Chest Radiograph for Interns

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Reported by Cristal Ann Laquindanum
Chest Radiograph for Interns
TMC Radiology Department

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  • The less dense an object is, the fewer xrays it absorbs, and the blacker it wll appearAir attenuates very little of the xray beam, allowing nearly full force of the beam to blacken the image. Fat, and soft tissues attenuate interediate amounts of the xray beam , resulting in proportional degrees of image blackening (shades of gray) radiation than thin structures iBone, metal, and radiographic contrast agents attenuate a large proportion of the xray beam, allowing very little radiation through to blacken the image. Thus, bone and metallic objects and structures opacified by xray contrast agents appear white on radiographs. Bone is densest naturally occurring tissue. It absorbs the greatest amount of xray and appears white on radiographs.Metal is even denser than bone and essentially absorbs all xrays, but unless you have bullets or artifical hip replacements, metal doesn’t naturally occur in humans
  • Underpenetration – mimic or hide true disease of left lower lung field (lower lobe pneumonia, left pleural effusion)Overpenetration – mistakenly think patient has emphysema or pneumothorax; pulmonary nodule may be invisible
  • In an AP film, the heart is farther from the film and is more magnifiedPortable chest x-rays are almost always done AP
  • In an AP film, the heart is farther from the film and is more magnifiedPortable chest x-rays are almost always done AP
  • Anterior structures (like the clavicles) will be projected higher on the film than posterior structures
  • A film which is apical lordotic (beam is angled up toward head) will have an unusually shaped heart and the sharp border of the left hemidiaphragm will be absentAnterior structures (like the clavicles) will be projected higher on the film than posterior structureshis projectionresults in clear visualization of the lung apices because the clavicle and first rib are projected above the pulmonary apex
  • Right – minor fissure separates upper and middle lobe. Major fissure middle lobe and lower lobeRight upper lobe – anterior apical and posteriorMiddle lobe – medial and lateralRight lower lobe – anterior, lateral, posterior and medialLeft – upper and lower lobes by left major fissure Left upper lobe is analogous to the combined right upper and middle , anterior, apicoposterior, superior and inferior lingular segmentsLeft lower lobe – anteromedial, lateral and posterior
  • Airways, including hilaradenopathy or enlargementBreast shadowsBones, e.g. rib fractures and lytic bone lesionsCardiac silhoutte, detecting cardiac enlargementCostophrenic angles, including pleural effusionsDiaphragm, e.g. evidence of free airEdges, e.g. apices for fibrosis, pneumothorax, pleural thickening or plaquesExtrathoracic tissuesFields (lung parenchyma), being evidence of alveolar fillingFailure, e.g. alveolar air space disease with prominent vascularity with or without pleural effusions
  • Airways, including hilaradenopathy or enlargementBreast shadowsBones, e.g. rib fractures and lytic bone lesionsCardiac silhoutte, detecting cardiac enlargementCostophrenic angles, including pleural effusionsDiaphragm, e.g. evidence of free airEdges, e.g. apices for fibrosis, pneumothorax, pleural thickening or plaquesExtrathoracic tissuesFields (lung parenchyma), being evidence of alveolar fillingFailure, e.g. alveolar air space disease with prominent vascularity with or without pleural effusions
