Chest X-ray Anna Americans

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Chest X-ray

.Anna Ben Ely M.D

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CHEST X-RAY The most common imaging

diagnostic study of the chest

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Technique

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Positioning The standard chest examination : PA (posterioranterior) + lateral chest x-ray

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Positioning  The standard chest examination consists

of a PA (posterioranterior) and lateral chest x-ray

 The films are read together  The PA exam is viewed

as if the patient is standing in front of you with his right side on your left

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Positioning The patient is facing towards the left on the lateral view

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Lateral Positioning  The lateral view is

obtained with the left chest against the cassette

 This diminishes the effect of

magnification on the heart

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PA versus AP

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AP supine film

magnification of the heart and widening of the mediastinum A Free sample background from www.powerpointbackgrounds.com

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AP supine film  The chest has a different appearance  The heart shadow is

magnified because it is an anterior structure  The pulmonary vasculature is also altered and appears more prominent  There is more equalization of the pulmonary vasculature when the size of the lower lobe vessels is compared to the upper A Free sample background from www.powerpointbackgrounds.com

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PA versus AP

This is a PA film compared to AP supine film A Free sample background from www.powerpointbackgrounds.com

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PA versus AP  The AP shows

magnification of the heart and widening of the mediastinum

 Whenever possible the patient should be

imaged in an upright PA position

 AP views

are less useful and should be reserved for very ill patients who cannot stand erect

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Lateral decubitus position

pleural effusion pneumothorax air trapping A Free sample background from www.powerpointbackgrounds.com

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Lateral decubitus position  Helps to assess the volume of pleural

effusion  Can demonstrate whether a pleural effusion is mobile or loculated  Helps to detect a pneumothorax  The dependant lung should increase in density due to the weight of the mediastinum. Failure to do so indicates air trapping A Free sample background from www.powerpointbackgrounds.com

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Chest X-ray anatomy

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Chest X-ray anatomy The radiologist needs to know the normal anatomy of the structures represented on a chest X-ray:      

Mediastinum and heart Hila Lungs Diaphragms Bony structures Soft tissue structures

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Mediastinum and heart

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Chest X-ray anatomy  This drawing shows

the anatomy of the lungs and mediastinum  These structures are present on every chest x-ray  If you know the location of these structures, this will help you understand the anatomy on chest x-rays and chest CT

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Mediastinum 1. Trachea 2. Right Ventricle 3. Left Ventricle 4. Left Atrium 5. Right Pulmonary Artery A Free sample background from www.powerpointbackgrounds.com

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Hila of lungs 

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The hila are made up of the main pulmonary arteries and major bronchi The left hilum is higher than the right Lymph nodes are not normally seen on a chest X-ray

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Lungs

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Lobes and Fissures

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Lobes and Fissures  The minor fissure divides the right middle

lobe from the right upper lobe and is sometimes is seen on the PA chest X-ray  There is no minor fissure on the left  The major fissures are not seen on the PA view because you are looking through them obliquely  If there is fluid in the fissure, it is occasionally manifested as a density at the lower lateral margin A Free sample background from www.powerpointbackgrounds.com

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Lobes and Fissures The patient has a pleural effusion extending into the fissure

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Lobes and Fissures

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Lungs/mediastinum relationship

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Diaphragm 

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The right hemidiaphragm is higher than the left ( the heart is pushing the left hemidiaphragm out) A gas bubble beneath the left hemidiaphragm

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Diaphragm

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Diaphragm  The right hemidiaphragm is usually

higher than the left

 The anterior portion of the

left hemidiaphragm is silouhetted out

 The anterior right hemidiaphragm

remains visible

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Bony structures

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Ribs  The right ribs (red arrows below)

larger due to magnification

are

 The right ribs usually projected posterior

to the left ribs if the patient was examined in a true lateral position

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Pathology

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Chest abnormalities  Mediastinum and heart  Lung

– Air way – Air spaces – Interstitium – Vascular – Neoplasm  Pleura  Diaphragm  Bony structures and soft tissues A Free sample background from www.powerpointbackgrounds.com

