learning objectives basic radiology: chest x-ray fundamentals · chest pain, and shortness of...

Basic Radiology: Chest X-Ray Fundamentals

John Mabee, PhD, PA-C Adjunct Assistant Professor Clinical Family Medicine

Keck School of Medicine of USC Division of Physician Assistant Studies

Primary Care Physician Assistant Program

CAPA Conference – October 9, 2014

This workshop is geared toward the Primary Care PA. Upon completion of this workshop, the participant should be able to:

•  List image & quality considerations of the chest x-ray study •  Recognize basic normal thoracic radiographic anatomy •  Perform a systematic review of the chest x-ray using an:

“A, B, C, D, E” approach •  Identify & interpret common radiographic presentation of

pathology •  Identify areas where pathology is commonly missed •  Describe useful signs & hints

Learning Objectives

Exposure

med-ed.virginia.edu

Underpenetrated

Image Quality

Overpenetrated

med-ed.virginia.edu

Image Quality

Exposure

med-ed.virginia.edu

Image Quality

Rotation

Bronchovascular structures seen thru heart T-spine disc spaces barely visible thru heart

Diaphragm: 8th-10th posterior or 5th-6th anterior rib

1 2

3

4

5

6

7

8

9

10

11

1

2

3

4

5

6

regionstrauma.org/blogs/ribtestlat.jpg

Image Quality

Inspiration

PA view

Lateral View

ultimatexray.blogspot.com

Sternum should be seen edge on Posteriorly, you should see 2 sets of ribs

Spine & lungs darken as you move caudally

R

d

L

Image Quality

radiologypics.com

(4th rib)

(5-6th rib)

Anatomy

Trachea

RPA

LPA

CarinCarinCarinaaaCarinCaCarinCarinCarinaa aa

Anatomy

PA view

Lateral view

radiologyassistant.nl



= Left pulmonary artery

= Right pulmonary artery

R L

Trachea

Retrosternal space

CXR Interpretation

• One approach to reading a CXR:

- A: Airways

- B: Bones

- C: Cardiomediastinal silhouette

- D: Diaphragm

- E: Everything else (plus lungs!)

Normal

• A: Airways • B: Bones • C: Cardio-

mediastinal silhouette

• D: Diaphragm • E: Everything

else (+lungs)

regionstrauma.org/blogs/ribtestlat.jpg

Selected Pathology & CXR Findings


Bronchopneumonia Lobar Pneumonia

Pneumonia

library.med.utah.edu library.med.utah.edu

Inflammatory “infiltrate” (pus)

in alveoli consolidation of

airspaces

Pneumonia

Bronchopneumonia Lobar Pneumonia © Elseiver 2005 library.med.utah.edu

• “Infiltrate” • Airspaces filled with pus (pneumonia) or other fluid (inflammation, CA, blood)

• Usually no loss of lung volume

radiologypics.com

Consolidation Silhouette Sign


•  Loss of the silhouette or lung/soft tissue interface caused by a mass or fluid in the normally air-filled lung

Silhouette Sign

RML

rad.usuhs.edu

Air Bronchogram

• Outline of airway tubes caused by filling of surrounding alveoli with fluid, cells or inflammatory exudates


• A 35-year-old man comes to the emergency department for evaluation of fever, and productive cough for the past 4 days. Temperature is 39.4°C (103°F). Physical examination shows rales over the right lower anterior chest. Chest x-ray study is shown.

Case 1 Case 1

emrems.com

Supine

+ silhouette sign

Focal area of consolidation by right heart

Sharp horizontal fissure Dx: Right middle lobe pneumonia

emrems.com

Case 1 Supine Supine

emrems.com

• A 58-year-old man is being evaluated in the intensive care unit. Two days ago, he was in a high speed car accident, and was treated for a closed right tibia and fibula fracture. Earlier today, he was intubated because of increasing dyspnea, tachypnea, and confusion. Chest x-ray study is shown.