  • Airways, including hilaradenopathy or enlargementBreast shadowsBones, e.g. rib fractures and lytic bone lesionsCardiac silhoutte, detecting cardiac enlargementCostophrenic angles, including pleural effusionsDiaphragm, e.g. evidence of free airEdges, e.g. apices for fibrosis, pneumothorax, pleural thickening or plaquesExtrathoracic tissuesFields (lung parenchyma), being evidence of alveolar fillingFailure, e.g. alveolar air space disease with prominent vascularity with or without pleural effusions
  • DeviationFBET Tube
  • Airways, including hilaradenopathy or enlargementBreast shadowsBones, e.g. rib fractures and lytic bone lesionsCardiac silhoutte, detecting cardiac enlargementCostophrenic angles, including pleural effusionsDiaphragm, e.g. evidence of free airEdges, e.g. apices for fibrosis, pneumothorax, pleural thickening or plaquesExtrathoracic tissuesFields (lung parenchyma), being evidence of alveolar fillingFailure, e.g. alveolar air space disease with prominent vascularity with or without pleural effusions
  • Airways, including hilaradenopathy or enlargementBreast shadowsBones, e.g. rib fractures and lytic bone lesionsCardiac silhoutte, detecting cardiac enlargementCostophrenic angles, including pleural effusionsDiaphragm, e.g. evidence of free airEdges, e.g. apices for fibrosis, pneumothorax, pleural thickening or plaquesExtrathoracic tissuesFields (lung parenchyma), being evidence of alveolar fillingFailure, e.g. alveolar air space disease with prominent vascularity with or without pleural effusions
  • Airways, including hilaradenopathy or enlargementBreast shadowsBones, e.g. rib fractures and lytic bone lesionsCardiac silhoutte, detecting cardiac enlargementCostophrenic angles, including pleural effusionsDiaphragm, e.g. evidence of free airEdges, e.g. apices for fibrosis, pneumothorax, pleural thickening or plaquesExtrathoracic tissuesFields (lung parenchyma), being evidence of alveolar fillingFailure, e.g. alveolar air space disease with prominent vascularity with or without pleural effusions
  • Airways, including hilaradenopathy or enlargementBreast shadowsBones, e.g. rib fractures and lytic bone lesionsCardiac silhoutte, detecting cardiac enlargementCostophrenic angles, including pleural effusionsDiaphragm, e.g. evidence of free airEdges, e.g. apices for fibrosis, pneumothorax, pleural thickening or plaquesExtrathoracic tissuesFields (lung parenchyma), being evidence of alveolar fillingFailure, e.g. alveolar air space disease with prominent vascularity with or without pleural effusions
  • Newborn infantAP diameter of the thorax is greater compared with the tranverse diameter than in adultsDiaphragm is higher, vertical diameter of the thoracic cavity relatively less than in the adultWith growth, chest becomes narrower and ribs gradually angulate downward from horizontal position Thymus is often large enough in early infancy to produce widening of the superior mediastinum -bilobed structure located in the anterior mediastinum that can cause considerable confusion simulate cardiomegaly, upper-lobe pneumonia, and atelectasis. Additionally, it can appear as a pathologic mass if it is aberrant in locationHeart is globular and is relatively large in comparison with the diameter of the chest than in adultsLeft ventricle becomes more prominent with age, resulting in downward displacement of the apex, and the relatively heart size gradually decreasesLungs more radiolucent than in the adult because the pulmonary interstitium usually is not visible., tracheal bifurcation gradually descends and reaches the adult level (T5) at about 10 yrs old The hilar shadows are relatively high and usually are situated at the level of the third thoracic vertebra.Diaphragm tends to be higher in infancy and childhood than in adult life; opposite to adult that left hemidiaphragm higher than the right (stomach is distended with air)
  • Two substances of the same density, in direct contact, cannot be differentiated from each other on x-rayCommon locationsLower lobes-diaphragmsRight heart border – RMLLeft heart border – LingulaLeft diaphragm – Heart (on lateral view)
