Chest x rays


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Chest x rays

  1. 1. Chest Xray - Views
  2. 2. PA View
  3. 3. AP viewThe clavicles project too high into the apices.The heart magnified over the mediastinum.The ribs will appear distorted or unnaturallyhorizontalPulmonary markings decresed visibilityBlunting of costophrenic angles
  4. 4. Lateral ViewPositionSeen in : ant mediastinalmasses, encysted pleural fluid, postbasal consolidation
  5. 5. Other Views• Decubitus - useful for differentiating pleural effusions from consolidation (e.g. pneumonia) ; Loculated effusions from free fluid in the pleura.
  6. 6. • Expiratory view and Inspiratory viewsDemonstrates Air trapping and diaphragm movementExp : pneumothorax and interstitial shadowing
  7. 7. • Lordotic viewClavicles projected upPancoast Tumour
  8. 8. • Apical View50 to 60 degrees
  9. 9. • Oblique viewRetrocardiac areaPosterior costophrenic angleChest wall
  10. 10. Normal Chest X-Ray
  11. 11. Scheme of viewing PA film1. Request form Name ,age, sex, date, clinical information2. Technical View Centering, patient position Side Markers Adequate inspiration Exposure/Penetrance3. Soft tissue and bony cage Subcutaneous emphysema, fractures4.Trachea Position, Outline5. Heart and Mediastinum Shape , Size, Displacement6.Diaphragms Outline ,Shape , Relative position7.Pleural spaces Position of horizontal fissure, costophrenic and cardiophrenic angles8.Lungs Local , generalized abnormalities, comparison of translucency and vascular marking sof the lungs
  12. 12. 9.Hidden areas Apices, Posterior sulcus, Mediastinum, Hila, Bones10. Hila Density, Position, Shape11. Below the Diaphragm Gas shadows, Calcification
  13. 13. PA VIEW AP VIEW• Chin up , shoulders rotated • Taken in cases when patient forward, taken in full is too ill to stand inspiration• With plate in front of chest • Film is placed behind the and back to the X-ray back and x-ray exposure machine from front .• Scapula away from the • Scapula closer to the lung upper lung fields fields• Clavicles less apically • Clavicles less apically displaced displaced• Vertebral neural arches • Vertebral disc spaces seen seen better • Relative cardiomegaly
  14. 14. Technical aspects of viewing a PA film• Centering – medial ends of clavicle equidistant from spinous process at t4/5- always look for gastric bubble,aortic arch and heart to confirm normal situs.• Penetration – disc spaces+vertebral bodies visible down to t8/9• Degree of Inspiration – full inspiration ant. Ends of 6th rib or post ends of the 10th rib on right hemidiaphragm. On expiration larger cardiac shadow and basal opacity due to crowding of normal vascular markings.
  15. 15. Trachea• Upper part- midline• Lower part- deviates slightly around aortic knuckle- marked on expiration• Left bronchus not clearly visualized due to aorta• 25mm in males , 21 mm in females• Right paratracheal stripe- 60% N- 5mm• Angle of carina- 60 -75 degrees
  16. 16. Mediastinum and Heart• Mediastinum, Heart, Spine , Sternum• Cardiothoracic ratio – less than 50% in PA and less than 60% in AP. Increased in AP and expiration• Right and Left heart borders formed• Thymus- triangular Sail shaped structure – Wave sign of Mulvey
  17. 17. Diaphragm• Right higher than left• Normal position of diaphragm, higher in supine• Curves which steepen towards chest wall- costophrenic angles are acue• Cardiophrenic angles may be blunted due to presence of fat pads
  18. 18. The Fissures• Horizontal fissure seen often incompletely running from the hilum to the region of the sixth rib• Fissures seen clearly seen on lateral view• Accessory fissure- Azygos fissure comma shaped right sided triangular based peripherally
  19. 19. Lungs• Hidden areas- Apices, Mediastinum and hila, Diaphragms, Bones• Hila- 97% left higher than right., Clearly defined borders –concave lateral borders- mainly formed by pulmonary areteries and upper lobe veins. Lymph nodes not normal• Bronchovascular markings seen upto – 2/3rd of the lung field• Lymphatics – normally not seen
  20. 20. Lung zones• When describing the lungs divide them into three zones - upper, middle and lower.• Each of these zones occupies approximately one third of the height of the lungs.• The lung zones do not equate to the lung lobes.• Upper zone- from 2nd costal cartilage to axilla• Middle zone- between 2nd and 4th costal cartilage.• Lower zone- below 4th costal cartilage.
