報告醫師: 李士毅醫師 指導醫師: 林榮祿醫師 Chest x-ray reading 報告醫師: 李士毅醫師 指導醫師: 林榮祿醫師

Check List(1) Check patient data, position, technical quality and normal anatomy. Review systematically Initial survey Review skeletal structures of shoulder girdles and chest wall Review mediastinum: overall size and shape trachea: position margins: SVC, ascending aorta, right atrium, left subclavian artery, aortic arch, main pulmonary artery, left ventricle lines and stripes: paratracheal, paraspinal, paraesophageal (azygoesophageal), paraaortic retrosternal clear space Review hila: normal relationships size Check patient name, position, technical quality. Initial survey Soft tissue including breast, chest wall, companion(同伴,伴侶;朋友) shadow. 4. Review soft tissues and skeletal structures of shoulder girdles and chest wall. 5. Review abdomen for bowel gas, organ size, abnormal calcifications, free air, etc. 6. Review soft tissues and spine of neck. 7. Review spine and rib cage: check alignment(隊列,一直線), disc space narrowing, lytic or blastic regions, etc. 8. Review mediastinum: - overall size and shape - trachea: position - margins: SVC, ascending aorta, right atrium, left subclavian artery, aortic arch, main pulmonary artery, left ventricle - lines and stripes: paratracheal, paraspinal, paraesophageal (azygoesophageal), paraaortic - retrosternal clear space

Check List(2) Review lungs and pleura: compare lung sizes evaluate pulmonary vascular pattern: compare upper to lower lobe, right to left, normal tapering to periphery pulmonary parenchyma pleural surfaces fissures - major and minor - if seen compare hemidiaphragms follow pleura around rib cage Soft tissue including breast, companion shadow . Review abdomen for bowel gas, organ size, abnormal calcifications, free air, etc. Review soft tissues and spine of neck. Review spine and rib cage: check alignment, disc space narrowing, lytic or blastic regions, etc. Check patient name, position, technical quality. Initial survey Soft tissue including breast, chest wall, companion(同伴,伴侶;朋友) shadow. 4. Review soft tissues and skeletal structures of shoulder girdles and chest wall. 5. Review abdomen for bowel gas, organ size, abnormal calcifications, free air, etc. 6. Review soft tissues and spine of neck. 7. Review spine and rib cage: check alignment(隊列,一直線), disc space narrowing, lytic or blastic regions, etc. 8. Review mediastinum: - overall size and shape - trachea: position - margins: SVC, ascending aorta, right atrium, left subclavian artery, aortic arch, main pulmonary artery, left ventricle - lines and stripes: paratracheal, paraspinal, paraesophageal (azygoesophageal), paraaortic - retrosternal clear space

Check List Check patient data, position, technical quality and normal anatomy. Review systematically Initial survey Review skeletal structures of shoulder girdles and chest wall Review mediastinum Review hila Review lungs and pleura Soft tissue including breast, companion shadow Check patient name, position, technical quality. Initial survey Soft tissue including breast, chest wall, companion(同伴,伴侶;朋友) shadow. 4. Review soft tissues and skeletal structures of shoulder girdles and chest wall. 5. Review abdomen for bowel gas, organ size, abnormal calcifications, free air, etc. 6. Review soft tissues and spine of neck. 7. Review spine and rib cage: check alignment(隊列,一直線), disc space narrowing, lytic or blastic regions, etc. 8. Review mediastinum: - overall size and shape - trachea: position - margins: SVC, ascending aorta, right atrium, left subclavian artery, aortic arch, main pulmonary artery, left ventricle - lines and stripes: paratracheal, paraspinal, paraesophageal (azygoesophageal), paraaortic - retrosternal clear space

1. Data base Name Date - important for comparing prior exams - Serial image Position markers - right(R) vs. left(L) Type of film Patients position supine, upright, lateral, etc. 6. Technical quality 1. Patient's name. 2. Date exam done (very important if comparing prior exams). 3. Check for position markers - right vs. left, upright 4. Type of film (although this is a chest program, practice noticing if it is a plain film, CT, angio, MRI, etc.) 5. Patients position supine, upright, lateral, decubitus. 6. Technical quality of exam learn what are the acceptable limits for the exam. You can't find a subtle pneumothorax if there is patient motion(動作,姿態;手勢,眼色) or the film is overexposed.