  • Chest Radiograph for Interns

    1. 1. Chest Radiograph <br />For Interns <br />Reported by: Cristal Ann G. Laquindanum<br /> ASMPH Class of 2012<br />
    2. 2. References<br />Brant and Helm’s<br />Paul and Juhls<br />Learningradiology.com<br />Clinical Radiology Made Ridiculously Simple<br />School lectures<br />
    3. 3. Outline<br />Normal Chest Radiograph – adult and pediatric<br />Requirement for chest xray film<br />Anatomy<br />Common pathologies – pleural effusion, pneumothorax, pneumonia, PTB<br />
    4. 4. BACKTO*radiology*BASICS<br />
    5. 5. More dense = More Xrays = WHITER / radioopaque<br />Less dense = Less Xrays = BLACKER / radiolucent<br />
    6. 6. Is it good enough? <br />Recognizing a TECHNICALLY ADEQUATE chest radiograph<br />
    7. 7. Penetration <br />Inspiration<br />Rotation<br />Magnification<br />Angulation<br />Factors to Evaluate: <br />
    8. 8. Penetration<br />You should be able to see the thoracic spine through the heart <br />
    9. 9. Underpenetration<br />> Left hemidiaphragm may not be visible on the frontal film; left lung base may appear opaque<br />> Pulmonary markings may appear more prominent<br />Overpenetration<br />> Lung markings may seem decreased or absent<br />
    10. 10. Inspiration<br />
    11. 11. Rotation<br />If the spinous process of the vertebral body is equidistant from the medial ends of each clavicle, there is NO rotation<br />
    12. 12. If the spinous process appears closer to the right clavicle (redarrow), the patient is rotated toward their own left side<br />If the spinous process appears closer to the left clavicle (redarrow), the patient is rotated toward their own right side<br />
    13. 13. Severe rotation may make the pulmonary arteries appear larger on the side farther from the film<br />
    14. 14. Magnification<br />vs<br />PA <br />AP <br />
    15. 15. AP <br />AP vs PA <br />
    16. 16. PA <br />AP vs PA <br />
    17. 17. Angulation<br />If the x-ray beam is angled toward the head (mostly because the patient is semi-recumbent), the film so obtained is called an “apical lordotic” view <br />
    18. 18. Clavicles<br />Unusually shaped heart<br />
    19. 19. Penetration see spine through the heart<br />Inspiration at least 8-9 posterior ribs<br />Rotation spinous process between clavicles<br />Magnification AP films will slightly magnify the heart<br />Angulation clavicle over 3rd rib<br />Factors to Evaluate: <br />
    20. 20. How to read a Chest Xray:<br /> Basics<br /> Technically Adequate<br />☐ Anatomy<br />
    21. 21.
    22. 22.
    23. 23. Trachea<br />Upper Lobes<br />Aortic knob<br />Left <br />Pulmonary Artery<br />Right<br />Atrium<br />Left <br />Ventricle<br />Lower Lobes<br />
    24. 24.
    25. 25. Trachea<br />Upper Lobes<br />Aortic knob<br />Carina<br />Left <br />Pulmonary Artery<br />Right<br />Atrium<br />Left <br />Ventricle<br />Lower Lobes<br />Costophrenic Angle<br />Gastric bubble<br />
    26. 26. Upper lobes<br />Right<br />middle lobe<br />Lower lobes<br />Lingula<br />
    27. 27. RADIOLOGY<br />
    28. 28. Airway (trachea)<br />Bones (clavicles, ribs)<br />Cardiomediastinalsilhoutte<br />Diaphragms (and the costophrenic angles) <br />Everything Else (lung fields, soft tissues, tubes, lines, wires, devices, etc)<br />
    29. 29. Airway (trachea)<br />
    30. 30.
    31. 31. Bones (clavicles, ribs)<br />
    32. 32.
    33. 33. Cardiomediastinalsilhoutte<br />
    34. 34. Cardiomediastinalsilhoutte<br />
    35. 35. Diaphragms (and the costophrenic angles) <br />
    36. 36. Diaphragms (and the costophrenic angles) <br />
    37. 37. Everything Else (lung fields, soft tissues, tubes, lines, wires, devices, etc)<br />
    38. 38.
