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  • 1. The Normal Chest
  • 2. General Considerations in Chest Interpretation
  • 3.
    • Developing the interpretative skills begins by looking at as many normal films as possible to develop an eye for the normal range…………
  • 4.  
  • 5. Objectives
    • To be familiar with the normal chest roentgenogram
    • Identify anatomical structures
    • Know deviations from normal
  • 6. Structures Visualized
  • 7. Inspect
    • mediastinum
    • heart and great vessels
    • trachea and central bronchi
    • lungs and diaphragm
    • bony thorax and soft tissue of thorax and neck
  • 8. Note:
    • compare lungs interspace by interspace
  • 9. Remember
    • make the initial examination of the film without knowledge of the clinical findings
    • But before making a decision, xray observations must be correlated with all available clinical findings
  • 10. Patterns of Pulmonary Opacity
    • Alveolar or Air Space Pattern
        • char by homogenous opacity
    • Interstitial Pattern
        • char by an increased prominence of the perivascular, interlobular and parenchymal interstitial spaces
  • 11. First things first…
      • Patient's name
      • Date exam done
      • Check for position markers
  • 12. Other things to check..
    • Patient’s position
    • Type of film
    • Technical quality of the film
    • General Body Size, Shape, and Symmetry
    • Male vs. Female
    • Is this an infant, child, young adult, elderly person?
    • Survey for foreign objects - tubes, IV lines, EKG leads, surgical drains, prosthesis, etc., as well as non-medical objects, bullets, shrapnel, glass, etc.
  • 14. The Adult Chest
  • 15. Bony Thorax
    • Shoulder girdles
    • Ribs
    • Cervical vertebrae
    • Thoracic vertebrae
    • Clavicles
    • Scapulae
  • 16. What is normal?
    • Age
    • Body habitus
        • Angulation of the ribs
          • Hyperesthenic--- minimal
          • Asthenic------- maximal
  • 17. Bony Thorax
    • ICS are numbered according to the rib above them.
    • Anterior vs. posterior
  • 18.
    • Costal cartilage not calcified
    • Calcification- mottled appearance
    • men- peripheral
    • women- central
  • 19. Rhomboid Fossa
    • anatomic variant of no clinical significance
    • produce shadow on chest x-ray
    • skin folds produce linear shadows in any direction
    • breast shadow increased opacity over the lower thorax
    • nipple shadows-round opacity in 4th anterior interspace or lower
    • metallic nipple markers
  • 21. Nipple Shadow Breast Shadow
  • 22.
    • produced by skin and ST over clavicles
    • 2-3 mm to 1 cm
    • projects beyond the lungs
    Clavicular Companion Shadow
  • 23. Nodules and ST Masses
    • may simulate pulmonary nodules
    • subQ or deeper tissues of thoracic wall--->more sharply defined than intrapulmonary lesions
    • CT scan if unsure
  • 24. Mediastinum
    • the space lying between the right and left pleurae in and near the median sagittal plane of the chest
  • 25. Anatomic Division and Contents
    • post aspect of the sternum to anterior aspect of thoracic vertebrae
    • contains all thoracic viscera exept lungs
  • 26.
    • Divisions
    • A- anterior
    • B- middle
    • C- post
  • 27. Anterior Mediastinum
    • aka: prevascular space
    • above: thoracic inlet
    • lat: pleura
    • ant: sternum
    • post: pericardium and great vessels
    • contents: loose areolar tissue, LN, lymphatic vessels
  • 28. Middle Mediastinum
    • aka: vascular space
    • ant: anterior mediastinum
    • post: post mediastium
    • contains the heart and the pericardium, ascending and transverse arch of the aorta, SVC, azygos, brachiocephalic vein and arteries and phrenic nerves upper vagus nerves, trachea and its bifurcation, the main bronchi, pulmo artery and branches, pulmo veins, lymph nodes
  • 29. Posterior Mediastinum
    • aka: post vascular space
    • lies behind the heart and pericardium
    • extends from the level of the thoracic inlet to the 12th thoracic vertebra
    • contents: thoracic portion of the descending aorta, esophagus, thoracic duct, azygos and hemi azygos veins, lymph nodes, sympathetic chains and inferior vagus nerves.
