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Chest Radiography Interpretation

Chest Radiography Interpretation. M Chadi Alraies, MD Chief Medical Resident Case Western Reserve University SVCH. Reading CXR’s. Have a structured method! Be consistent with that method Don’t take short cuts LOOK AT ALL YOUR PATIENTS XRAYS YOURSELF (and with your resident of course!)

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Chest Radiography Interpretation

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  1. Chest Radiography Interpretation M Chadi Alraies, MD Chief Medical Resident Case Western Reserve University SVCH M C Alraies

  2. Reading CXR’s • Have a structured method! • Be consistent with that method • Don’t take short cuts • LOOK AT ALL YOUR PATIENTS XRAYS YOURSELF (and with your resident of course!) • PRACTICE…PRACTICE… PRACTICE

  3. What is a Chest Radiograph? SHADOW

  4. Start at the beginning • Identification! • Correct patient • Correct date and time • Correct examination • Are old films available? • DO THIS EVERYTIME – It buys you time and is vitally important.

  5. Approach to the CXR: Technical Aspects • Projection – PA or AP • Position – Upright or Supine (Supine folks are sick) • Inspiratory effort • 9-10 posterior ribs • Penetration • thoracic intervertebral disc space just visible • Positioning/rotation • medial clavicle heads equidistant to spinous process

  6. Projection

  7. Portable (AP or Antero-posterior) FILM

  8. PA (Postero-anterior) FILM

  9. Projection PA AP

  10. Low Lung Volumes

  11. Proper Exposure Over Exposure

  12. 9

  13. Mental Break

  14. Anatomy RUL RML

  15. RUL (Right Upper Lung)

  16. RML (Right Middle Lung)

  17. RLL (Right Lower Lung)

  18. Right Sided Fissures

  19. LUL (Left Upper Lung)

  20. LLL (Left Lower Lung)

  21. Left Side Fissure LUL LLL

  22. What to Evaluate • Lungs • Pleural surfaces • Cardiomediastinal contours • Bones and soft tissues • Abdomen

  23. Where to Look • Apices • Retrocardiac areas (left and right) • Below diaphragm

  24. Apical TB

  25. Left Retrocardiac Opacity

  26. Normal Anatomy: Frontal CXR • Heart • Aorta • Pulmonary arteries • Airways • Diaphragm/costophrenic sulci

  27. Normal Anatomy: Lateral • Heart • Aorta • Pulmonary arteries • Airways • Spine

  28. Blackest air fat soft tissue calcium bone x-ray contrast metal Whitest Maximum x-ray Transmission (least dense tissue) Maximum x–ray Absorption (densest tissue)

  29. Chest Radiography: Basic Principles • A structure is rendered visible on a radiograph by the juxtaposition of two different densities

  30. Silhouette Sign • Loss of the expected interface normally created by juxtaposition of two structures of different density • No boundary can be seen between two structures of similar density

  31. Right Lower Lobe Pneumonia

  32. Differential X-Ray Absorption • The absence of a normal interface may indicate disease; • The presence of an unexpected interface may also indicate disease • The presence of interfaces can be used to localize abnormalities

  33. Chest Radiographic Patterns of Disease • Air space opacity • Interstitial opacity • Nodules and masses • Lymphadenopathy • Cysts and cavities • Lung volumes • Pleural diseases

  34. LUL Pneumonia

  35. Air Space Opacity • Components: • air bronchogram: air-filled bronchus surrounded by airless lung • confluent opacity extending to pleural surfaces • segmental distribution

  36. Air Space Opacity: DDX • Blood (hemorrhage) • Pus (pneumonia) • Water (edema) • hydrostatic or non-cardiogenic • Cells (tumor) • Protein/fat: alveolar proteinosis and lipoid pneumonia

  37. Interstitial Opacity: Small Nodules

  38. Interstitial Opacity: Lines

  39. Interstitial Opacity: Lines & Reticulation

  40. Interstitial Opacity • Hallmarks: • small, well-defined nodules • lines • interlobular septal thickening • fibrosis • reticulation

  41. Interstitial Opacity: DDX • Idiopathic interstitial pneumonias • Infections (TB, viruses) • Edema • Hemorrhage • Non–infectious inflammatory lesions • sarcoidosis • Tumor

  42. Well-Defined Calcification Mass Ill-Defined

  43. Nodules and Masses • Nodule: any pulmonary lesion represented in a radiograph by a sharply defined, discrete, nearly circular opacity 2-30 mm in diameter • Mass: larger than 3 cm

  44. Nodules and Masses • Qualifiers: • single or multiple • size • border definition • presence or absence of calcification • location

  45. Right Paratracheal Lymphadenopathy

  46. Right Hilar LAN

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