HOW READ CHEST XR -5     ANAS SAHLE ,MD
Brief review
POSITION                            PA                                                 AP                                 ...
ConsolidationInfection causes                    Non-infection causes                        Broncho-                     ...
Abscess1.   Cavitating infective consolidation.2.    Single or multiple lesions.3.   organisms.         1. Bacterial (Stap...
Radiological features• Most commonly occur in the apicoposterior  aspect of the upper lobes or the apical  segment of the ...
Heart failure            Radiological features:• Right heart failure (this is usually due to chronic  airways disease).   ...
Heart failure• Left heart failure:• Stage 1 – there is venous upper lobe blood diversion with thickened  upper lobe veins ...
Left heart failureradiology feature         Stage-1                               Stage-2                   Stage-3
Sarcoidosis                  Radiological features:• Stage 1 – bilateral hilar and mediastinal lymphadenopathy  (particula...
Case-1• 55-year-old male was admitted in shock.• He was recently diagnosed with inoperable  lung cancer.• Clinical exam al...
CASE-1
POSITION      •PA CXRQUALITY       •Poor Technical Quality              •(PENETRATION,ROTATION?)                •Heterogen...
discussion• Beck described a triad of hypotension, muffled heart sounds, and elevated  jugular venous pressure due to card...
Case-2• This 40-year-old  male of African  origin was  asymptomatic.
POSITION      •PA CXR              •Poor Technical QualityQUALITY       •(PENETRATION?)                •Bi-lateral hilar e...
discussion                  Sarcoidosis.• The main differential diagnoses would be:     • Lymphoma.     • Tuberculosis.• b...
Case-3• This elderly  male has  exertional  dyspnea,  orthopnea,  and  paroxysmal                          a  nocturnal   ...
POSITION      •AP CXR              •Poor Technical QualityQUALITY       •(rotation ?)                •Bi-lateral perihilar...
After diuresis
Discussion• The CXR shows classic evidence of left ventricular failure, :           – cardiomegaly (cardiothoracic ratio 5...
Case-4• This elderly  female  presented with  left-sided chest  pain of three  months’  duration
POSITION      •AP CXRQUALITY       •Poor Technical Quality              •(rotation ?)                •Homogenous density i...
Discussion• The CXR shows a moderate-sized left pleural  effusion, which is loculated.• There is also globular cardiomegal...
Case-5• This 24-year-old female was asymptomatic.• Six months ago, she presented with  pneumonia-like symptoms of cough, f...
POSITION      •PA CXRQUALITY       •Good Technical Quality               •Ill defined opacity in right lower              ...
Discussion• The CXR shows a right lower lobe infiltrate• In addition, there seems to be a beady  appearance to the infiltr...
How  read  chest xr  5
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How read chest xr 5

  1. 1. HOW READ CHEST XR -5 ANAS SAHLE ,MD
  2. 2. Brief review
  3. 3. POSITION PA AP QUALITY ROTATION PENETRATION INSPIRATION LESION HomoDensityinfiltratio Heterogenous Centralperiph Silhouet n Wellill defined Zone eral Necrotic sign MEDIASTINAL Central deviasionwided COSTO-PHRENIC ANGEL Freeoblitern OTHER Bone soft tissuediaphragm
  4. 4. ConsolidationInfection causes Non-infection causes Broncho- WEGNER CardiacPneumonia Lymphoma alveolar COP Sarcoid disease failure carcinoma
  5. 5. Abscess1. Cavitating infective consolidation.2. Single or multiple lesions.3. organisms. 1. Bacterial (Staphylococcus aureus, Klebsiella, Proteus, Pseudomonas, TB and anaerobes). 2. fungal pathogens are the most common causative4. ‘Primary’ lung abscess – large solitary abscess without underlying lung disease is usually due to anaerobic bacteria.5. Associated with aspiration and/or impaired local or systemic immune response (elderly, epileptics, diabetics, alcoholics and the immunosuppressed)
  6. 6. Radiological features• Most commonly occur in the apicoposterior aspect of the upper lobes or the apical segment of the lower lobe.• CXR may be normal in the first 72 h.• CXR – a cavitating essentially spherical area of consolidation usually>2 cm in diameter, but can measure up to 12 cm.• There is usually an air-fluid level present.
  7. 7. Heart failure Radiological features:• Right heart failure (this is usually due to chronic airways disease). – the heart size is normal with a prominent elevated apex due to right ventricular hypertrophy. – Pulmonary arterial enlargement and venous upper lobe diversion in keeping with pulmonary arterial and venous hypertension. – There may be pleural effusions with fluid tracking in the oblique and horizontal fissures. – Beware these may look like mass lesions on the frontal radiograph.
  8. 8. Heart failure• Left heart failure:• Stage 1 – there is venous upper lobe blood diversion with thickened upper lobe veins bilaterally.• Stage 2 – interstitial pulmonary oedema – prominent peripheral interstitial thickening (Kerley B lines) bilaterally at both bases with apparent peribronchial thickening at both hila• Stage 3 – alveolar (air space) pulmonary oedema – patchy bilateral perihilar air space consolidation giving a ‘Bat’s wing’ appearance.• The consolidation may become confluent and xtensive.• Occasionally asymmetry may be misleading and can be due to the way in which the patient had been lying or the presence of concomitant chronic lung disease.• There is venous upper lobe blood diversion with thickened upper lobe veins bilaterally.