  21. 21. Lymph Nodes• Bronchopulmonary( hilar) nodes – appear as hilar masses• Carinal nodes- widening of the carinal angle• Tracheobronchial nodes- right paramedian stripe• Anterior, Posterior, Paratracheal, parietal
  22. 22. Below the diaphragm• Gas• Chilaiditis syndrome
  23. 23. Soft tissue and Bony Cage• Breasts may partially obscure the lungs.• Skin folds tend to be confused with consolidation as they overlap the lung fields• Sternum• Clavicle• Scapulae• Ribs- rib notching• Spine- check bone and rib destruction
  24. 24. ABCDEFGHI!!• Bones and Soft tissue• Airway• Cardiac Silhouette, Mediastinum.• Diaphragms• Effusion• Fields of lung• Gastric Air Bubble• Hilum• Instruments.
  25. 25. Line shadowsBy: Michelle Rasiah
  26. 26. Introduction• Normal blood vessels and fissures form linear shadows• Certain lung diseases also form linear shadows• Linear shadow  < 5 mm wide• Band shadow  > 5 mm thick
  27. 27. Causes for linear shadows• Kerley’s lines• Plate-like atelectasis• Pulmonary infarcts• Thickened fissures• Pulmonary / pleural scars• Bronchial wall thickening• Sentinel lines• Curvilinear shadows• Anamolous vessels• Artefacts• Bronchoceles
  28. 28. Kerley lines• Pulmonary lymphatics are usually not visible• Lymphatics drain the interstitial fluid and foreign particles• They run in the interlobular septa and drain to the hilum• Thickened lymphatics and surrounding connective tissue = Kerley lines• Divided into 3 types – Kerley A lines – thickened deep septa – Kerley B lines – thickened interlobular septa – Kerley C lines
  29. 29. Formation of Kerley B lines Acinus  5 - 6 mm in diameter  alveoli, alveolar duct, resp. bronchiole 3 - 5 acini = secondary pulmonary lobule Each lobule is separated by septa (interlobular septa) Thickening of these septa = Kerley B lines
  30. 30. Types Kerley A line Kerley B line Kerley C lineThin Thin, transverse, faint FineNon branching Non branching Interlacing lines2 – 6 cm long 1 -3 cm long Seen throughout lung1 – 2 mm thick 1- 2 mm thick “Spider web” like appearanceRadiating from hila Lateral part of lung base extending to pleura (common in costophrenic angle)not following course of Frequently seen than A &Cartery, vein or bronchi lines Lines arranged in step ladder like pattern (0.5 to 1 cm apart) ALWAYS perpendicular to pleural surface
  31. 31. • Kerley B lines can be: Transient Persistent Pulmonary edema Dilated lymphatics Chronic interstitial edema Hemosiderin dust deposition Interstitial fibrosis• They are present in the base of the lung due to hydrostatic pressure and gravity
  32. 32. Disk atelectasis Impaired diaphragmatic motion UnderventilationCollapse of small pulmonary sub divisions Fleischner line formation
  33. 33. Differentiation Fleischner’s lines Kerley B lines Linear scarsFewer in number (1 -2) More in number May show fine strands emanating from bordersIrregularly placed Regularly placed (0.5 to 1 Associated pleural effusion cm gaps)Located deep in lung Superficial PermanentThicker Thin
  34. 34. Thickening of fissures
  35. 35. Mucous filled bronchi
  37. 37. • Nodular lesions could be classified as1. solitary pulmonary nodules2. Multiple pulmonary nodules• Solitary nodule is defined as an x-ray density completely surrounded by normal aerated lung with circumscribed margins of any shape usually 1- 6cm in greatest diameter.• If its <3cm → ‘Coin lessions’• If > 3cm → massesCannon ball lesions:Multiple nodules, widely disseminated,usually multiple, clearly demarcated 1- 2cm in diameter circular shadows throughout the lung fields (characteristic of secondary deposits)Milliary shadows : Multiple small shadows 2-4mm in diameter