    39. 39. Lungs more radiolucent<br />Thymus is often large,<br />Widening of superior mediastinum<br />Ribs angulate downward<br />Heart is globular and large<br />Left ventricle more prominent with age<br />Diaphragm is higher<br />Left > Right<br />
    40. 40. Pathologies<br />Pleural effusion<br />Atelectasis<br />Pneumothorax<br />Pneumonia<br />Pulmonary Tuberculosis<br />
    41. 41. Pleural Effusion<br />complete opacification of the right mid and lower zones is due to fluid in the pleural cavity<br />meniscus sign - concavity of the fluid level due to surface tension with the pleura<br />Blunting of costophrenic angle may be due to a small pleural effusion or focal pleural thickening.<br />May coexist with pneumothorax or entrapped within fissures mimicking a tumor.<br />Right pleural effusion in a patient with nephrotic syndrome<br />The flattened and laterally displaced curvature of the right hemidiaphragm indicates presence of subpulmonic pleural fluid<br />
    42. 42. Pleural Effusion<br />Patient cannot stand? <br />lateral decubitus<br />Ultrasound or CT thorax as alternative modalities for early detection of small pleural effusion. <br />Ultrasound advantage: no radiation; can be used to guide drainage<br />CT advantage: evaluate the underlying lung and mediastinal structures to identify the cause of the effusion<br />
    43. 43. Pneumothorax<br />Pneumothorax represents abnormal air accumulation within pleural cavity. This may be due to trauma (accidental or iatrogenic), underlying pulmonary disease (e.g. asthma) or idiopathic in origin<br />Erect chest radiograph in full expiration is diagnostic in majority of cases<br />If the patient is unable to stand erect, lateral decubitus view may be helpful<br />
    44. 44. Pneumothorax<br />Radiologic Findings:<br />Contralateral mediastinalshift<br />Depression of ipsilateralhemi-diaphragm<br />Compressive atelectasis of adjacent normal lung<br />presence of significant increased intrathoracic pressure<br />Role of imaging in patients with pneumothorax:<br />1. Confirm the clinical diagnosis<br />2. Assess extent of pneumothorax <br />3. Detect signs of tension<br />4. Follow-up examination to monitor resolution of pneumothorax after drainage<br />
    45. 45. The right lung (white open arrows) has been pushed medially. The mediastinum is shifted to the left (black arrow). This appearance is typical of tension pneumothorax.<br /> Magnified view of a PA chest radiograph of a right pneumothorax. The visceral pleura (arrow heads) is seen as a thin white line. <br />
    46. 46. Pneumonia<br />Role of imaging in patients with pneumonia<br />1. Confirm the clinical diagnosis<br />2. Detect possible complications such as pleural effusion / empyema or lung abscess if clinically not responsive to appropriate antibiotic treatment<br />3. Follow-up CXR to monitor response to treatment <br />may take 4-6 weeks for consolidative changes to resolve<br />Radiologic improvement usually lags behind clinical improvement<br />If radiologic signs still present after adequate treatment, underlying predisposing factors have to be excluded (e.g. central obstructive carcinoma in elderly patients)<br />
    47. 47. Pneumonia<br /><ul><li>Air bronchogram sign- The inflammatory exudate within air-spaces and interstitium of the affected lung causes the opacification and air-filled bronchioles outlined by adjacent fluid-filled alveoli in affected lung
    48. 48. Visualization of air in the intrapulmonary bronchi
    49. 49. Abnormal
    50. 50. Denotes a pulmonary lesion/consolidation (excludes a pleural or mediastinal lesion)
    51. 51. Seen in pneumonia, pulmonary edema or pulmonary infarct </li></ul>Silhouette <br />sign<br />
    52. 52. Pneumonia<br />Pneumonia caused by certain organisms may produce characteristic radiologic features<br />Unilateral lobar involvement in streptococcus infection<br />Bilateral patchy involvement sometimes with cavitation in staphylococcus pneumonia<br />Upper lobe involvement with cavitation in pulmonary TB<br />Bilateral symmetrical perihilar distribution which progresses rapidly over 3-5 days in PCP pneumonia in immunocompromised patients<br />
    53. 53. Bilateral patchy involvement sometimes with cavitation in staphylococcus pneumonia<br />
    54. 54.