1 2 3 (erect) 4 4 1

Introduction Serial image: Doubling time Point of disease(location/size) Make diagnosis easily Pneumonia Edema Tumor 1. First, training your eyes to cover the film in a systematic way so all body parts and systems are examined 2. Second, being able to interpret and understand what you see: can you separate normal and its variants from abnormal?

Position Chest x-ray P-A view A-P A-P supine Lateral (Lt’/Rt’) Lateral decubitus (Lt’/Rt’) Lordotic Oblique(Rt’/Lt’; post/anterior) Decubitus= lying down Lordotic(脊柱前凸的) 3. Oblique(斜的;傾斜的) - helpful localize lesions and eliminate superimposed structures. -Right anterior oblique for left side lesion  Far the light, move more laterally, and image more laterally as the point in stright when PA view.  Lt’ lesion with Rt’ ant. Oblique for increase difference distance.

Position Speical position for special purpose A-P supine: Ambulatory limit A-P Lateral (Lt’/Rt’): Anatomy reading Lateral decubitus: Effusion or thickening Lordotic: Apical lesion Oblique: Eliminate superimposed lesion Affect read result - eg. redistritubion Phenomenon (slide 183) Decubitus= lying down Lordotic(脊柱前凸的) 3. Oblique(斜的;傾斜的) - helpful localize lesions and eliminate(排除) superimposed structures. -Right anterior oblique for left side lesion  Far the light, move more laterally, and image more laterally as the point in stright when PA view.  Lt’ lesion with Rt’ ant. Oblique for increase difference distance.

PA Lateral(left) Right ant. oblique View AP AP supine Rt’ Lat. decubitus

P-A view

Rt’ Lateral decubitus view Rt’ Lateral view Rt’ Lateral decubitus view Lateral view of the same patient Right lateral decubitus (right side down) view of the same patient, showing layering of the large effusion along the right chest wall.

Technical quality Ideal KV exposure 4 basic radiographic densities Key points Apex Retrocardiac lung marking Trachea position Spine Scapula You can't find a subtle pneumothorax if there is patient motion or the film is overexposed. 4 basic radiographic densities 1. First, training your eyes to cover the film in a systematic way so all body parts and systems are examined 2. Second, being able to interpret and understand what you see: can you separate normal and its variants from abnormal? Motion: 移動

There is a small pneumothorax present on the radiograph to the left There is a small pneumothorax present on the radiograph to the left. It is located in the left pulmonary apex. If you compare the lucency of the lung fields in the first few intercostal spaces, you will notice that the left apex is slightly more lucent than the right. In the left third intercostal space, there is a thin white line (see magnified picture below) that represents the pleural surface of the lung. Increased lucency more peripheral to this line is the air trapped in the pleural Def A state characterized by the presence of gas within the pleural space. CxR The only direct sign is identification of a visceral pleural line. An air-fluid level in the hemithorax provides indirect evidence of a hydropneumothorax

Technical quality Ideal KV exposure 4 basic radiographic densities Air Fat Water(soft tissue) Bone(metal) 1. First, training your eyes to cover the film in a systematic way so all body parts and systems are examined 2. Second, being able to interpret and understand what you see: can you separate normal and its variants from abnormal? Motion: 移動

Normal Anatomy Anatomy & projection The sihouette sign General anatomy Lobar anatomy Segmental anatomy The sihouette sign

Normal Anatomy Anatomy & projection General anatomy Lobar anatomy Posterior process Rib(Ant/Post) Left 2/Right 4 Costothoracic ratio Central trachea Hilar: Lt>Rt Lung field: Central> Peripheral/ Peripheral clear zone Pleura: Linear Diaphragm: Right >left/ Angle/Gastric pattern Subcutaneous tissue Lobar anatomy Segmental anatomy