  38. 38. Solitary pulmonary nodule causesMalignant• Primary nodule• Secondary nodule• Lymphoma• Plasmacytoma• Alveolar cell carcinomaBenign• Hamartoma• Adenoma• Connective tissue tumoursGranuloma• Tuberculosis• Histoplasmosis• Paraffinoma• Sarcoidosis
  39. 39. Infection• Round pneumonia• Abscess• Hydatid• Amoebic• Fungi• ParasitesOthers• Pulmonary haematoma, Pulmonary infarct• Collagen diseases-Rheumatoid arthritis, Wegeners granulomatosis• Congenital-Bronchogenic cyst, Sequestrated segmen,Congenital bronchial atresia , AVM• impacted mucus• Amyloidosis, Intrapulmonary lymph node• Pleural- fibroma, tumor, loculated fluid
  40. 40. Multiple nodulesTumours• Benign-hamartoma, laryngeal papillomatosis• Malignant-metastases, lymphomaInfection• Granuloma-tuberculosis, histoplasmosis, fungi i• Round pneumonia• Abscesses• Hydatid cystsInflammatory• Caplans syndrome• Wegeners granulomatosis• Sarcoidosis• Drugs
  41. 41. Vascular• Arteriovenous malformations• Haematomas• InfarctsMiscellaneous• Mucus impaction• Amyloidosis
  42. 42. Multiple nodules –canonball appaernace (choriocarcnoma)Metastatic lesions
  43. 43. Miliary TB
  44. 44. Tuberculoma: It appears Round or oval, sharply circumscribed nodule that isseldom more than 4 cm in diameter. Central calcification and satellitelesions are common, as is calcification of hilar lymph nodes. This X-ray shows :Single smooth, well-defined pulmonary nodule in the left upper lobe. In the absence of a central nidus of calcification, this appearance is indistinguishable from that of a malignancy.
  45. 45. TUBERCULOMA:(A) Frontal and (B) lateral views of the chest show a largeleft lung soft-tissue mass (arrows) containing dense central calcification
  46. 46. Rheumatoid nodulesLarge nodules in pulmonary parenchyma bilaterallypresent, discrete similar to opacities of metastatic lesions –Rhuematoid arthritis
  47. 47. Bronchogenic CarcinomaCarcinoma of bronchus. A large, round soft-tissue mass ispresent at the right apex. Blunting of the right costophrenic angle is due toa small pleural effusion.
  48. 48. Hamartoma-popcorn calcification
  49. 49. Histoplasmosis-calcifiedgranuloma(coin lesion)
  50. 50. Pulmonary infarctionChest radiograph with ‘classical’ Chest X ray after 4 days, priorappearance of a pulmonary infarction – to treatment, showing massivea wedge-shaped lesion peripherally set increase in volume of lesion.against the pleura
  51. 51. Lung abscess (air fluid level)
  52. 52. Alveolar Shadows Neena S
  53. 53. Air-space (Acinar/alveolar) pattern• When distal airways and alveoli are filled with fluid, whether it is a transudate, exudate or blood, acinus forms a nodular 4-8mm shadow.• These coalesce into fluffy ill-defined round or irregular cotton-wool shadows.• Non-segmental, homogenous or patchy, but frequently well defined adjacent to fissures.
  54. 54. Cont…• Vascular markings usually obscured locally.• Air bronchogram and silhouette sign are characteristic• Ground-glass appearance of generalised homogenous haze with a “bat’s wing” or “butterfly” perihilar distribution may be seen, sparing the peripheral lungs.
