Más contenido relacionado


Chest X rays.pptx

  1. Interpretation of Chest X-Rays Chair Person : Dr. Muralidhar Presenter : Dr. Akash Jain
  2. Introduction • Chest X-rays are the most commonly used radiographic imaging by physicians. • Chest X-rays should always be used in conjunction with the clinical findings. • Always compare with previous X-rays whenever available.
  3. Relative Densities: • The hierarchy of relative densities from least dense (Black) to most dense (white) : • Gas (air in the lungs) • Fat (fat layer in soft tissue) • Water (same density as heart and blood vessels) • Bone (the most dense of the tissues) • Metal (foreign bodies)
  4. Factors Determine the technical quality of the Radiograph: • Inspiration • Penetration property • Rotation
  5. Inspiration • The chest radiograph should be obtained with the patient in full inspiration to help assess intrapulmonary abnormalities • At full inspiration, 6 anterior ribs, 10 posterior ribs are seen and the right hemi-diaphragm should be observed at about the level of the 8th to 10th rib posteriorly, or the 5th to 6th rib anteriorly.
  6. Anatomical Part Inspiration Expiration Superior Mediastinum Normal Magnified Trachea Straight May be buckled Heart Normal size Magnified Lungs Fully expanded Partially expanded Broncho-vascular markings Well spread out Crowded Diaphragm Lowest Highest Rib Cage Anterior ends lower Anterior and posterior same level Lung Volume Normal Reduced
  7. Penetration Property • On a properly exposed chest radiograph: • The lower thoracic vertebrae should be visible through the heart • The broncho vascular structures behind the heart(trachea, aortic arch, pulmonary arteries, etc.) should be seen.
  8. Underexposure In an under exposed chest radiograph, the cardiac shadow is opaque, with little or no visibility of the thoracic vertebrae. The lungs may appear much denser and whiter, gives appearance of infiltrates.
  9. Overexposed With greater exposure of the chest radiograph, the heart becomes more radiolucent and the lungs become proportionately darker. Often gives the appearance of lacking lung tissue, as would be seen in a condition such as emphysema.
  10. Rotation • Patient rotation can be assessed by observing the clavicular heads and determining whether they are equal distance from the spinous processes of the thoracic vertebral bodies.
  11. Chest X-Ray Views 1. Posterior-anterior(PA) 2. Lateral 3. Anterior-posterior(AP) 4. Lateral Decubitus
  12. Posterior-anterior (PA) Position • The standard position for obtaining a routine adult chest radiograph • Patient stands upright with the anterior wall of chest placed against the front of the film • The shoulders are rotated forward enough to touch the film, ensuring that the scapulae do not obscure a portion of the lung field • Usually taken with the patient in full inspiration • The PA film is viewed as if the patient is standing in front of you
  13. Anterior-Posterior (AP) Position • Used when the patient is debilitated, immobilized, or unable to cooperate with the PA procedure • Film is placed behind the patient’s back with the patient in a supine position • Heart is at a greater distance from the film hence appear more magnified than in a PA • The scapulae are usually visible in the lung fields because they are not rotated out of the view as they are in a PA
  14. Parameter PA View AP View Position Erect Supine Patient’s hands On hips Along the sides Scapula Away from lung fields Over the lung fields Clavicle Project over the lung fields Project above lung apices Ribs Posterior ribs are distinct Anterior ribs are distinct Marker PA AP
  15. Lateral Position • Patient stands upright with the left side of the chest against the film and the arms raised over the head • Allows the viewer to see behind the heart and diaphragmatic dome • Typically used in conjunction with a PA view of the same side of chest to help determine the three-dimensional position of organs or abnormal densities
  16. Lateral Decubitus Position • The patient lies on either the right or left side rather than in the standing position as with a regular lateral radiograph • The radiograph is labeled according to the side that is placed down (a left lateral decubitus radiograph would have the patient's left side down against the film • Often useful in revealing a pleural effusion that cannot be easily observed in an upright view, since the effusion will collect in the dependent position
  17. Approach : ABCDEFGHI
  18. AIRWAY
  20. CARDIA
