how to read cxr
TRANSCRIPT
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HOW TO READ CXRHOW TO READ CXR
DR R KR PRADHAN, MDLOWER ASSAM HOSPITAL
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IntroductionIntroduction
CXR Routinely obtained, most commonInherent physical exam limitationsChest x-ray limitationsCXR finding not always diagnosticPhysical exam and chest x-ray provide
compliment
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Essentials Before Getting Essentials Before Getting StartedStarted
Exposure– Overexposure– Underexposure
Sex of Patient– Male– Female
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EXPOSURE
Over Over ExposureExposure
Proper ExposureProper Exposure
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Essentials Before Getting StartedEssentials Before Getting Started
Path of x-ray beam– PA– AP– LAT
Patient Position– Upright– Supine
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Essentials Before Getting Essentials Before Getting StartedStarted
Breath– Inspiration– Expiration
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Systematic ApproachSystematic Approach• Name/marker/rotation/
penetration
• Airway
• Heart
• Mediastinum
• Lungs• Zones
(upper/middle/lower)
• Bones
• Diaphragm
• Soft Tissues
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Systematic ApproachSystematic Approach
Bony Fragments– Ribs– Sternum– Spine– Shoulder girdle– Clavicles
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Systematic ApproachSystematic Approach
Soft Tissues– Breast shadows– Supraclavicular areas– Axillae– Tissues along side of
breasts
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Systematic ApproachSystematic 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
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Systematic ApproachSystematic Approach
Diaphragm and Pleural Surfaces– Diaphragm
Dome-shaped Costophrenic angles
– Normal pleural is not visible
– Interlobar fissures
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Systematic ApproachSystematic Approach
Mediastinum and Heart– Heart size on PA– Right side
Inferior vena cava Right atrium Ascending aorta Superior vena cava
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Systematic ApproachSystematic Approach
Mediastinum and Heart– Left side
Left ventricle Left atrium Pulmonary artery Aortic arch Subclavian artery and
vein
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Systematic ApproachSystematic Approach
Abdomen and Neck– Abdomen
Gastric bubble Air under diaphragm
– Neck Soft tissue mass Air bronchogram
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Summary of Density Summary of Density
Air Fat (Grey) Water Tissue Bone
Tissue
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Lung AnatomyLung Anatomy Trachea Carina Right and Left Pulmonary
Bronchi Secondary Bronchi Tertiary Bronchi Bronchioles Alveolar Duct Alveoli
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Lung AnatomyLung Anatomy
Right Lung– Superior lobe– Middle lobe– Inferior lobe
Left Lung– Superior lobe– Inferior lobe
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Lung Anatomy on Chest X-rayLung Anatomy on Chest X-ray
PA View:– Extensive overlap– Lower lobes extend
high Lateral View:
– Extent of lower lobes
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Lung Anatomy on Chest X-rayLung Anatomy on Chest X-ray The right upper lobe
(RUL) occupies the upper 1/3 of the right lung.
Posteriorly, the RUL is adjacent to the first 3 to 5 ribs.
Anteriorly, the RUL extends inferiorly as far as the 4th right anterior rib
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Lung Anatomy on Lung Anatomy on CXRCXR
The right middle lobe is typically the smallest of the three, and appears triangular in shape, being narrowest near the hilum
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Lung Anatomy on Lung Anatomy on CXRCXR
The right lower lobe is the largest of all three lobes, separated from the others by the major fissure.
Posteriorly, the RLL extend as far superiorly as the 6th thoracic vertebral body, and extends inferiorly to the diaphragm.
Review of the lateral plain film surprisingly shows the superior extent of the RLL.
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Lung Anatomy on Chest X-rayLung Anatomy on Chest X-ray These lobes can be separated
from one another by two fissures.
The minor fissure separates the RUL from the RML, and thus represents the visceral pleural surfaces of both of these lobes.
Oriented obliquely, the major fissure extends posteriorly and superiorly approximately to the level of the T4 vertebral body.
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LEFT Lung Anatomy LEFT Lung Anatomy on CXRon CXR
The lobar architecture of the left lung is slightly different than the right.
Because there is no defined left minor fissure, there are only two lobes on the left; the left upper & lower lobes
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Lung Anatomy on Chest X-rayLung Anatomy on Chest X-ray
Left lower lobes
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LLL-LAT
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LAT VIEW-CXRLAT VIEW-CXR These two lobes are
separated by a major fissure, identical to that seen on the right side, although often slightly more inferior in location.
The portion of the left lung that corresponds anatomically to the right middle lobe is incorporated into the left upper lobe.