  55. 55. Silhouette Sign• An intrathoracic lesion touching a border of the heart, aorta, or diaphragm will obliterate that border on the radiograph.• An intrathoracic lesion not anatomically continous with a border of one of these structures will not obliterate that border.• Eg. Lower lobe pneumonia, disease of lingula
  56. 56. Causes of air space filling• Pulmonary edema • Alveolar blood – Cardiac – Non-cardiac – Pulmonary haemorrhage • Hypoalbuminemia – Goodpasture’s syndrome • Uraemia – Pulmonary infarction • ARDS • Tumours • Mendelson’s syndrome • Heroin overdose – Alveolar cell carcinoma• Infections – Lymphoma, leukaemia – Localised – Metastatic adenocarcinoma – Generalised eg. Pneumocystis, parasites, fungi • Miscellaneous• Neonatal – Alveolar proteinosis – Aspiration – Eosinophilic lung – Hyaline membrane disease – Sarcoidosis – Amyloidosis – Wegener’s granulomatosis – Allergic bronchopulmonary aspergillosis
  57. 57. Pulmonary Edema• Produces air space opacities with variable distribution.• Sparing of the apices and extreme lung bases.• “Butterfly” or “Bat wings” distribution – central lungs affected more.• With progression – opacities coalesce to form a “white-out” on chest radiograph.• Blurring of blood vessels occurs.• Air bronchogram – indicating intra alveolar edema.
  58. 58. picture
  59. 59. Radiologic signs of collapse Preethi .N.B
  60. 60. The term collapse is used when a whole lobe or lung is involved.Atelectesis is defined as diminished volumeaffecting all or part of a lung, whichmay or maynot include loss of normal lucency in the affectedpart of lung .Pulmonary atelectasis can be divided into sixtypes, based on mechanism: resorptive, adhesive,compressive, passive, cicatrization, and gravity-dependent
  61. 61. LOBAR ATELECTASISRadiologic signs of lobar atelectasis :- Director Indirect .Direct signs include increased opacificationof the airless lobe and displacement offissures.
  62. 62. Indirect signs include displacement of hilar andcardiomediastinal structures toward the side ofcollapse, narrowing of the ipsilateral intercostalspaces, elevation of the ipsilateralhemidiaphragm, compensatory hyperinflationand hyperlucency of the remaining aeratedlung, and obscuration or desilhouetting of thestructures adjacent to the collapsed lung(eg, diaphragm and heart borders). Additionalradiologic features vary according to the site ofatelectasis.
  63. 63. RADIOLOGY OF PLEURAL DISEASES Nikitha James 080201018
  64. 64. PLEURAL EFFUSION• Pleural effusion initially manifests as basal peripheral opacities that first fill the costo- phrenic angle.
  65. 65. Curve Of Ellis
  66. 66. Massive Pleural Effusion
  67. 67. Pneumothorax• Chest X-ray PA view shows – Sharply defined edge of the deflated lung – Complete translucency between the lung and the chestwall.
  68. 68. Tension Pneumothorax
  70. 70. Consolidation Consolidation- replacement of air in one or more acini by fluid or solid material, but does not imply a particular pathology or etiology. Communications between the terminal airways allows fluid to spread between adjacent acini- responsible for larger area of involvement Commonest causes  Acute inflammatory exudate from pneumonia.  Non cardiogenic pulmonary oedema  Cardiogenic pulmonary oedema  Hemorrhage  Aspiration
  71. 71. Radiologic features AIR BRONCHOGRAM- contrast between the column of air which is present in the airway and the surrounding opaque acini Normally the lung fields are radioluscent and the bronchi are not separately visualised But when, there is opacification of the alveoli due to various reasons (eg: fluid accumulation is pulmonary oedema)the bronchi stand out as radiolucent in contrast to the adjacent alveoli that are radio opaque
  72. 72. an x-ray for a patient with right middlezone consolidation and demonstrates air bronchograms
  73. 73. Silhouette sign: If the airspace adjacent to one of the normal mediastinal or diaphragmatic contours is filled with dense material i.e. consolidated, then the normal air-soft tissue interface is lost and the normally seen edge of the silhouette disappears
  74. 74. .
  75. 75. Upper lobe consolidation
  76. 76. Middle and Lower lobe consolidation
  77. 77. Left lower lobe consolidation
  78. 78. Chest X Ray in Mediastinal Lesions Manasa
  79. 79. • On the lateral radiograph• drawing an imaginary line anterior to the trachea and posteriorly to the inferior vena cava.• The middle and posterior compartments can be separated by an imaginary line passing 1 cm posteriorly to the anterior border of the vertebral bodies.