  • 30. Mediastinal Pleural Reflections
  • 31. Anterior Junction Line
    • anterior to trachea, behind sternum
    • from sternal angle downward and to the left
    • represents the apposition of the visceral and parietal pleura of the upper lobes
    • projected over the trachea as thin linear shadow, convex to the left
  • 32. Posterior Junction Line
    • post to trachea and esophagus
    • from the thoracic inlet downward to level of the azygos and aortic arches
    • represents the approximation of visceral and parietal pleura of the upper lobes posteriorly
    • projects over the tracheal air shadow and is convex to the left
  • 33. Azygoesophageal Recess
    • extends from the inferior surface of the azygos arch downward and to the left to level of the diaphragm
    • outlines medial aspect of the right lower lobe and right lateral aspect of the esophagus
    • concave on its right
  • 34. Right Paratracheal Stripe
    • consists of the right lateral tracheal wall and adjacent parietal and visceral pleura of the right upper lobe.
    • widened or altered by tracheal mediastinal and pleural disease
  • 35. Paraspinal Interphase (pleural reflection)
    • right side- posteriorly between parietal pleura and lateral aspect of thoracic vertebrae
    • left side- left lateral wall of the descending aorta with lung
  • 36. Lymph Nodes
    • Anterior mediastinal (prevascular)
    • Paratracheobronchial
  • 37. Normal nodes are small and cannot be identified on normal chest radiographs
  • 38. Anterior Mediastinal (prevascular)
    • R: ant to SVC and R innominate vein
    • L: anterior to aorta and carotid artery
    • Ductus Nodes lie ant to ligamentum arteriosum in the aortopulmonary window
  • 39. Paratracheobronchial
    • Paratracheal
    • Subcarinal (bifurcation)
    • Hilar
  • 40. Trachea
    • A band of radiolucency in the midline
    • Very slight deviation to the RIGHT at level of aortic arch
    • Extends from C6 to T5 then divides
  • 41.  
  • 42.
    • The angle formed by the bronchi with the sagittal plane is equal bilaterally until 15yo
    • Tracheal deviation to the right increases the angle on the left
    • Subcarinal angle = 60 0
    Nice to know………….
  • 43. Right Main Bronchi
    • More vertical than left
    • 2 primary branches
        • Eparterial bronchus
        • Hyparterial bronchus
  • 44. Left Main Bronchi
    • longer, deviates more laterally than right
    • Divides into
        • Lower lobe bronchus
        • Left upper lobe bronchus
  • 45. Aortic Nipple
    • left superior intercostal, vein seen in cross section as it courses around the aorta
  • 46.
    • local concavity or notch between the aortic arch and the pulmonary artery
    Aortopulmonary Window
  • 47. HILUM
    • Contains the
        • Pulmonary arteries and veins
        • Bronchi
        • Bronchial arteries and veins
        • Lymph nodes
  • 48. Hilar Height Ratio
    • Useful in determining relative volume gain or loss in lower vs. upper lobes
    • Height above hilum
    • Height below hilum
    • Right=1.3
    • Left= 0.84
  • 49. CT of the Mediastinum
  • 50. Relationships at the level of the origin of the three branches of the aortic arch
  • 51.  
  • 52. Origin of the three branches of the Aortic Arch
    • The esophagus -anterior to and slightly to the left of the body of a thoracic vertebra.
    • The trachea is anterior to and slightly to the right of the esophagus.
    • The brachiocephalic artery, left common carotid artery, and left subclavian artery each appears in transverse section.
    • The thymus (if present) casts a triangular image directly anterior to the left brachiocephalic vein.
  • 53. Level of the aortic-pulmonary window
  • 54.  
  • 55.
    • Esophagus lies directly anterior to and to the left of the body of a thoracic vertebra.
    • The main stem bronchi appear in oblique section just above or below the level of the carina.
    • The azygos vein appears at the level where it arches over the right main stem bronchus and ends via union with the superior vena cava
    • The region in the scan between the origin and end of the aortic arch represents the aortic pulmonary window.
