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Chest X-Ray Review. SYMPTOMS : Bad or persistent cough Chest pain Chest injury Coughing up blood Fever Shortness of breath S/P fall. Why order a CXR?. Pleural effusion Pneumothorax Hemothorax Pulmonary embolus Trauma Monitoring chest drainage TB. Lung cancer Chest pain (MI?)
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SYMPTOMS: Bad or persistent cough Chest pain Chest injury Coughing up blood Fever Shortness of breath S/P fall Why order a CXR?
Pleural effusion Pneumothorax Hemothorax Pulmonary embolus Trauma Monitoring chest drainage TB Lung cancer Chest pain (MI?) Hypertension Screening Pneumonia COPD Asthma Why order a CXR?
Normal Chest X-Ray Compare symmetry Review organs (bones, lungs, heart) in sequence Left to Right then… Top to Bottom Random free search Recognition of abnormal first requires knowledge of normal. Over diagnosis of normal variation may be more serious than omission & may lead to needless & harmful therapy.
Chest X-RayFindings • Is heart enlarged or normal? • Signs of heart failure and fluid overload? • Does patient have pneumonia or collapsed lung? • Is there evidence of emphysema? • Are there findings of an aortic aneurysm? • Is there fluid in the sac that surrounds the lung? • Is there free air under the diaphragm? • Is there a tumor in the lung that could represent cancer?
Systematically evaluate chest wall, mediastinum, lungs, pleural space, heart, large arteries, ribs & diaphragm. Also evaluate neck, axilla, thyroid gland & abdomen The Normal Chest X-Ray What does air under diaphragm signify? What is best position for this diagnosis?
You can recognize air, water & bone density on chest x-ray Lung fields appear dark because of air. 99% of the lung is air. The Normal Chest X-Ray
The pulmonary vasculature, interstitial space, constitutes 1% of the lung Gives a lacy lung pattern. Most disease states replace air with a pathological process which usually is a liquid density and appears white. The Normal Chest X-Ray
Supine position Decreases lung volume, increased heart size Basilar infiltrates & interstitial spaces accentuated Increases venous return to the heart Semi-upright position Enlarges normal structures Changes air-fluid levels Failure to hold breath Lung structures & diaphragm blurred Expiration film Basilar infiltrates & interstitial spaces accentuated Increased heart size Poor Quality CXR
What is wrong with this lung tissue??? Missed Diagnoses 10% of all x-ray interpretations have errors Nothing!! But the clavicle is fractured! Especially if there are multiple problems, don’t focus on the most obvious abnormality!
IDENTIFICATION Correct patient Correct date & time Correct examination Right vs. Left side Comparison film TECHNIQUE Complete exam? All views Entire anatomical area included? Projection Is the film AP or PA? The width of heart & mediastinum larger on AP film Position Systematic CXR Interpretation
TECHNIQUE, cont. Penetration Over-penetrated dark films can obscure subtle pathologies Under-penetrated white films may given impression of diffuse increased density Systematic CXR Interpretation • TECHNIQUE, cont. • Inspiration • Normal, erect, inspiratory CXR shows 9.5-10.5 ribs. • Less inspiration appears diffusely denser • Diaphragms elevated causing heart & mediastinum to appear enlarged
Systematic CXR Interpretation • Order of exam is important. • Start with "less significant" • Tendency to stop looking as soon as find pathology • Identify atelectasis behind heart shadow! • Don’t notice tip of ET tube is in right main stem bronchus, causing the atelectasis!
Systematic CXR Interpretation • TECHNIQUE, cont. • Rotation • Determined by distance between spinous process & medial clavicle • Affects heart size & shape, aortic tortuosity, mediastinal widening, density of lung fields
Systematic CXR Interpretation • INTERPRETATION • Extraneous material • Contrast • Lines, tubes, clips • All properly located? • Soft tissues • Asymmetry • Calcifications • Diaphragms & Below • Free air • Dilated bowel • Abnormal position • INTERPRETATION • Bones • Fracture, dislocation • Mineralization • Lung fields • Asymmetry • Consolidation • Nodules, lesions • Heart • Size & shape • Cardiothoracic ratio
Systematic CXR Interpretation • INTERPRETATION • Pulmonary vascularity • Taper at periphery • Narrow toward upper lobes with erect film • Asymmetry • Interstitial markings • Very fine • If indistinct, prominent suspect edema, fibrosis • INTERPRETATION • Mediastinum • Width • Masses • Contour • Hila • Asymmetry • Vessel aneurysm • Trachea & carina
CONSOLIDATION • Alveolar space filled with inflammatory exudate • WBC, bacteria, plasma, and debris
Congestive Heart Failure • Increased heart size: cardiothoracic ratio >0.5 • Large hila with indistinct markings • Fluid in interlobar fissures • Pleural effusions, alveolar edema
ARDS • Congestion • Interstitial and alveolar edema • Collapsed or distended alveoli • Bilateral
SARCOIDOSIS • Granulomatous Inflammation • Bilateral & symmetrical hilar & mediastinal LAD • Generalized fibrosis
ATELECTASIS • No ventilation to lobe beyond the obstruction • Trapped air absorbed by pulmonary circulation • Segmental/lobar density • Compensatory hyper-inflation of normal lungs.