Diaphragm: 1.5-2 rib beadth(4 cm)

* Cardiothoracic ratio(N <0.5)- CTR

Normal Anatomy Anatomy & projection General anatomy of lateral view Right diaphragm Left diaphragm Spine Scapula Axiallary fold Sternum Subcutaneous tissue Trachea Aortic arch Main bronchus Pulmonary artery Heart Retrosternal clear space Retrocardiac clear space Costophrenic angle Costocardiac angle

5 8 4 13 9 6 10 11 12 3 7 14 16 1 2 15 16

Normal Anatomy Anatomy & projection The sihouette sign General anatomy Lobar anatomy Fissures Def: Pleura surround by air 3 main(1 minor; 2 major) 3 accessory(Azygos; inferior & superior accessory) If fissure do not appear a thin line? - Ans: ? Segmental anatomy The sihouette sign

Normal Anatomy Anatomy & projection The sihouette sign General anatomy Lobar anatomy Fissures Def: Pleura surround by air 3 main(1 minor; 2 major) 3 accessory(Azygos; inferior & superior accessory) If fissure do not appear a thin line - Pneumonia(Bulging) - Atelectasis (Deviation) - Pleural effusion (Pseudotumor) Segmental anatomy The sihouette sign

Type of film (although this is a chest program, practice noticing if it is a plain film, CT, angio, MRI, etc.) Patients position - supine, upright, lateral, decubitus. Technical quality of exam - learn what are the acceptable limits for the exam. You can't find a subtle pneumothorax if there is patient motion or the film is overexposed.

Lobar anatomy 1 2 1 2 5 3-4 3-4-5 3-4-6 6 1,2: Upper lobe 3,4: Lower lobe 5: Middle lobe 6: Lingula lobe

Normal Anatomy Anatomy & projection The sihouette sign Define Position Interface is invisible when two areas of similar radiodensity touch. Position

Normal Anatomy Anatomy & projection The sihouette sign Define Location Heart/Asending aorta Desending aorta/Diaphragm Airbronchogram Incomplete border

Normal Anatomy Anatomy & projection General anatomy Lobar anatomy Segmental anatomy Rt’: 1-10 Lt’ 1-10 (1+2, 7+8)

1 1 2 2 3 3 Type of film (although this is a chest program, practice noticing if it is a plain film, CT, angio, MRI, etc.) Patients position - supine, upright, lateral, decubitus. Technical quality of exam - learn what are the acceptable limits for the exam. You can't find a subtle pneumothorax if there is patient motion or the film is overexposed.

4 4 5 5 4: Middle lobe(Lateral) 5: Middle lobe (Medial )

6 6 Superior accessory fissure

7 7 9 9 7: Medial basal 9: Lateral basal Contact major fissure: 7,8 Contact posterior thoracic wall: 9,10

8 10 8 10 8: Anterior basal 10: Posterior basal

1+2 1+2 3 3

4 4 5 5 4: Middle lobe(Superior) 5: Medial (Inferior)

7+8 9 10 8: (7+8) 9, 10: Lateral /Posterior basal

Check List Check patient data, position, technical quality and normal anatomy. Review systematically Initial survey Review skeletal structures of shoulder girdles and chest wall Review mediastinum Review hila Review lungs and pleura Soft tissue including breast, companion shadow Check patient name, position, technical quality. Initial survey Soft tissue including breast, chest wall, companion(同伴,伴侶;朋友) shadow. 4. Review soft tissues and skeletal structures of shoulder girdles and chest wall. 5. Review abdomen for bowel gas, organ size, abnormal calcifications, free air, etc. 6. Review soft tissues and spine of neck. 7. Review spine and rib cage: check alignment(隊列,一直線), disc space narrowing, lytic or blastic regions, etc. 8. Review mediastinum: - overall size and shape - trachea: position - margins: SVC, ascending aorta, right atrium, left subclavian artery, aortic arch, main pulmonary artery, left ventricle - lines and stripes: paratracheal, paraspinal, paraesophageal (azygoesophageal), paraaortic - retrosternal clear space

Systematic review A-B-C-D-E-F-G-H or     Try interpret and understand what you see: D.D. normal v.s. abnormal? 1. First, training your eyes to cover the film in a systematic way so all body parts and systems are examined 2. Second, being able to interpret and understand what you see: can you separate normal and its variants from abnormal?