    55. 55. Upper lobe involvement with cavitation in pulmonary TB<br />
    56. 56. Bilateral symmetrical perihilar distributionPCP pneumonia in immunocompromisedpatients<br />
    57. 57. Pulmonary Tuberculosis<br />Radiologic Findings in PTB<br />Cavitation and air-fluid level- the opacity represents caseous necrosis in tuberculosis<br />Enlarged hilum– representinggranulomatous inflammation of lymph nodes, usually in primary TB<br />Fibrocalcificchanges in lung apex usually representing healing of previous TB infection<br />Multi-focal air-space opacities representing bronchogenic spread of infection<br />Tiny miliary nodules in both lungs representing miliary TB due to haematogenous spread of infection<br />
    58. 58.
    59. 59.
    60. 60. CASE PRESENTATION<br />
    61. 61. AM, 5year old female <br />CC: fever and cough<br />HPI: 6 days PTC – on and off fever (Tmax 39) + headache<br />3 days PTC – abdominal pain, consult done and was given Cefaclor and Ventolin expectorant<br />Morning PTC – symptoms persisted, one episode of post-tussive vomiting, decreased appetite  admission<br />HISTORY<br />
    62. 62. PAST MEDICAL HISTORY<br />TMC – Dengue and UTI – Oct 2010<br />VRMC – Pneumonia 2006<br />BIRTH HISTORY<br />Born full term via NSD to a 30 year old G2P2 (2002) <br />no fetomaternal complications<br />VACCINATION HISTORY<br />Only BCG, DPT, HepB, MMR x1, no HiB<br />
    63. 63. NUTRITIONAL HISTORY<br />Breastfed until 2 months, on milk formula until 15 months<br />Weaning at months, food preference fish<br />FAMILY HISTORY <br />unremarkable<br />
    64. 64. BP 90/60 , RR 30 , HR 118 , Temp 39.5 <br />Harsh breath sounds, equal chest expansion, rales R>L, no wheezes, no alar flaring, no retractions<br />Hyperactive bowel sounds, epigastric tenderness<br />Tachycardic, normal rhythm<br />PHYSICAL EXAMINATION<br />
    65. 65. PCAP C <br />IMPRESSION <br />
    66. 66. CBC - normal<br />Chest Xray (PA/Lat)<br />DIAGNOSTICS<br />
    67. 67. Patches of hazed densities are noted in the right middle lobe, bordered superiorly by the minor fissure. <br />Hazy densities are likewise seen in the posterior segment of the right lower lobe. <br />The pulmonary vascular pattern is within normal.<br />Cardiac shadow is normal in size and configuration.<br />The retrosternal and retrocardiac spaces are intact.<br />The diaphragm, costophrenic sulci, and the bony thorax are unremarkable.<br />Consider Pneumonia with beginning consolidation, right<br />
    68. 68. Patches of hazed densities are noted in the right middle lobe, bordered superiorly by the minor fissure. <br />Hazy densities are likewise seen in the posterior segment of the right lower lobe. <br />The pulmonary vascular pattern is within normal.<br />Cardiac shadow is normal in size and configuration.<br />The retrosternal and retrocardiac spaces are intact.<br />The diaphragm, costophrenic sulci, and the bony thorax are unremarkable.<br />Consider Pneumonia with beginning consolidation, right<br />
    69. 69. Admitted<br />VS q4<br />DAT<br />Monitor I&O<br />D5Nm 1 L x 69-70 cc/hr (M+10)<br />Paracetamol 250mg/5mL q4<br />Amoxicillin 250mg/5mL at 40mkd<br />Currently on 3rd hospital stay<br />MANAGEMENT<br />
    70. 70. That’s all Folks! <br />

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