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Chest x ray basic interpretation
- 1. JSS Medical College, Mysuru Basic Interpretation of Chest X-Ray Dr.Vikram Patil Assistant Professor, Radiology JSS Medical College and Hospital, Mysuru
- 2. JSS Medical College, Mysuru Air Fat Soft tissue Bone Metal least opaque to most opaque most lucent to least lucent Black to White Different tissues in our body absorb X-rays at different extents Before we start : 5 Radiographic Densities
- 3. JSS Medical College, Mysuru Before Interpreting the Radiograph … 1. Patient identification details 2. X-Ray view-PA or AP…. 3. Breath : Inspiration or Expiration 4. X-ray penetration : Under or Over penetrated 5. Rotation
- 4. JSS Medical College, Mysuru PA view AP view Scapula Seen in periphery of thorax Seen over lung fields Clavicles Project over lung fields Above the apex of lung fields Ribs Posterior ribs distinct Anterior ribs are distinct Marker PA AP View
- 5. JSS Medical College, Mysuru Inspiration Expiration Good Inspiration: • 6 anterior ribs visible • 10 posterior ribs visible
- 6. JSS Medical College, Mysuru Penetration Over-penetrated Under-penetrated If intervertebral disc are very clearly seen in the film If intervertebral disc are not seen in the film Correct exposure : Barely able to see the intervertebral disc through the heart
- 7. JSS Medical College, Mysuru Rotation
- 8. JSS Medical College, Mysuru Normal Lateral ViewNormal PA view Normal Radiograph
- 9. JSS Medical College, Mysuru ABCDEFGHI approach • Airway • Bones and Soft tissue • Cardia • Diaphragm • Effusions • Fields(Lung fields) • Gastric Bubble • Hila and mediastinum • Impression
- 10. JSS Medical College, Mysuru A-Airway
- 11. JSS Medical College, Mysuru B-Bones and Soft Tissues
- 12. JSS Medical College, Mysuru C-Cardia
- 13. JSS Medical College, Mysuru T CR CL CT RATIO = CR + CL / T CR + CL = TRANSVERSE CARDIAC DIAMETER T = TRANSVERSE THORACIC DIAMETER (at max TC dia) C-Cardia
- 14. JSS Medical College, Mysuru D-Diaphragm
- 15. JSS Medical College, Mysuru E-Effusions(Pleura)
- 16. JSS Medical College, Mysuru F-Lung Fields
- 17. JSS Medical College, Mysuru Lobar anatomy
- 18. JSS Medical College, Mysuru Lobar anatomy..
- 19. JSS Medical College, Mysuru Hidden Areas….
- 20. JSS Medical College, Mysuru Gastric Bubble
- 21. JSS Medical College, Mysuru H-Hilum and mediastinum
- 22. JSS Medical College, Mysuru Mediastinum
- 23. JSS Medical College, Mysuru Abnormal Chest X-ray • Radiopacity (whiteness) = increased density • Radiotranslucency (blackness) = decreased density
- 24. JSS Medical College, Mysuru Radio-opacity • Without Volume loss – Pneumonia, Pulmonary edema, hemorrhage, mass • With Volume loss – Atelectasis, Collapse
- 25. JSS Medical College, Mysuru Lobar Pneumonia • Involves single lobe • Unilateral • Air bronchogram Interstitial Pneumonia •Involves interstitial space •Ground glass appearance •Bilateral, symmetrical Bronchopneumonia •Central bronchi involved •Patchy bilateral disease •Asymmetrical •Peribronchial cuffing
- 26. JSS Medical College, Mysuru Subtypes of Interstitial opacities Reticular Too many lines Nodular Too many dots Reticulo-nodular Too many lines and dots
- 27. JSS Medical College, Mysuru Silhouette Sign • Loss of normally visible border of an intrathoracic structure caused by an adjacent pulmonary density
- 28. JSS Medical College, Mysuru Atelectasis- partial collapse Lobar collapse -collapse of an entire lobe •Elevation of the ipsilateral hemidiaphragm •Crowding of the ipsilateral ribs •Shift of the mediastinum towards the side •Crowding of pulmonary vessels or air bronchograms •Hyperinflation of adjacent normal lung
