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

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

What is a Chest Radiograph? SHADOW

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

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

Projection

Portable (AP or Antero-posterior) FILM

PA (Postero-anterior) FILM

Projection PA AP

Low Lung Volumes

Over Exposure Proper Exposure

9

Mental Break

Anatomy RUL RML

RUL (Right Upper Lung)

RML (Right Middle Lung)

RLL (Right Lower Lung)

Right Sided Fissures

LUL (Left Upper Lung)

LLL (Left Lower Lung)

Left Side Fissure LUL LLL

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

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

Apical TB

Left Retrocardiac Opacity

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

Normal Anatomy: Lateral Heart Aorta Pulmonary arteries Airways Spine

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

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

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

Right Lower Lobe Pneumonia

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

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

LUL Pneumonia

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

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

Interstitial Opacity: Small Nodules

Interstitial Opacity: Lines

Interstitial Opacity: Lines & Reticulation

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

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

Well-Defined Calcification Ill-Defined Mass

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

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

Right Paratracheal Lymphadenopathy

Right Hilar LAN

Right Hilar LAN

Left Hilar LAN

Subcarinal LAN *

AP Window LAN

Lymphadenopathy Non-specific presentations: Specific patterns: mediastinal widening hilar prominence Specific patterns: particular station enlargement

Cysts & Cavities Cyst: abnormal pulmonary parenchymal space, not containing lung but filled with air and/or fluid, congenital or acquired, with a wall thickness greater than 1 mm epithelial lining often present

Cysts & Cavities Cavity: abnormal pulmonary parenchymal space, not containing lung but filled with air and/or fluid, caused by tissue necrosis, with a definitive wall greater than 1 mm in thickness and comprised of inflammatory and/or neoplastic elements

Benign Lung Cyst : PCP Pneumatocele Uniform wall thickness 1 mm Smooth inner lining

Benign Cavities : Cryptococcus max wall thickness 4 mm minimally irregular inner lining

Indeterminate Cavities max wall thickness 5-15 mm mildly irregular inner lining

Malignant Cavities: Squamous Cell Ca max wall thickness 16 mm Irregular inner lining

Cysts & Cavities Characterize: wall thickness at thickest portion inner lining presence/absence of air/fluid level number and location

Pleural Effusion

Pleural Effusion

Pleural Calcification

Pleural Disease: Basic Patterns Effusion angle blunting to massive mobility Thickening distortion, no mobility Mass Air Calcification

Thoracic Aorta Aneurysm

Chest breast implants

Rib fx’s Mediast. OK Pulmonary contusion Subcu air Chest tube NG tube

MVC victim

Deep Right Mainstem Intubation Carina Tip of ET tube Deep Right Mainstem Intubation

Tip of ET Pneumomediastinum

Potential X ray findings wide mediastinum obliteration of aortic knob Rt mainstem shift up and right NG deviate to right pleural cap Major Vessel Injury

Pneumothoraces

Expiration reduces lung volume, making a small pneumo easier to see

Irregular linear opacities are present in both lungs, especially in the periphery and the bases of the lungs. The heart is slightly enlarged, but this is not related to the pulmonary abnormalities in this case.

Hodgkin’s Disease

Ao SVC Mediastinal Hematoma

Tracheal deviation to Rt. ET tube First rib fx Obliterated aortic knob NG shift to Rt. Chest tube

Lt. Internal Carotid Artery Rt. Subclavian Art. ET Lt. Subclavian Artery NG Aortic Rupture

Tension Pneumothorax on CT Mediastinum Rt. Lt. Ao

Hemothoraces

Hemothorax Supine Upright

Hemopneumothorax

Indistinct diaphragm

Elevated, irregular hemidiaphragm

Indistinct, elevated diaphragm Clavicle fx Suspicious Close-up Rib fxs Indistinct, elevated diaphragm Chest tube

Crushed right chest

After ventilated with PEEP