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Mediastinal abnormalities

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Cardiomegaly Cardiothoracic ratio more than 50 %

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Pericardial Effusion 

400-500 ml of fluid

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Pericardial Effusion  Pericardial effusion causes an enlarged

heart shadow that is globular shaped  Approximately 400-500 ml of fluid must be in the pericardium to lead to a detectable change in the size of the heart shadow on PA CXR  Pericardial effusion can be definitively diagnosed with echocardiography or CT

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Pneumomediastinum

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Pneumomediastinum

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Pneumomediastinum 

Findings for pneumomediastinum include: – streaky lucencies over the mediastinum that extend into the neck – separation of the parietal pleura along the mediastinal borders

 

Pneumomediastinum should be distinguished from pneumopericardium and pneumothorax In pneumopericardium air does not enter the neck

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Anterior Mediastinal Mass

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Anterior Mediastinal Mass  4 "T's"

– Thymic tumors – Teratoma – Thyroid mass – Terrible lymphadenopathy  aortic aneurysm  pericardial cyst  epicardial fat pad

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Middle Mediastinal Mass

saccular aortic aneurysm A Free sample background from www.powerpointbackgrounds.com

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Middle Mediastinal Mass  The most common cause of a middle

mediastinal mass is lymphadenopathy

hiatial hernia  aortic aneurysm  thyroid mass  duplication cyst  bronchogenic cyst 

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Posterior Mediastinal Mass

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Posterior Mediastinal Mass  Neoplasm  Lymphadenopathy  Aortic aneurysm  Adjacent pleural or lung mass  Neurenteric cyst  Lateral meningocele  Extramedullary hematopoiesis

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Lung abnormalities

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Air space pathology

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Air space pathology Alveolar infiltrate-alveolar spaces are filled with some material  Pus (pneumonia)  Blood (pulmonary hemorrhage)  Fluid (pulmonary edema)  Cells ( Carcinoma)

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Air Bronchogram 

Air within bronchus

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Filling of surrounding alveoli by fluid

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causes : – lung consolidation – pulmonary edema – nonobstructive pulmonary atelectasis – neoplasm

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Air Bronchogram

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Silhouette sign The right heart border is silhouetted out

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Silhouette sign  The silhouette sign is loss of lung/soft

tissue interface caused by a mass or fluid in the normally air filled lung

 The sign is commonly applied to the

heart, aorta and diaphragm

 The location of this abnormality can help

to determine the location anatomically

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Silhouette sign

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Pneumonia -LLL   

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indistinct borders air bronchograms silhouetting of the lt. diaphragm

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Pneumonia- RML indistinct borders air bronchograms silhouetting of the right heart border

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Pneumonia Consolidation: air spaces filled with bacteria or other microorganisms and pus  is NOT associated with volume loss  bacteria, viruses, mycoplasmae, fungi  x-ray findings :

– airspace opacity, – lobar consolidation – interstitial opacities – may have an associated pleural effusion

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Pulmonary neoplasm

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Solitary Pulmonary Nodule 

compare with prior films if available

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nodule unchanged for two years - almost certainly benign



completely calcifiedbenign

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Solitary Pulmonary Nodule     

A solitary nodule in the lung can be absolutely innocuous or potentially a fatal lung cancer After detection the initial step in analysis is to compare the film with prior films if available A nodule that is unchanged for two years is almost certainly benign If the nodule is completely calcified it is benign Suspicious nodules should be worked up further with a biopsy or PET scan

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Solitary Pulmonary Nodule

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Lung cancer

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Airways pathology

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Atelectasis  Atelectasis is collapse or incomplete

expansion of the lung or part of the lung

 It is most often caused by an

endobronchial lesion, such as mucus plug or tumor

 It can also be caused by extrinsic

compression by a mass or by pleural effusion

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Atelectasis RUL

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

the lobe migrates superomedially toward the apex and mediastinum

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Elevation of minor fissure

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Elevation of lower lobe artery