- 29. JSS Medical College, Mysuru Golden S sign • Central mass obstructing the upper lobe bronchus . • Should raise suspicion of a primary Bronchogenic Carcinoma • First described by R Golden
- 30. JSS Medical College, Mysuru Sarcoidosis Staging I Bilateral Hilar adenopathy II Bilateral Hilar adenopathy with diffuse pulmonary infiltrates III Diffuse pulmonary infiltrates without hilar adenopathy IV Severe fibrosis
- 31. JSS Medical College, Mysuru Lung Malignancy
- 32. JSS Medical College, Mysuru NF Mets Nipple shadow
- 33. JSS Medical College, Mysuru Effusions …. Meniscus sign + Subpulmonic effusion Hydropneumothorax Phantom tumor
- 34. JSS Medical College, Mysuru Pleural … Tubercular Pleurisy Asbestosis Mesothelioma
- 35. JSS Medical College, Mysuru Loculated Empyema
- 36. JSS Medical College, Mysuru Complete U/L Lung agenesis
- 37. JSS Medical College, Mysuru Pulmonary Arterial Hypertension Enlargement of the pulmonary trunk and main pulmonary arteries Disproportionately small peripheral vessels Oligemic lungs Prune tree appearance
- 38. JSS Medical College, Mysuru Pulmonary Venous Hypertension Upper lobe veins in first intercostal space >3mm Interstitial edema with Kerley B lines Airspace edema with confluent airspace opacities PCWP mildly increased PCWP around 20 PCWP around 25
- 39. JSS Medical College, Mysuru Pulmonary Edema ARDS Distribution Bat winged pattern Diffuse bilateral coalescent opacities Time Develops over 1 week Develops by 12-24 hrs of insult Cardia Cardiomegaly No Cardiomegaly Kerley lines Present Absent Pleural effusions Usually Present Usually absent Air Bronchogram Present Absent On Diuretic Therapy Usually resolves Fairly constant over time Pulm Edema vs ARDS
- 40. JSS Medical College, Mysuru Radiotranslucency
- 41. JSS Medical College, Mysuru Pneumothorax
- 42. JSS Medical College, Mysuru Tension Pneumothorax Inspiratory Film Expiratory Film
- 43. JSS Medical College, Mysuru Cavity Thin wall-TB <4mm Thick wall-Malignancy >16mm Air crescent sign-Aspergilloma Air fluid level-Abscess
- 44. JSS Medical College, Mysuru Emphysema • Hyperinflation: – Flattened hemi-diaphragms: most reliable sign – Increased radiolucency of the lungs – Increased retrosternal airspace – Increased antero-posterior diameter of chest – Widely spaced ribs
- 45. JSS Medical College, Mysuru Congenital Lobar Emphysema
- 46. JSS Medical College, Mysuru Air at Unusual Locations Subcutaneous Emphysema Perforation Pneumomediastinum Pneumopericardium
- 47. JSS Medical College, Mysuru ICU- Tubes & Lines Tip at Junction of SVC & Right atrium
- 48. JSS Medical College, Mysuru Mediastinal abnormalities • Hilum overlay sign: On a frontal Chest X-ray, Mass projected at the level of the hilum is either anterior or posterior to the hilum.
- 49. JSS Medical College, Mysuru Posterior mediastinal mass Spine Sign Cervicothoracic sign Mediastinal masses
- 50. JSS Medical College, Mysuru EXTRAMEDULLARY HEMATOPOESIS • Smooth lobular mass in paravertebral gutter, in lower thorax • Bilateral and symmetrical • Due to compensatory expansion of marrow in congenital hemolytic anaemia Thoraco-abdominal sign: Lesion extends below the dome of diaphragm-Lesion in the posterior chest Lesion terminates at the dome –Lesion in the anterior chest
- 51. JSS Medical College, Mysuru Hiatus Hernia with gastric volvulus
- 52. JSS Medical College, Mysuru Looks Normal????
