27

28. PULMONARY ANGIOGRAPHY


perfusion-: 29. SCINTIGRAPHYventillation lung imaging

Suspected pulmonary embolism; made by injecting Tc99m labelled macroaggregates of albumen, lung images will show defects in areas where the vessels are occluded.

Airway disease, chronic obstructive pulmonary disease, detects redistribution of blood flow away from poorly ventilated region.


Normal ventilation (V) and 30.SCINTIGRAPHY: perfusion (Q) scans.


Ventilation study= inhalation of radioactive gas

Perfusion study= infusion of radioactive compound

31. PULOMNARY EMBOLISM

• Normal anterior and posterior ventilation studies

• Abnormal perfusion study showing upper lobe defect (arrow), suggesting pulmonary embolism


OF 32.EXAMINATION SEQUENCE CHEST RADIOGRAPH

Look for the mediastinal structures: trachea, aorta, hila and heart

Estimate (Measure) cardiothoracic ratio: heart (H)/chest (C)

View the lung fields View pleural lines: diaphragmatic, parietal,

apical, and mediastinal View the bones of the chest: scapulae, clavicles

and ribs View soft tissues of the chest wall



33. EXAMINATION SEQUENCE

33

trachea, aorta, hila and heart

Hila showing pulmonary arteries

Measuring of cardiothoracic ratio

Viewing the lung fields

Viewing pleural lines: diaphragmatic, parietal, apical, and mediastinal

Viewing the bones of the chest: scapulae, clavicles and ribs

Viewing soft tissues of the chest wall

34. Normal routine (PA) chest XR


35. CHEST IMAGING (General Radiographic Patterns)

Normal reticular Interstitial or Nodular pattern Collapse (atelectasis) Consolidation Pleural effusion Pneumothorax Hyperinflation (emphysema) Cystic, cavitary or solid lesions Calcifications


pattern of lung fields (A) as 36.Normal reticular lung shadowing (B) interstitial compared to


A B36

37. NODULE


Solitary circular nodule in right midzone with hilar lymphadeno-pathy =bronchial carcinoma

37

38. ATELECTASIS (COLLAPSE)

Atelectasis: lobar and segmental:

Lobar atelectasis: is the most clinically significant and frequently due to an endo-bronchial mass such as a bronchial carcinoma or adenoma. Secondary signs of lobar collapse include shifting of the mediastinum to the atelectatic side, elevation of diaphragm, and a loss of silhouette sign caused by the affected lobe and adjacent structures.


39. RIGHT UPPER LOBE COLLAPSE


Right upper lobe collapse due to mass in the right hilum (note elevated concave transverse fissure)

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Upward movement of lesser fissure and forward movement of upper part of oblique fissure

40. PA & Lateral views of right middle lobe collapse


Movement of fissure in right middle lobe collapse

Right middle lobe collapse: note loss of right cardiac border (loss of silhouette)

41. Oblique fissure moves forwards in left upper lobe collapse


Oblique fissure moves forwards in left upper lobe collapse

Lateral view of forward movement of fissure in left upper lobe collapse (arrows)

Hazy left upper and middle zone in left upper lobe collapse in PA view

42.INTERSTITIUM AND AIRSPACES IN LUNG ACINUS


Acinus: thickening of interstitium in interstitial lung disease

Acinus: fluid in airspace in airspace lung diseaseNormal

interstitium and airspace

43.PNEUMONIC CONSOLIDATION


Right (1) and Left (2) pneumonic consolidation: note air bronchogram in Xray (1,2) and CT (3 (

44.PLEURAL EFFUSION


Large left pleural effusion: note concave surface

Small amount of pleural effusion seen in (b) not seen in PA (a), as demonstrated by decubitus film (c)

b

c

45. PNEUMOTHORAX


Right tension pneumothorax: shown as absence of lung markings to to right lung collapse. Note mediastinal shift to the left 45

Right pneumothorax: note absence of lung markings. Note the lung edge

46.EMPHYSEMA: enlargement of air spaces. Localized areas of no or fewer lung markings


Bilateral large emphysematous bullae. Note flattened diaphragm and small heart. 46

CT CHEST: LUNG WINDOW:emphysematous bullae of various size

47.Other Specific Patterns

Bronchiectasis

Widening of mediastinum (masses) Hilar lympadenopathy Solitary and multiple nodules Interstitial lung disease Chest wall, pleura and diaphragm


48. BRONCHIECTASIS


Bronchiectasis in plain XR (A) and bronchogram (B), normal bronchogram is inserted (C), CT bronchiectasis (D)

A B

C

48D

49. Widening of upper mediastinum in retrosternal goitre shown by XR (A) and CT (B)


A

B

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50. LOBULATED HILAR MASSES= LYMPHOMA


51. Pulmonary metastasis shown in XR (A) and CT (B)


AB

51

52. IMAGING MANIFESTATIONS OF TUBERCULOSIS


53. TUBERCULOSIS


Cavitating consolidation in left appex with fluid level suggesting active tuberculosis

Calcification flakes of healed tuberculosis

54. FIBROSING ALVEOLITIS AND PNEUMOCONIOSIS


Linear fibrous stands in fibrosing alveolitis shown by CT. Normal CT lung window (insert)

Course nodular shadowing in coal miners pneumoconiosis

55.COVID-19-CT APPEARANCE


Ground glass (A,B) and consolidative lesions (C) with peripheral lung destruction.

C

UNIT-2 IMAGING CHEST [RESPIRATORY]. CHEST.pdf · 2020-04-05 · Scapula rotated out of the lung...

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