  9. 9. Left heart failureradiology feature Stage-1 Stage-2 Stage-3
  10. 10. Sarcoidosis Radiological features:• Stage 1 – bilateral hilar and mediastinal lymphadenopathy (particularly right paratracheal and aortopulmonary window nodes).• Stage 2 – lymphadenopathy and parenchymal disease.• Stage 3 – diffuse parenchyma disease only.• Stage 4 – pulmonary fibrosis• The parenchymal disease involves reticulonodular shadowing in a perihilar, mid zone distribution.• There is bronchovascular and fissural nodularity.• Rarely air space consolidation or parenchymal bands may also be present.• Fibrosis affects the upper zones where the hilar are pulled superiorly and posteriorly.• Lymph nodes can demonstrate egg shell calcification
  11. 11. Case-1• 55-year-old male was admitted in shock.• He was recently diagnosed with inoperable lung cancer.• Clinical exam also showed distended neck veins and muffled heart sounds.
  12. 12. CASE-1
  13. 13. POSITION •PA CXRQUALITY •Poor Technical Quality •(PENETRATION,ROTATION?) •Heterogenous density •In right middle zone from hilum toLESION chest wall. •That obliterate right heart border •With silhouet sign. •Central trachea and mediasteinal.MEDIASTINAL •Cardiomegaly .ANGELS •Free costo-phrenic angels.OTHER •No
  14. 14. discussion• Beck described a triad of hypotension, muffled heart sounds, and elevated jugular venous pressure due to cardiac tamponade from pericardial effusion.• Immediate pericardiocentesis is life-saving.• The common causes of pericardial effusion Include: • malignancy, • congestive heart failure. • Tuberculosis. • systemic lupus erythematosus. • Dressler’s syndrome. • uremia.• This CXR shows : • a globular enlargement of the heart, typical of a large pericardial effusion. • In addition, there is a mass in the right lung in keeping with the primary lung cancer.
  15. 15. Case-2• This 40-year-old male of African origin was asymptomatic.
  16. 16. POSITION •PA CXR •Poor Technical QualityQUALITY •(PENETRATION?) •Bi-lateral hilar enlargement.LESION •Central trachea and mediasteinal.MEDIASTINAL •Free costo-phrenic angels.ANGELS •NoOTHER
  17. 17. discussion Sarcoidosis.• The main differential diagnoses would be: • Lymphoma. • Tuberculosis.• but the lymphadenopathy would then be asymmetrical.
  18. 18. Case-3• This elderly male has exertional dyspnea, orthopnea, and paroxysmal a nocturnal b dyspnea. c A+b>c2
  19. 19. POSITION •AP CXR •Poor Technical QualityQUALITY •(rotation ?) •Bi-lateral perihilar infeltration.LESION •With upper zone diversion •Kerley b line? •Central trachea and mediasteinal.MEDIASTINAL •Cardiomegaly.ANGELS •Free costo-phrenic angels. •There are sternotomy wires.OTHER •right internal jugular central venous line.
  20. 20. After diuresis
  21. 21. Discussion• The CXR shows classic evidence of left ventricular failure, : – cardiomegaly (cardiothoracic ratio 50%), – upper lobe pulmonary venous diversion, – and Kerley B lines (which indicate distension of lymphatics).• In addition, there is evidence of sternotomy wires, suggesting previous coronary artery bypass surgery (CABG).• Following diuresis, the pulmonary infiltrates have cleared Only fluid and blood on the chest radiograph can clear rapidly (within days).• This patient also has a right internal jugular central venous line.
  22. 22. Case-4• This elderly female presented with left-sided chest pain of three months’ duration
  23. 23. POSITION •AP CXRQUALITY •Poor Technical Quality •(rotation ?) •Homogenous density in left upper zone obscured aortic arc.LESION •Many opacity at left peripheral chest wall •Right pushed trachea.MEDIASTINAL •Cardiomegaly.ANGELS •Left obliterans costo-phrenic angels. •No .OTHER
  24. 24. Discussion• The CXR shows a moderate-sized left pleural effusion, which is loculated.• There is also globular cardiomegaly, suggesting a pericardial effusion.• Pleural tap showed malignant cells consistent with the diagnosis of adenocarcinoma of the lung.• In addition, the second, third, and fourth ribs on the left side demonstrate lytic lesions in keeping with bony metastases.
  25. 25. Case-5• This 24-year-old female was asymptomatic.• Six months ago, she presented with pneumonia-like symptoms of cough, fever, and purulent sputum.
  26. 26. POSITION •PA CXRQUALITY •Good Technical Quality •Ill defined opacity in right lower zone close to chest wallLESION •Central trachea ,mediastinal.MEDIASTINALANGELS •Hazy costo-phrenic angels. •No .OTHER
  27. 27. Discussion• The CXR shows a right lower lobe infiltrate• In addition, there seems to be a beady appearance to the infiltrates.• Pneumonic changes on CXR typically resolve within three months.• She subsequently underwent a bronchoscopy and transbronchial lung biopsy which showed BOOP.

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