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Right Upper Lobe Atelectasis  Right upper lobe atelectasis - the lobe

migrates superomedially toward the apex and mediastinum

 Elevation of minor fissure  Elevation of lower lobe artery

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Atelectasis RML

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Atelectasis RML  May cause minimal changes on frontal

chest film  Loss of definition of the right heart border  Right middle lobe collapse is easy seen in the lateral view  Wedge of opacity pointing to the hilum

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Atelectasis  Linear increased density associated with

volume loss  Apex at the hilum  Signs of volume loss : fissural, tracheal, or mediastinal shift towards the collapse  Compensatory hyperinflation of adjacent lobes  Hilar elevation (upper lobe collapse) or depression (lower lobe collapse) A Free sample background from www.powerpointbackgrounds.com

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Vascular abnormalities

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Pulmonary congestion Cardiomegaly Cephalization Haziness of vascular margins

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Pulmonary congestion  Is one of the most common abnormalities

evaluated by CXR  It occurs when the heart fails to maintain adequate forward flow  Increased cardiothoracic ratio (>50%)  Cephalization - upper zone veins become equal in size or larger than lower zone veins  Kerley lines - interstitial edema A Free sample background from www.powerpointbackgrounds.com

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Pulmonary congestion Kerley lines

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Pulmonary Edema 

Pulmonary congestion may progress to pulmonary edema with leakage of fluid into the interstitium, alveoli and pleural space



Cardiogenic pulmonary edema can show: – – – – – –

Increased cardiac size Kerley lines Peribronchial cuffing Patchy shadowing with air bronchograms “Bat wing" pattern Pleural effusion

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Pulmonary Edema "bat wing" pattern

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Pulmonary Edema Diffuse pulmonary edema with loss of both hemidiaphragms and silouhetting of the heart

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Pulmonary Edema The film was taken two days later after partial resolution of the edema

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Interstitial pathology

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Reticular-nodular pattern

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Emphysema

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Emphysema  Emphysema is loss of elastic recoil of the

lung with destruction of pulmonary capillary bed and alveolar septa  It is caused most often by cigarette smoking  Emphysema is seen on CXR as :

– diffuse hyperinflation – flattening of diaphragms – increased retrosternal space – bullae (lucent, air-containing spaces without vessels) A Free sample background from www.powerpointbackgrounds.com

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Pleural abnormalities

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Pleural Effusion  CHF,

infection (parapneumonic), trauma, PE, tumor, autoimmune disease, renal failure

 200 ml of fluid - frontal film  75ml – lateral  Larger unilateral effusions are most

probably malignant

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Pleural Effusion

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Pneumothorax  Air

inside the thoracic cavity but outside the lung

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Most common- iatrogenic Trauma Spontaneous pneumothorax- without obvious inciting incident: idiopathic, asthma, COPD, pulmonary infection, neoplasm, Marfanâs syndrome, smoking cocaine Tension PTX : air enters the pleural cavity and is trapped during expiration

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Small pneumothorax

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Pneumothorax 

   

On CXR, a PTX appears as air without lung markings in the least dependant part of the chest The air is found peripheral to the white line of the pleura In an upright film this is most likely seen in the apices A PTX is best demonstrated by an expiration film It can be difficult to see when the patient is in a supine position

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Tension pneumothorax right sided tension pneumothorax with right sided lucency and leftward mediastinal shift

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Hydropneumothorax Air/fluid level within pleural cavity

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Bones and soft tissues pathology

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Trauma - Rib fracture

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S/p Rt. mastectomy  Increased lucency

in Rt. lower lung field  Absent Rt. breast shadow  Straight, sharp axial fold

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CHEST CT

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Chest CT  Without CM IV  With CM IV ( vessels, heart, lymph nodes)  With CM IV – angio (suspected aortic rupture

or dissection, PE)  HRCT – interstitial lung diseases

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Windows  Mediastinum (soft tissues)

– Heart – great vessels – pleural effusion – SOL – lymph nodes  Lungs  Bones

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Tissue Hounsfield Unit Air

-1000

Fat

-40 to -100

Fluid 0 to 20 Soft Tissue 20 to 100 Bone 1000 A Free sample background from www.powerpointbackgrounds.com

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