HOW READ CHEST XR -1    ANAS SAHLE ,MD
1. Technical Quality                             OUTLINE2. look at the mediastinal3. look at the lungs4. diaphragm5. Soft ...
Technical Quality
RPPIIs the film centered? RotationIs it PA or AP film ? PositioningIs it exposed properly ? PenetrationIs it a good inspir...
observing the clavicular heads    determining whether they areequal distance fromthe spinous process   of the thoracic  ve...
Is this filmcentered?
Is this filmcentered?
Why do you have to know whether  the film is centered or not ?   Difficult to evaluatethe position of      Mediastinum if ...
RPPIIs the film centered? RotationIs it PA or AP film ? PositioningIs it exposed properly ? PenetrationIs it a good inspir...
If the scapulae no longer overlie the lung fields               then the film is PAIf the scapulae overlie the lung fields...
Why do you have to know whether       it is PA or AP film?
The PA (posterioranterior)       Positioning                Note that the x-ray                 tube is 72 inches         ...
The Supine AP (anteriorposterior) positionNote that the x-ray tube is 40 inches”111.76 cm” from    the patient
Heart appears larger
Mediastinum widens
Diaphragms are    higher
Pulmonary vesselssize is same in upperand lower lung fields
RPPIIs the film centered? RotationIs it PA or AP film ? PositioningIs it exposed properly ? PenetrationIs it a good inspir...
The thoracic spine   disc spaces should be barelyvisible through the        heart
Bony details of the      spineare not usually seen
On the other hand  penetration is  sufficient thatbronchovascular    structurescan usually be seenthrough the heart
Normal Penetrated   An overpenetrated    PA film              PA film
Normal Penetrated   underpenetrated PA    PA film                film
RPPIIs the film centered? RotationIs it PA or AP film ? PositioningIs it exposed properly ? PenetrationIs it a good inspir...
The   diaphragm    should befound at about  the level of the 8th - 10th  posterior rib  or 5th - 6thanterior rib on      g...
Why Do You Have To Know         Whether  It Is Good Inspiration   Or Poor Inspiration?
Mediastinum  appears   wider
Heart size appears  larger
Lung bases   look  whiter(mistaken for interstitial  disease)
look at the lungs
Scan both    lungsstarting at the  apices andworking downcomparing left with right atthe same level
The lungsextend behind  the heart     solook here too
Compare and    contrast    vascular  markings inupper vs. lowerlung fields in PA      view
List conditions, where vascular markings are           prominent in upper lung fields• Mitral stenosis• Congestive heart f...
Compare and    contrast    vascular   markings in outer third vs.inner two thirds    of lungs
increased markings in outer third of lung fields?                                increased                             pul...
increased markings in outer third of lung fields?•    In :    2. Interstitial disease    3. Lymphangitic malignant spread ...
Fissures
The MinorFissure divides   the Right Middle Lobefrom the Right  Upper Lobe     and issometimes not   well seen
Localizing lesions
The position of lesioncan be described in terms of           zones
To accurately localize a lesion on chest X rayyou need to look at both the PA and lateral                     films
First look at the    PA film
The upper zone lies above the anteriorborder of the 2nd rib
The middle zone lies between the right anterior borders of the 2nd and 4th ribs
The lower zone lies between the right anterior border ofthe 4th rib and the    diaphragm
It does not give anyinformation about the    lobes of the lung
Look at the borders of the lesion• If the lesion is next to a dense (white)  structure then the border between the  lesion...
This is calledthe silhouette     sign               RML                              lingula                              ...
Now look at the  lateral film
Identify the oblique fissure• (pass obliquely downwards from the T4/T5  vertebrae through the hilum ending at the  anterio...
Identify the horizontal fissure• (pass horizontally from the midpoint of the  hilum to the anterior chest wall)
If the lesion lies posterior to the oblique fissure it           must lie within the lower lobe
If the lesion lies anterior to the oblique fissure it        may be in the upper or middle lobe
If the lesion is below the horizontal fissure it is in                   the middle lobe
If the lesion is above the horizontal fissure it is in                   the upper lobe
There is no middle lobe on the left
The white lesion
LungThe white lesion                   pleura
parenchymaLung      Airway       Pneumonectomy
Consolidation       is another term for      air space shadowing                             Alveolar spaceparenchyma     ...
Alveolar space             Consolidationparenchyma              interstitial
CollapseAlveolar space                 air spaces filling
Loss of volume of part of the lung
On the PA film:The right lung should be larger than the left  If it is not suspect an area of right sided                 ...
The major (Primary) sign     opacification of the     affected lobe due to          airlessness
The major (Primary) sign     displacement of the      interlobar fissure
The Secondary signs   displacement of the  mediastinal structures
The Secondary signs   The right diaphragmshould be higher than theleft (the difference should     be less than 3cm)       ...
The Secondary signsdecrease in the distanceof the intercostals spaces
The Secondary signs displacement of the hila
The Secondary signs     compensatory   overinflation of the     remaining lung
The heart border should be distinct If the lung adjacent to the heart is collapsed  then the heart border will appear blur...
Atelectasis Right Upper Lobe
Atelectasis Right Upper Lobe
Atelectasis Right Upper Lobe
Homogenous        Atelectasis Right Upper Lobe density right upper lung field.Mediastinal shift to right.Loss of silhou...
RML Atelectasis
Vague density in right lower lung field (almost a normal film).                    RML                  Atelectasis
Dramatic RML atelectasis in lateral view,Movement of transverse fissure.Other findings include:Azygous lobe           ...
RML Lateral Segment    Atelectasis
RML Lateral Segment    Atelectasis
RLL Atelectasis
Right lower lobe atelectasis
Complete atelectasis of the right lung
Atelectasis Left Upper Lobe
Mediastinal shift to left.Density left upper lung field.Loss of aortic knob and left hilar silhouettes.                ...
A:Forwardmovementof obliquefissureC:AtelectaticLULB:Herniatedright lung              Atelectasis Left Upper Lobe
Bowing     sign•LUL atelectasis or following resection•The oblique fissure bows forwards
Bowing sign
Left Lower Lobe Atelectasis
Inhomogeneous cardiac density.Triangular retrocardiac density.Left hilum pulled down.                        Atelectasi...
Left Lower Lobe Atelectasis
•Lateralleftdiaphragmnot visible•Increaseddensityover lowerspine              Left Lower Lobe Atelectasis
Atelectasis Left Lung
How read chest xr 1
How read chest xr 1
How read chest xr 1
How read chest xr 1
How read chest xr 1
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How read chest xr 1

  1. 1. HOW READ CHEST XR -1 ANAS SAHLE ,MD
  2. 2. 1. Technical Quality OUTLINE2. look at the mediastinal3. look at the lungs4. diaphragm5. Soft tissues and bones
  3. 3. Technical Quality
  4. 4. RPPIIs the film centered? RotationIs it PA or AP film ? PositioningIs it exposed properly ? PenetrationIs it a good inspiration film? Inspiration
  5. 5. observing the clavicular heads determining whether they areequal distance fromthe spinous process of the thoracic vertebral bodies
  6. 6. Is this filmcentered?
  7. 7. Is this filmcentered?
  8. 8. Why do you have to know whether the film is centered or not ? Difficult to evaluatethe position of Mediastinum if the film is not centered
  9. 9. RPPIIs the film centered? RotationIs it PA or AP film ? PositioningIs it exposed properly ? PenetrationIs it a good inspiration film? Inspiration
  10. 10. If the scapulae no longer overlie the lung fields then the film is PAIf the scapulae overlie the lung fields then the film is AP
  11. 11. Why do you have to know whether it is PA or AP film?
  12. 12. The PA (posterioranterior) Positioning Note that the x-ray tube is 72 inches “182.88 cm” away
  13. 13. The Supine AP (anteriorposterior) positionNote that the x-ray tube is 40 inches”111.76 cm” from the patient
  14. 14. Heart appears larger
  15. 15. Mediastinum widens
  16. 16. Diaphragms are higher
  17. 17. Pulmonary vesselssize is same in upperand lower lung fields
  18. 18. RPPIIs the film centered? RotationIs it PA or AP film ? PositioningIs it exposed properly ? PenetrationIs it a good inspiration film? Inspiration
  19. 19. The thoracic spine disc spaces should be barelyvisible through the heart
  20. 20. Bony details of the spineare not usually seen
  21. 21. On the other hand penetration is sufficient thatbronchovascular structurescan usually be seenthrough the heart
  22. 22. Normal Penetrated An overpenetrated PA film PA film
  23. 23. Normal Penetrated underpenetrated PA PA film film
  24. 24. RPPIIs the film centered? RotationIs it PA or AP film ? PositioningIs it exposed properly ? PenetrationIs it a good inspiration film? Inspiration
  25. 25. The diaphragm should befound at about the level of the 8th - 10th posterior rib or 5th - 6thanterior rib on good inspiration
  26. 26. Why Do You Have To Know Whether It Is Good Inspiration Or Poor Inspiration?
  27. 27. Mediastinum appears wider
  28. 28. Heart size appears larger
  29. 29. Lung bases look whiter(mistaken for interstitial disease)
  30. 30. look at the lungs
  31. 31. Scan both lungsstarting at the apices andworking downcomparing left with right atthe same level
  32. 32. The lungsextend behind the heart solook here too
  33. 33. Compare and contrast vascular markings inupper vs. lowerlung fields in PA view
  34. 34. List conditions, where vascular markings are prominent in upper lung fields• Mitral stenosis• Congestive heart failure• Alpha one antitrypsin deficiency
  35. 35. Compare and contrast vascular markings in outer third vs.inner two thirds of lungs
  36. 36. increased markings in outer third of lung fields? increased pulmonary flow• In: 1. Left to right shunts (ASD, VSD, PDA)
  37. 37. increased markings in outer third of lung fields?• In : 2. Interstitial disease 3. Lymphangitic malignant spread 4. CHF with increased lymphatic flow
  38. 38. Fissures
  39. 39. The MinorFissure divides the Right Middle Lobefrom the Right Upper Lobe and issometimes not well seen
  40. 40. Localizing lesions
  41. 41. The position of lesioncan be described in terms of zones
  42. 42. To accurately localize a lesion on chest X rayyou need to look at both the PA and lateral films
  43. 43. First look at the PA film
  44. 44. The upper zone lies above the anteriorborder of the 2nd rib
  45. 45. The middle zone lies between the right anterior borders of the 2nd and 4th ribs
  46. 46. The lower zone lies between the right anterior border ofthe 4th rib and the diaphragm
  47. 47. It does not give anyinformation about the lobes of the lung
  48. 48. Look at the borders of the lesion• If the lesion is next to a dense (white) structure then the border between the lesion and that structure will be lost
  49. 49. This is calledthe silhouette sign RML lingula LLL RLL LLL
  50. 50. Now look at the lateral film
  51. 51. Identify the oblique fissure• (pass obliquely downwards from the T4/T5 vertebrae through the hilum ending at the anterior third of the diaphragm)
  52. 52. Identify the horizontal fissure• (pass horizontally from the midpoint of the hilum to the anterior chest wall)
  53. 53. If the lesion lies posterior to the oblique fissure it must lie within the lower lobe
  54. 54. If the lesion lies anterior to the oblique fissure it may be in the upper or middle lobe
  55. 55. If the lesion is below the horizontal fissure it is in the middle lobe
  56. 56. If the lesion is above the horizontal fissure it is in the upper lobe
  57. 57. There is no middle lobe on the left
  58. 58. The white lesion
  59. 59. LungThe white lesion pleura
  60. 60. parenchymaLung Airway Pneumonectomy
  61. 61. Consolidation is another term for air space shadowing Alveolar spaceparenchyma interstitial
  62. 62. Alveolar space Consolidationparenchyma interstitial
  63. 63. CollapseAlveolar space air spaces filling
  64. 64. Loss of volume of part of the lung
  65. 65. On the PA film:The right lung should be larger than the left If it is not suspect an area of right sided collapse
  66. 66. The major (Primary) sign opacification of the affected lobe due to airlessness
  67. 67. The major (Primary) sign displacement of the interlobar fissure
  68. 68. The Secondary signs displacement of the mediastinal structures
  69. 69. The Secondary signs The right diaphragmshould be higher than theleft (the difference should be less than 3cm) elevation of the hemidiaphragm
  70. 70. The Secondary signsdecrease in the distanceof the intercostals spaces
  71. 71. The Secondary signs displacement of the hila
  72. 72. The Secondary signs compensatory overinflation of the remaining lung
  73. 73. The heart border should be distinct If the lung adjacent to the heart is collapsed then the heart border will appear blurredRight heart border is Left heart border is blurred blurred RML collapse lingular collapse
  74. 74. Atelectasis Right Upper Lobe
  75. 75. Atelectasis Right Upper Lobe
  76. 76. Atelectasis Right Upper Lobe
  77. 77. Homogenous Atelectasis Right Upper Lobe density right upper lung field.Mediastinal shift to right.Loss of silhouette of ascending aorta.Movement of oblique and transverse fissures.
  78. 78. RML Atelectasis
  79. 79. Vague density in right lower lung field (almost a normal film). RML Atelectasis
  80. 80. Dramatic RML atelectasis in lateral view,Movement of transverse fissure.Other findings include:Azygous lobe RML Atelectasis
  81. 81. RML Lateral Segment Atelectasis
  82. 82. RML Lateral Segment Atelectasis
  83. 83. RLL Atelectasis
  84. 84. Right lower lobe atelectasis
  85. 85. Complete atelectasis of the right lung
  86. 86. Atelectasis Left Upper Lobe
  87. 87. Mediastinal shift to left.Density left upper lung field.Loss of aortic knob and left hilar silhouettes. Atelectasis Left Upper Lobe
  88. 88. A:Forwardmovementof obliquefissureC:AtelectaticLULB:Herniatedright lung Atelectasis Left Upper Lobe
  89. 89. Bowing sign•LUL atelectasis or following resection•The oblique fissure bows forwards
  90. 90. Bowing sign
  91. 91. Left Lower Lobe Atelectasis
  92. 92. Inhomogeneous cardiac density.Triangular retrocardiac density.Left hilum pulled down. Atelectasis Left Lower Lobe
  93. 93. Left Lower Lobe Atelectasis
  94. 94. •Lateralleftdiaphragmnot visible•Increaseddensityover lowerspine Left Lower Lobe Atelectasis
  95. 95. Atelectasis Left Lung

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