- 53. JSS Medical College, Mysuru Coarctation of aorta
- 54. JSS Medical College, Mysuru Kartegeners Syndrome
- 55. JSS Medical College, Mysuru Take home message • Look carefully for patient identification details and technical issues • Be systematic in approach • It’s a chest X-ray, not a lung x-ray. • Concentrate on hidden areas • Compare with old films and lateral films
- 56. JSS Medical College, Mysuru This presentation will be made available on www.jssmcradiology.com Thank you
Editor's Notes
- Ensure trachea is visible and in midline Trachea gets pushed away from abnormality, eg pleural effusion or tension pneumothorax Trachea gets pulled towards abnormality, eg atelectasis Trachea normally narrows at the vocal cords View the carina, angle should be between 60 –100 degrees Beware of things that may increase this angle, eg left atrial enlargement, lymph node enlargement and left upper lobe atelectasis Follow out both main stem bronchi Check for tubes, pacemaker, wires, lines foreign bodies etc If an endotracheal tube is in place, check the positioning, the distal tip of the tube should be 3-4cm above the carina Check for a widened mediastinum Mass lesions (eg tumour, lymph nodes) Inflammation (eg mediastinitis, granulomatous inflammation) Trauma and dissection (eg haematoma, aneurysm of the major mediastinal vessels)
- Usually positioned with one-third of its diameter to the right, and two-thirds to the left of the thoracic vertebrae spinous processes. The right atrium makes up the right heart border and the left ventricle the left heart border. Poor distinction of the right heart border suggests consolidation of the right middle lobe. Poor distinction of the left heart border suggests lingular consolidation. Cardiothoracic ratio (CTR): Compares the transverse diameter of the heart to the internal thoracic diameter (inner aspect of the ribs) at its widest point. Should be less than 0.5 (50%) on a PA CXR, but may appear magnified on AP films. Abnormally increased CTR occurs with ventricular dilatation (usually left), cardiac failure and a pericardial effusion.
- The right is usually higher than the left by 1–3 cm. Pleural effusions will blunt the costophrenic angles. Loss of diaphragmatic outline indicates fluid, consolidation or collapse of adjacent lung (i.e. of the right or left lower lobe). Both hemidiaphragms are flat in chronic obstructive limitation disease such as emphysema. Free gas under a diaphragm on an erect film indicates rupture of an abdominal hollow viscus, such as the duodenum or small or large intestine. It also occurs after laparoscopy with the deliberate introduction of a pneumoperitoneum.
- evel with the T6–7 intervertebral space on either side of the mediastinum, and are made up of the pulmonary arteries and veins. The left hilum is usually higher (2cm) and squarer than the V-shaped right hilum. Unilateral or bilateral hilar enlargement can be caused by Enlarged hilar lymph nodes (e.g. sarcoidosis or infection) Hilar malignancy (e.g. small-cell carcinoma) Vascular disease (e.g. pulmonary hypertension or proximal pulmonary artery aneurysms). Superior mediastinum:Should have a width <8 cm on a PA CXR. A widened mediastinum can be associated with: AP CXR view, which magnifies the heart and mediastinal structures Unfolded aortic arch (not pathological) or a thoracic aortic aneurysm Mediastinal lymphadenopathy, retrosternal thyroid, thymoma (can be particularly massive in children) Paravertebral mass, oesophageal dilatation Ruptured aorta in deceleration trauma from vehicle crash or fall from a height. Look for evidence of mediastinal emphysema (abnormal air) secondary to: Penetrating wound ± lacerated lung Perforation of oesophagus or trachea Asthma and whooping cough (pneumomediastinum).
- Frontal chest radiograph showing a questionable mass near the right cardiophrenic angle
- Except in the case of very advanced disease with bulla formation, chest radiography does not image emphysema directly, but rather infers the diagnosis due to associated features 2-3: It should be remembered, however, that the most common plain film appearance of COPD is "normal" and the role of chest radiography is to eliminate other causes of lung symptoms such as infection, bronchiectasis or cancer
- Multiple rib fractures complicated by left hemidiaphragm injury, left pneumothorax (treated by drain) and widespread surgical emphysema (tracking subcutaneous air)