    Level of the aortic-pulmonary window
  • 56. Level of the roots of the ascending aorta and pulmonary trunk
  • 57.  
  • 58.
    • The azygos vein, esophagus, and descending thoracic aorta all appear in the posterior mediastinum.
    • Lobar or segmental bronchi lie on either side of the oblate outline of the left atrium.
    • The roots of the ascending aorta and pulmonary trunk lie directly anterior to the left atrium.
    • A crescent-shaped right atrium lies directly to the right of the root of the ascending aorta.
    Level of the roots of the ascending aorta and pulmonary trunk
  • 59. LUNGS
    • Lobar and Segmental Anatomy
  • 60. Right Lung
  • 61.  
  • 62. Left Lung
  • 63.  
  • 64. Bronchopulmonary Segmental Anatomy
  • 65.
    • These segments are the basic functional units of the lung
    • Each pyramid-shaped segment is
        • Enveloped by a connective tissue sheath
        • Supplied by a single segmental bronchus and a single pulmonary arterial branch
        • Oriented so that its apex projects toward the hilum of the lung
    Bronchopulmonary Segments of the Lungs
  • 66.  
  • 67. Right Lung Bronchogram
  • 68. Left Lung Bronchogram
  • 69. Surface projections of the lungs and the pleural cavities
    • The apex of each lung projects above the medial third of the clavicle.
    • Interlobar fissures
        • The oblique fissure begins posteriorly in the upper thoracic region, crosses the 5th and 6th ribs, curves laterally to the midaxillary line, and courses along the lower border of the 6 th rib to the lateral border of the sternum.
        • The right lung's horizontal fissure courses along the lower border of the 4th rib from the midaxillary line to the lateral border of the sternum
  • 70.
    • At midinspiration in quiet breathing, the lower margin of each lung lies at the level:
        • The sixth rib anteriorly at the midclavicular line
        • The eighth rib laterally at the midaxillary line
        • The tenth rib posteriorly at the lateral border of the vertebral column
  • 71.
    • The surface projection of the
    • costodiaphragmatic margin of each pleural
    • cavity passes through:
        • The eighth rib anteriorly at the midclavicular line
        • The tenth rib laterally at the midaxillary line
        • The eleventh or twelfth rib posteriorly at the lateral border of the vertebral column
    Costodiaphragmatic Margin
  • 72. Diaphragm
    • The chief muscle of inspiration
    • Accounts for 2/3 of the lungs' volumetric increase during inspiration
    • Most effective respiratory muscle when a person is supine
  • 73. Diaphragm
    • higher R
    • level of post arc of 10th rib
    • 5th anterior rib or interspace on deep inspiration
    • ribs below not clearly seen – opaque abdominal contents
  • 74.  
  • 75. Costophrenic Angle
  • 76.
    • Thin serous membrane
    • Visceral pleura is NOT often definitely outlined in the normal subject
    • AP diameter greater than transverse diameter
    • Diaphragm is higher
    • Ribs horizontal in infancy then angulate downwards with growth
    • Sternum not completely ossified at birth- ossifies in segmental manner
    • Two ossification centers in each segment
    • Significance:
    • Appear as small, rounded opacities, maybe mistaken for lesions
    • thymus gland produce widening of the mediastinum
    • Heart in NB is globular and large relative to the chest
    • Lungs of infant and child more radiolucent
    • Hilar shadow high at level of T3
    • Tracheal bifurcation reaches T5 at 10 yo
    • Diaphragm higher, left maybe higher
  • 82. Chest In Advancing age
  • 83. Chest In Advancing age
    • Increase dorsal kyphotic curve
    • Increase AP diameter of chest
    • Osteopenia
    • Calcifications in costal cartilages
    • Aorta becomes elongated, dilated and tortuous
  • 84. Chest In Advancing age
    • Emphysematous changes in lungs
    • Apical scarring
    • Senile emphysema
    • Lower domes, less acute costophrenic angles
  • 85.  
  • 86. Review
  • 87. Pls visit: