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How read chest xr 2

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cxr read practical approche

How read chest xr 2

  1. 1. HOW READ CHEST XR -2 ANAS SAHLE ,MD
  2. 2. Technical Quality
  3. 3. RPPIIs the film centered? RotationIs it PA or AP film ? PositioningIs it exposed properly ? PenetrationIs it a good inspiration film? Inspiration
  4. 4. observing the clavicular heads determining whether they areequal distance fromthe spinous process of the thoracic vertebral bodies
  5. 5. RPPIIs the film centered? RotationIs it PA or AP film ? PositioningIs it exposed properly ? PenetrationIs it a good inspiration film? Inspiration
  6. 6. 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
  7. 7. RPPIIs the film centered? RotationIs it PA or AP film ? PositioningIs it exposed properly ? PenetrationIs it a good inspiration film? Inspiration
  8. 8. Normal Penetrated An overpenetrated PA film PA film
  9. 9. Normal Penetrated underpenetrated PA PA film film
  10. 10. RPPIIs the film centered? RotationIs it PA or AP film ? PositioningIs it exposed properly ? PenetrationIs it a good inspiration film? Inspiration
  11. 11. The diaphragm should befound at about the level of the 8th - 10th posterior rib or 5th - 6thanterior rib on good inspiration
  12. 12. look at the lungs
  13. 13. Scan both lungsstarting at the apices andworking downcomparing left with right atthe same level
  14. 14. Compare and contrast vascular markings inupper vs. lowerlung fields in PA view
  15. 15. List conditions, where vascular markings are prominent in upper lung fields• Mitral stenosis• Congestive heart failure• Alpha one antitrypsin deficiency
  16. 16. Compare and contrast vascular markings in outer third vs.inner two thirds of lungs
  17. 17. increased markings in outer third of lung fields? increased pulmonary flow• In: 1. Left to right shunts (ASD, VSD, PDA)
  18. 18. increased markings in outer third of lung fields?• In : 2. Interstitial disease 3. Lymphangitic malignant spread 4. CHF with increased lymphatic flow
  19. 19. Fissures
  20. 20. Localizing lesions
  21. 21. The position of lesioncan be described in terms of zones
  22. 22. To accurately localize a lesion on chest X rayyou need to look at both the PA and lateral films
  23. 23. First look at the PA film
  24. 24. The upper zone lies above the anteriorborder of the 2nd rib
  25. 25. The middle zone lies between the right anterior borders of the 2nd and 4th ribs
  26. 26. The lower zone lies between the right anterior border ofthe 4th rib and the diaphragm
  27. 27. It does not give anyinformation about the lobes of the lung
  28. 28. 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 lostThis is calledthe silhouette sign
  29. 29. Now look at the lateral film
  30. 30. Lateral Positioning
  31. 31. A brief look at the lateral CXR Key points• There should be adecrease in densityfrom superior toinferior in theposterior mediastinum.• The retrosternalairspace should beof the same densityas the retrocardiacairspace.
  32. 32. Identify the oblique fissure• (pass obliquely downwards from the T4/T5 vertebrae through the hilum ending at the anterior third of the diaphragm)
  33. 33. Identify the horizontal fissure• (pass horizontally from the midpoint of the hilum to the anterior chest wall)
  34. 34. If the lesion lies posterior to the oblique fissure it must lie within the lower lobe
  35. 35. If the lesion lies anterior to the oblique fissure it may be in the upper or middle lobe
  36. 36. If the lesion is below the horizontal fissure it is in the middle lobe
  37. 37. If the lesion is above the horizontal fissure it is in the upper lobe
  38. 38. There is no middle lobe on the left
  39. 39. POSITION PA AP QUALITY ROTATION PENETRATION INSPIRATION LESION Homo HeterogenousDensityinfiltration necrotic Zone Centralperipheral Silhouet sign MEDIASTINAL Central deviasionwided COSTO-PHRENIC ANGEL Freeoblitern OTHER Bone soft tissuediaphragm
  40. 40. CASE-1This elderlymale hadrecent onsetof streakyhemoptysis.?
  41. 41. POSITION •AP CXRQUALITY •Poor Technical Quality •homogeneous density in the right upper zoneLESION , elevation of the transverse fissure •Central trachea and mediasteinalMEDIASTINAL •Free costo-phrenic angelsANGELS •NOOTHER
  42. 42. S sign• homogeneous density in the right upper zone• elevation of the transverse fissure ( Instead of the transverse fissure being straight)• there is a bulge at the medial end giving it an inverted S shape.• Golden described this sign and the explanation for it is that the upper lobe collapse is due to a right hilar mass which accounts for the medial bulge
  43. 43. 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.
  44. 44. Case-2This middle-agedfemale complained of:•Hemoptysis•loss ofweighttwo months’ duration.
  45. 45. POSITION •PA CXRQUALITY •Poor Technical Quality •(poor penetration). •hazy, veil-like opacificationLESION •in the left upper zone,obscured aortic arc,from hilar to peripheral •Central trachea and mediasteinalMEDIASTINAL •Obscured left costo-phrenic angelsANGELS •Elevate left hemidiaphragm •NOOTHER
  46. 46. Illustration• The CXR shows evidence of left upper lobe collapse.• There is a hazy, veil-like opacification in the left upper lobe, which does not have a sharp inferior margin unlike right upper lobe collapse.• This is because there is usually no left transverse fissure and the lobe collapses anteriorly..• There is also volume loss in the left hemithorax as evidenced by an elevated left hemidiaphragm and crowding of the left upper ribs.• Sometimes the trachea may also be deviated to the same side and the aortic knuckle may be obscured by the collapse
  47. 47. Mediastinal shift to left.Density left upper lung field.Loss of aortic knob and left hilar silhouettes. Atelectasis Left Upper Lobe
  48. 48. A:Forwardmovementof obliquefissureC:AtelectaticLULB:Herniatedright lung Atelectasis Left Upper Lobe
  49. 49. Bowing sign•LUL atelectasis or following resection•The oblique fissure bows forwards
  50. 50. Bowing sign
  51. 51. CASE-3• 50-year-old female with a past history of tuberculosis had• chronic cough over the past year.
  52. 52. POSITION •PA CXRQUALITY •GOOD Technical Quality •NoLESION •Left lung smaller than right •Left deviation trachea andMEDIASTINAL mediasteinal •Obscured left costo-phrenic angelsANGELS •Elevate left hemidiaphragm •NOOTHER
  53. 53. Inhomogeneous cardiac density.Triangular retrocardiac density.Left hilum pulled down. Atelectasis Left Lower Lobe
  54. 54. •Lateralleftdiaphragmnot visible•Increaseddensityover lowerspine Left Lower Lobe Atelectasis

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