Clinical aspects of CXR Interpretation

Abhiraj KaleDept. of Clinical Pharmacy,

KLES Dr.Prabhakar Kore Hospital & MRC,

Belgaum.

Objectives

To review ordering a chest x-ray To review the normal findings including

skeletal and soft tissue landmarks To present a systematic procedure for

interpreting chest x-rays To cover common abnormal findings in the

primary care setting.

Ordering a Chest X-Ray

Order by chief complaint Views: PA (standard frontal chest film)

Lateral (marked by which side of chest is against the film – good to assess the area behind the heart)

Positioning: Lying vs. Upright

Right vs. Left

Systematic Interpretation

Suggested Routine Label (Verify ID factors) Orientation Quality Skeletal Structures Soft Tissue Structures

Before Interpreting a Film

Make sure it’s the right patient. Know the patient’s story. Have older films, if available. Place films on the view box as though you are facing

the patient. Check the quality: You should be able to see the

outlines of the vertebral bodies within the heart shadow. Check for rotation (symmetrical clavicles). Know normal anatomy

Essentials Before Getting Started

Exposure Overexposure Underexposure

Sex of Patient Male Female

Path of x-ray beam PA AP

Patient Position Upright Supine

Essentials Before Getting Started

Systematic Approach

Bony Framework Soft Tissues Lung Fields and Hila Diaphragm and Pleural Spaces Mediastinum and Heart Abdomen and Neck

Systematic Approach

Bony Fragments Ribs Sternum Spine Shoulder girdle Clavicles

Systematic Approach

Soft Tissues Breast shadows Supraclavicular areas Axillae Tissues along side of

breasts

Systematic Approach

Lung Fields and Hila Hilum

Pulmonary arteries Pulmonary veins

Lungs Linear and fine nodular

shadows of pulmonary vessels

Blood vessels 40% obscured by other

tissue

Diaphragm and Pleural Surfaces Diaphragm

Dome-shaped Costophrenic angles

Normal pleural is not visible

Interlobar fissures

Systematic Approach

Mediastinum and Heart Left side

Left ventricle Left atrium Pulmonary artery Aortic arch Subclavian artery and

vein

Systematic Approach

Systematic Approach

Abdomen and Neck Abdomen

Gastric bubble Air under diaphragm

Neck Soft tissue mass Air bronchogram

Opacity

Air < fat < liver < blood < muscle < bone < barium < lead

Skeletal Structures

Skeletal Structures Scapulae Humeri & Shoulder

Joints Clavicles Ribs (9+ = good

inflation) Spine

Assessment Check for symmetry,

spacing, and fractures. Check for linearity of

the spine.

Pitfalls to Chest X-ray Interpretation

Poor inspiration Over or under penetration Rotation Forgetting the path of the x-ray beam

PA View:1. Aortic arch2. Pulmonary trunk3. Left atrial appendage4. Left ventricle5. Right ventricle6. Superior vena cava7. Right hemidiaphragm8. Left hemidiaphragm9. Horizontal fissure

The Normal Chest X-ray

The Normal Chest X-ray

Lateral View:1. Oblique fissure

2. Horizontal fissure

3. Thoracic spine and retrocardiac space

4. Retrosternal space

Soft Tissue Structures

Neck and Esophagus Symmetry, masses

Trachea Deviation, ID bifurcation, should not be able to ID airways further out because they are thin walled.

Breasts Symmetry, nipples may be visible

Diaphragm Right usually higher

Costophrenic Angles Should be sharp and clear (no fluid density)

Cardiophrenic Angles Should be fairly clear

Vasculature Check for position and calcification

Hilum- L side generally higher and looks smaller than R

Heart Size (1/2 width of thorax), Ventricles

Soft Tissue Structures

LungsPleura Closed cavities enveloping

each lung. Visceral layer connects with the lung tissue, while the Parietal layer is thicker and attached to the wall of the thorax.

Right Lung Has 2 fissures separating 3 lobes

Left Lung Has 1 fissure separating 2 lobes

Chest-Xray TermsSilhouette Sign: When a margin or

structure is masked by another density

Right Side of heart masked by a RML pneumonia

The Silhouette Sign

An intra-thoracic radio-opacity, if in anatomic contact with a border of heart or aorta, will obscure that border. An intra-thoracic lesion not anatomically contiguous with a border or a normal structure will not obliterate that border.

Stages of Evaluating an Abnormality

1. Identification of abnormal shadows

2. Localization of lesion

3. Identification of pathological process

4. Identification of etiology

5. Confirmation of clinical suspension Complex problems

Introduction of contrast medium CT chest MRI scan

Abnormal X-Ray Findings

Upper Respiratory Infections Skeletal Injury Atelectasis Pneumothorax Pleural Effusion Cavitation Masses and/or Nodules Chronic Lung Disease Foreign Body

Case 1

Case 1

A single, 3cm relatively thin-walled cavity is noted in the left midlung. This finding is most typical of squamous cell carcinoma (SCC). One-third of SCC masses show cavitation

Cavitation:cystic changes in the area of consolidation due to the bacterial destruction of lung tissue. Notice air fluid level.

Case 5

Tuberculosis

Case-4

Pneumonia: a large pneumonia consolidation in the right lower lobe. Knowledge of lobar and segmental anatomy is important in identifying the location of the infection

Case-5

CHF:a great deal of accentuated interstitial markings, Curly lines, and an enlarged heart. Normally indistinct upper lobe vessels are prominent but are also masked by interstitial edema.

Case-6

Chest wall lesion: arising off the chest wall and not the lung

Case-6

Pleural effusion: Note loss of left hemi diaphragm. Loss of cp angle

Csae-7

Lung Mass

Metastatic Lung Cancer: multiple nodules seen

Case-8

Right Middle Lobe Pneumothorax: complete lobar collapse

PneumoniaBacterial PCP

Acute Bronchitis

Streaky Densities

Skeletal InjuryRib Fractures

Atelectasis

Definition: Air volume loss. Collapse is a synonymous term.

Right Lung atelectasis and Pneumothorax

Cavitation:

A pocket of air surrounded by a membrane or wall of varying thickness.

Tuberculosis

Masses and/or Nodules .

COPD

Pulmonary Edema

CHF

Foreign Body

References

Brass-Mynderse, N. (2004). CXR interpretation. N440 advanced assessment and clinical diagnosis week five diagnostic testing self-study packet. Handout.

Chandrasekhar, A.J. (2005). Chest X-ray. Retrieved November 29, 2005 from http://www.meddean.luc.edu/lumen/MedEd/medicine/pulmonar/cxr/cxr.htm.

Ritter, B. Basics of chest x-ray interpretation: A programmed Study. Retrieved November 29, 2005 from

http://www.usfca.edu/fac-staff/ritter/chestxra.htm.

THANQ U