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THE CXRTHE CXR PA View:
1. Aortic arch2. Pulmonary trunk3. Left atrial appendage4. Left ventricle5. Right atrium6. Superior vena cava7. Right hemidiaphragm8. Left hemidiaphragm9. Horizontal fissure
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Normal CXR-LATNormal CXR-LAT
Lateral View:1. Oblique fissure2. Horizontal fissure3. Thoracic spine and
retrocardiac space4. Retrosternal space5. Retratracheal space
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The Silhouette SignThe 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.
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Putting It All TogetherPutting It All Together
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Understanding Pathological Understanding Pathological ChangesChanges
Most disease states replace air with a pathological process- Fluid, cells
Each tissue reacts to injury in a predictable fashion
Lung injury or pathological states can be either a generalized or localized process
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Liquid DensityLiquid DensityLiquid density Increased air density
Generalized Localized
Diffuse alveolarDiffuse interstitialMixedVascular
InfiltrateConsolidationCavitationMassCongestionAtelectasis
Localized airway obstructionDiffuse airway obstructionEmphysemaBulla
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ConsolidationConsolidation Lobar consolidation:
– Alveolar space filled with inflammatory exudate
– Interstitium and architecture remain intact
– The airway is patent– Radiologically:
A density corresponding to a segment or lobe
Airbronchogram, and No significant loss of lung
volume
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AtelectasisAtelectasis Loss of air Obstructive atelectasis:
– No ventilation to the lobe beyond obstruction
– Radiologically: Density corresponding to
a segment or lobe Significant loss of volume Compensatory
hyperinflation of normal lungs
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Stages of Evaluating an Stages of Evaluating an AbnormalityAbnormality
1. Identification of abnormal shadows2. Localization of lesion3. Identification of pathological process4. Identification of etiology5. Confirmation of clinical suspicion
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Putting It Into PracticePutting It Into Practice
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Case 1Case 1
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A single, 3cm relatively thick-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
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Case 2Case 2
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LUL Atelectasis: Loss of heart borders/silhouetting. Notice over inflation on unaffected lung
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Case 3Case 3
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Right Middle and Left Upper Lobe Pneumonia
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Case 4Case 4
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Cavitation:cystic changes in the area of consolidation due to the bacterial destruction of lung tissue. Notice air fluid level.
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Cavitation
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Case 5Case 5
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Tuberculosis
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Case 6Case 6
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COPD: Decrease in heart diameter, flattening of the diaphragm, and increase in the size of the retrosternal air space. In addition the upper lobes will become hyperlucent due to destruction of the lung tissue.
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Case 7Case 7
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Pseudotumor: fluid has filled the fissure creating a density that resembles a tumor (arrow). Fluid and soft tissue are indistinguishable on plain film. Further analysis, however, reveals a classic pleural effusion in the right pleura. Note the right lateral gutter is blunted and the right lateral diaphragm is obscured.
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Case 8Case 8
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Pneumonia: a large pneumoniac consolidation in the right lower lobe. Knowledge of lobar and segmental anatomy is important in identifying the location of the infection
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Case 9Case 9
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CHF: accentuated interstitial markings, Kerley B lines, and an enlarged heart. Normally indistinct upper lobe vessels are prominent but are also masked by interstitial edema.
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24 hours after diuretic therapy
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Case 10Case 10
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RT HILAR NODE
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AORTO-PA WINDOW NODE
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Chest wall lesion: arising off the chest wall and not the lung
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Case 11Case 11
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Pleural effusion: Note loss of left hemidiaphragm. Meniscus sign
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Case 12Case 12
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Lung Mass
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Case 13Case 13
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Small Pneumothorax: LUL
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Case 15Case 15
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Right Pneumothorax: complete lower /middle lobar collapse
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Post chest tube insertion and re-expansion
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Case 16Case 16
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Metastatic Lung Cancer: multiple nodules seen
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Case 17Case 17
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Right upper lower lobe pulmonary nodule
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Case 18Case 18
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Tuberculosis
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Case 19Case 19
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Perihilar mass: Hodgkin’s disease
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Case 20Case 20
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Widened Mediastinum: Aortic Dissection
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Case 21Case 21
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REVIEW AREAS
THE APICESTHORACIC INLETLUNG OVERLYING SCAPULACOSTOPHRENIC ANGLESSUBPHRENIC REGIONSRETROCARDIAC REGIONCARDIOPHRENIC ANGLES
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APEX
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RETROCARDIAC OPACITY
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LUNG OVERLYING SCAPULA
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PITFALLSPITFALLS
Poor inspirationOver or under penetrationRotationPseudopneumothoraxNipple shadowsButtonsHair braids
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