Case 2

Case 2


- Diffuse bilateral infiltrates - Appropriate positioning of ET tube [5 cm above carina or midway between clavicles & carina]

• Dx: ARDS


Case 2

LVH & Pulmonary Edema

Alveolar Edema

library.med.utah.edu

library.med.utah.edu library.med.utah.edu

Cardiomegaly

en.wikipedia.orgwiki/File:Cardiomegally.png

Normal: < 50% of thoracic diameter

Pulmonary Edema

• ↑ prominence of interstitial lines

• Kerley B (septal) lines

• Cephalization of the pulmonary vasculature

• Peribronchial cuffing

radiopaedia.org

Pulmonary Edema •  “Bat wing" pattern & air bronchograms

radiologyassistant.nl Bilateral perihilar infiltrates

• A 58-year-old man is seen in the emergency department because of increasing dyspnea and orthopnea for the past 2 days. Pulse rate is 98/min, blood pressure is 132/84 mmHg, respirations are 22/min. Physical examination shows bilateral scattered rales, intermittent wheezes, and a S3. Chest x-ray study is shown.

Case 3

medicalforum.wordpress.com

Case 3

Cardiomegaly Prominent bilateral pulmonary vasculature Cephalization of vessels Kerley B lines Dx: - Heart failure - Pulmonary edema

Case 3

medicalforum.wordpress.com

Emphysema Dilated Airways library.med.utah.edu




Emphysema

• Bilateral diffuse hyperinflation, flattening of diaphragms, ± bullae

• Narrowing of the cardiac silhouette

unchainedfitness.com

12

• A 66-year-old woman is seen in the office for progressive shortness of breath for the past 2 months. She smokes 2 packs of cigarettes per day for the past 40 years. Physical examination shows pursed lip breathing, and mild curvature of the thoracic spine. Heart sounds are distant, but without murmur or gallop. Lung sounds are normal. Chest x-ray study is shown.

Case 4

Case 4

en.academic.ru

- Hyperinflation - Hyperlucency - Flattening of the diaphragm - Narrowing of the cardiac silhouette

• Dx: Emphysema

Case 4

en.academic.ru

11

?

?

Pulmonary Nodules & Masses

• Most common nodule ⇒ granuloma

library.med.utah.edu library.med.utah.edu library.med.utah.edu

Hamartoma Squamous Cell CA Adenocarcinoma

Solitary Pulmonary Nodule

- Discrete, well-marginated round opacity < 3 cm diameter - Surrounded by lung parenchyma - Does not touch hilum or mediastinum - Ø adenopathy, atelectasis or pleural effusion

radiopaedia.org en.wikipedia.org

?

Solitary Pulmonary Nodule

•  Calcification pattern (if present):

Most likely benign

Suspicious

robochest.com

robochest.com

• Anterior: - Thymic tumors - Lymphomas

• Middle: - Thyroid tumors - Lymphomas • Posterior: - Neurogenic tumors - Esophageal masses

Other possibilities: cysts, hemangiomas, lipomas + many more

Mediastinal divisions

Mediastinum

(retrosternal space)

Anterior Posterior

Middle

Mediastinal Lines radiologyassistant.nl

Mediastinum: 8 cm (supine)

Aortic Knob

Pulmonary Artery

Aorto- Pulmonary Window

Mediastinum

Mediastinum radiologyassistant.nl

Hodgkin Disease

Mass in aortopulmonary window Mass in retrosternal space

Mediastinum & Hila

Mediastinum – lines? Hila – dilated vessels or nodes?

Nodes – there are round densities where you don’t expect to see blood vessels


Sarcoidosis

• A 68-year-old man is seen in the emergency department because of sharp tearing chest pain radiating to the upper back that began 1 hour ago. He is lightheaded, and has nausea. Pulse rate is 80/min, blood pressure is 200/110 mmHg, respirations are 18/min. Physical examination shows grade II/VI diastolic murmur over the aortic area, and diminished pulses in both lower extremities. Chest x-ray study is shown.