  22. Normal cardiac contour (PA view and Lateral view)
  23. CT Ratio - Cardiomegaly Adults >0.50 Neonates >0.60 AP film >0.57
  24. LA enlargement Shadow in shadow – early sign Straightening of left heart border Elevation of left main bronchus Splaying of carina (>600 . )
  25. RA enlargement Right border >5.5cms from midline or 3.5cms from right sternal border Spans > 2½ intercostal spaces in its vertical extent Exceeds 1/3rd the total diameter of heart >50% vertical height compared with mediastinal height
  26. LV enlargement (PA view) • LV apex forms an obtuse angle with the diaphragm • Increased CT ratio
  27. LV hypertrophy (PA view) • LV hypertrophy causes only a rounded contour of LV border • Shmoo sign
  28. RV enlargement (PA view) Overall increase in cardiac shadow with a triangular configuration Tilting-up and posterior displacement of LV Apex forms an acute angle with diaphragm
  29. RV enlargement (Lateral view) • Sternal contact sign : Earliest and most sensitive sign • Obliteration of Holtzneck’s space NORMAL
  30. Pulmonary vascularity  Normal  Increased pulmonary blood flow (Plethora)  Decreased pulmonary blood flow (Oligemia)  Pulmonary venous hypertension  Pulmonary arterial hypertension
  31. Normal pulmonary vasculature 1 2 3 1) RDPA <17mm 2) Larger lower lobe vessels 3) Gradual tapering of vessels from centre to periphery
  32. Pulmonary Plethora ≥3 end on view in one lung field or ≥5 in both lung fields
  33. Pulmonary Oligemia Hilar, lobar, and segmental pulmonary arteries appear small Concave or absent main pulmonary artery segment Lung fields have an overexposed or emphysema like appearance
  34. Pulmonary Venous Hypertension
  35. GRADE 1 (Cephalisation - Deer Antler Sign)
  36. GRADE 2 (Interstitial edema – Kerley B lines)
  37. GRADE 2 (Interlobar effusion – Phantom tumor)
  38. GRADE 3- Alveolar edema (Bat Wing appearance)
  39. Grades of PVH Grade Stage X ray Finding PCWP I Cephalisation Deer Antler Sign, Inverted moustache sign 12-18 mmHg II Interstitial edema Kerley B lines 19-25 mmHg III Alveolar edema Bat wing appearance >25 mmHg
  40. Pulmonary Arterial Hypertension Enlargement of the pulmonary trunk and main pulmonary arteries Disproportionately small peripheral vessels Oligemic lungs Prune tree appearance
  41. Pericardial Effusion
  42. Pulmonary Embolism
  45. Pneumothorax
  46. Hydro pneumothorax
  47. F-Lung Fields • Normally, there are visible markings throughout the lungs due to the pulmonary arteries and veins, continuing all the way to the chest wall. • Both lungs should be scanned, starting at the apices and working downward, comparing the left and right lung fields at the same level.
  48. F-Lung Fields
  49. Lungs • On a PA radiograph, the minor fissure can often be seen as a faint horizontal line dividing the RML from the RUL. • The major fissures are not usually seen on a PA view because they are being viewed obliquely.
  50. Lobar anatomy
  51. Lobar anatomy …
  52. Hidden areas…
  53. AIR BRONCHOGRAM SIGN • When the internal tubular outline of a bronchus is visible within a thoracic opacity...that is an air bronchogram. • It is most commonly associated with a simple pneumonia. Sometimes it occurs with pulmonary oedema.
  54. The Cardiac density
  55. Chronic Bronchitis
  56. Emphysema
  57. Lung Apices
  58. Peripheral Opacities
  59. H-Hilum and mediastinum
  60. H-Hilum and mediastinum • The hila consist primarily of the major bronchi and the pulmonary veins and arteries. • The hila are not symmetrical, but contain the same basic structures on each side. • The hila may be at the same level, but the left hilum is commonly higher than the right. • Both hila should be of similar size and density
  64. Mediastinum • The trachea should be centrally located or slightly to the right • The aortic arch is the first convexity on the left side of the mediastinum • The pulmonary artery is the next convexity on the left, and the branches should be traceable as it fans out through the lungs • The lateral margin of the superior vena cava lies above the right heart border
  65. Mediastinum
  66. ICU – Tubes and Lines
  67. Ryles Tube
  68. Central Venous Catheter
  69. Artificial Valves
  70. PREVIOUS CXR • Previous CXRS your best friend. You see a real or possible abnormality on the CXR. • Was it there before? Has it got larger or smaller? Is it unchanged? • A previous CXR will often highlight an important but subtle change. • On the other hand it will frequently provide reassurance that all is well.
  71. Take Home Message