  80. 80. • Approximately 60% of all mediastinal masses arise in the anterior mediastinum, 25% appear in the posterior mediastinum, and 15% occur in the middle mediastinum• Most masses (> 60%) are: – Thymomas – Neurogenic Tumors – Benign Cysts – Lymphadenopathy• In children the most common (> 80%) are: – Neurogenic tumors – Germ cell tumors – Foregut cysts• In adults the most common are: – Lymphomas – Lymphadenopathy – Thymomas – Thyroid masses
  81. 81. Superior mediastinum• origins of the Sternohyoid and Sternothyroid• the aortic arch• the innominate artery• the thoracic portions of the left common carotid and the left subclavian arteries• the innominate veins• the upper half of the superior vena cava• the left highest intercostal vein• the vagus, cardiac, phrenic, and left recurrent nerves; the trachea, esophagus, and thoracic duct;• the remains of the thymus, and• some lymph glands
  82. 82. LUNG MASS OR MEDIASTINAL MASS ?• A lung mass abutts the mediastinal surface and creates acute angles with the lung, while a mediastinal mass will sit under the surface creating obtuse angles with the lung
  83. 83. Anterior Mediastinum• loose areolar tissue,• some lymphatic vessels which ascend from the convex surface of the liver,• two or three anterior mediastinal lymph glands• small mediastinal branches of the internal mammary artery.
  84. 84. Anterior MediastinumSignsObliterated retrosternal clear spaceObliterated cardiophrenic angleHilum overlay sign
  85. 85. • Hilum Overlay Sign• When there is a mediastinal mass and you still can see the hilar vessels through this mass, then you know the mass does not arise from the hilum. This is known as the hilum overlay sign. Because of the geometry of the mediastinum most of these masses will be located in the anterior mediastinum.
  86. 86. • The four Ts make up the mnemonic for anterior mediastinal masses:• Thymoma (myasthenia, upper anterior mediatinum)• Teratoma (germ cell)• Thyroid• Terrible Lymphoma
  87. 87. THYMOMA• thymoma
  88. 88. LYMPHOMA
  89. 89. Middle MediastinumIt contains• The heart enclosed in the • the bifurcation of the pericardium trachea and the two• the ascending aorta bronchi• the lower half of the • the phrenic nerves superior vena cava with • some bronchial lymph the azygos vein opening glands. into it• the pulmonary artery dividing into its two branches• the right and left pulmonary veins
  90. 90. Middle MediastinumSignsWidened paratracheal stripesAP window massDisplaced azygoesophageal recess on the rightLateral ‘doughnut’
  91. 91. • Adenopathy Infection (fungal and mycobacterial) Neoplasm (bronchogenic carcinoma, metastases, lymphoma, leukemia) Sarcoidosis• Aneurysm/vascular• Abnormalities of development Bronchogenic cyst Pericardial cyst Esophageal duplication cyst
  92. 92. • Saccular aortic aneurysm
  94. 94. Posterior Mediastinum• Thoracic part of the descending aorta• the azygos and the two hemiazygos veins• the vagus and splanchnic nerves,• the esophagus• the thoracic duct• some lymph glands.
  95. 95. Common • Mesenchymal tumor• Neural tumors (fibroma, lipoma, leiomyoma• Neurogenic , hemangioma, lymphangio (neuroblastoma, ganglioneu ma) roma, ganglioneuroblastom • Abscess a) • Pancreatic pseudocyst• Nerve root tumors • Esophageal varices (schwannoma, neurofibrom • Hematoma a, malignant schwannoma)Less common • Traumatic• Paraganglionic cell tumors • pseudomeningocele (chemodectoma, pheochro • Bochdalek hernia mocytoma) • Extramedullary• Spinal tumor hematopoiesis (metastases, primary bone • Descending thoracic aortic tumor) aneurysm• Lymphoma• Invasive thymoma
  96. 96. On conventional radiographs look for:• Cervicothoracic Sign• Widening of the paravertebral stripes
  97. 97. • Cervicothoracic sign• The anterior mediastinum stops at the level of the superior clavicle. Therefore, when a mass extends above the superior clavicle, it is located either in the neck or in the posterior mediastinum. When lung tissue comes between the mass and the neck, the mass is probably in the posterior mediastinum. This is known as the Cervicothoracic Sign.
  98. 98. SCHWANNOMA
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