Case 5 Case 5

- Widened mediastinum > 8 cm

- Tracheal shift (right) • Dx: aortic dissection

Case 5



Hemopneumothorax

Hemopneumothorax

• Violation of pleural space

• Loss of vascular markings

• Hyperlucent hemithorax

• Air-fluid level with hemothorax

anesthesia2000.com

• A 27-year-old woman is evaluated in the emergency department for left-sided chest pain, and shortness of breath. During the primary survey, decreased breath sounds are heard over the left chest wall. Chest x-ray study is shown.

Case 6


Case 6

- Visceral pleura edge is seen

- No vascular markings on outer lung field

- Air-fluid level behind left diaphragm

- Scoliosis! • Dx: Pneumothorax

Case 6 radiologyassistant.nl

Pneumothorax: Size or %?*

a=apex-to-cupula distance (American): 3 cm b=interpleural distance @ hilum (British): 2 cm

≈ 50% pneumo

“Small” < 3 cm “Large” > 3cm

“Small” < 2 cm “Large” > 2cm

*MacDuff A, et al. Management of spontaneous pneumothorax: British Thoracic Society pleural disease guideline 2010. Thorax 2010 (Suppl 2):ii18-ii31.

Pleural Effusion radiologyassistant.nl

Fluid accumulation in the pleural cavity: - serous fluid [transudate or exudate] - pus (empyema) - blood (hemothorax) - lymph (chylothorax)

Pleural Effusion

• Fluid collection in pleural space → blunting of costophrenic ∠

• Minimum volume on XR: - ≈ 250 mL on PA view - ≈ 75 mL on lateral view

yale.edu/imaging

Pleural Effusion •  Lateral decubitus view → fluid “layering”

dijlh.net

Empyema

Pus


• A 28-year-old man is seen in the office because of fever, chills, and productive cough for the past week. Over the past 2 days, he has developed left-sided chest pain, and progressive shortness of breath. Pulse rate is 110/min, blood pressure is 108/72 mmHg, respirations are 28/min, and temperature is 39.4°C (103°F). Physical examination shows decreased breath sounds over the lower ⅔’s of the left chest. Chest x-ray study is shown.

Case 7

Case 7 - Opacification (white out) of lower ⅔ of left hemithorax - Meniscus - Deviation of trachea & heart to right - Elevation of right horizontal fissure • Dx: Pleural effusion (empyema)

Case 7

Atelectasis • Collapse or incomplete expansion of

lung or lung segment • Characteristics: - ↑ opacity of airless lobe (+ volume loss) - displacement of fissures, hilar & cardiomediastinal structures toward side of collapse - elevation of ipsilateral hemidiaphragm - ↑ lucency of aerated lung - ± silhouette sign

Atelectasis Patterns


ML

LUL

LLL

•  RUL atelectasis - “ ” density - Right tracheal shift - ∅ retrosternal clear space on lateral view




radiologyassistant.nl di l i t

RUL

•  RML atelectasis - Silhouette sign right heart - “ ” density on lateral view

radiologyassistant.nl radiologyassistant.nl

radiologyassistant.nl radiologyassistant.nl ML

•  RLL atelectasis - “ ” density right heart - Right tracheal shift - Elevation right diaphragm - “ ” density posterior CP ∠ on lateral view

en.wikipedia.org wikidoc.org

radiologyassistant.nl radiologyassistant.nl radiologyassiRLL


•  LUL atelectasis - General haze over left lung - ± left hilar mass - Left tracheal shift & elevated left diaphragm - ∅ retrosternal clear space


radrounds.com radrounds.com

radiologyassisLUL


•  LLL atelectasis - “ ” density left heart - Elevation left diaphragm - “ ” density posterior CP ∠ on lateral view


radiologyass

LLL

learning objectives basic radiology: chest x-ray fundamentals · chest pain, and shortness of...

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