Systematic review A-B-C-D-E-F-G-H A: Airway B: Bone C: CV D: Diaphragm E: Extra-pulmonary F: Lung field G: Gastric bubble H: Hilum/Hernia 1. First, training your eyes to cover the film in a systematic way so all body parts and systems are examined 2. Second, being able to interpret and understand what you see: can you separate normal and its variants from abnormal?

Systematic review     Initial survey Review skeletal structures of shoulder girdles and chest wall Review mediastinum Review hila Review lungs and pleura: Soft tissue including breast, companion shadow. . 1. First, training your eyes to cover the film in a systematic way so all body parts and systems are examined 2. Second, being able to interpret and understand what you see: can you separate normal and its variants from abnormal?

Check List Check patient data, position, technical quality and normal anatomy. Review systematically Initial survey Review skeletal structures of shoulder girdles and chest wall Review mediastinum Review hila Review lungs and pleura Soft tissue including breast, companion shadow Check patient name, position, technical quality. Initial survey Soft tissue including breast, chest wall, companion(同伴,伴侶;朋友) shadow. 4. Review soft tissues and skeletal structures of shoulder girdles and chest wall. 5. Review abdomen for bowel gas, organ size, abnormal calcifications, free air, etc. 6. Review soft tissues and spine of neck. 7. Review spine and rib cage: check alignment(隊列,一直線), disc space narrowing, lytic or blastic regions, etc. 8. Review mediastinum: - overall size and shape - trachea: position - margins: SVC, ascending aorta, right atrium, left subclavian artery, aortic arch, main pulmonary artery, left ventricle - lines and stripes: paratracheal, paraspinal, paraesophageal (azygoesophageal), paraaortic - retrosternal clear space

Initial survey General Body Size, Shape, and Symmetry Sex Age(cartilage/aortic arch /asending aorta/Pulmonary trunk) Infant/ child/ young adult/ elderly person Foreign objects tubes, IV lines, EKG leads, surgical drains, prosthesis non-medical objects, bullets, shrapnel, glass, etc 1. General Body Size, Shape, and Symmetry 2. Male vs. Female 3. Is this an infant, child, young adult, elderly person? 4. Survey for foreign objects - tubes, IV lines, EKG leads, surgical drains, prosthesis, etc., as well as - non-medical objects, bullets, shrapnel(砲彈碎片), glass(玻璃), etc

Check List Check patient data, position, technical quality and normal anatomy. Review systematically Initial survey Review skeletal structures of shoulder girdles and chest wall Review mediastinum Review hila Review lungs and pleura Soft tissue including breast, companion shadow Check patient name, position, technical quality. Initial survey Soft tissue including breast, chest wall, companion(同伴,伴侶;朋友) shadow. 4. Review soft tissues and skeletal structures of shoulder girdles and chest wall. 5. Review abdomen for bowel gas, organ size, abnormal calcifications, free air, etc. 6. Review soft tissues and spine of neck. 7. Review spine and rib cage: check alignment(隊列,一直線), disc space narrowing, lytic or blastic regions, etc. 8. Review mediastinum: - overall size and shape - trachea: position - margins: SVC, ascending aorta, right atrium, left subclavian artery, aortic arch, main pulmonary artery, left ventricle - lines and stripes: paratracheal, paraspinal, paraesophageal (azygoesophageal), paraaortic - retrosternal clear space

Skeletal structures Refresh gross anatomy radiology Overall size, shape, contour of each bone. Density( mineralization) Compare cortical thickness to medullary cavity, trabecular pattern, Erosions, fractures, any lytic or blastic regions. Joints Articular relationships Joint spaces narrowed, widened Calcification in the cartilages Air in the joint space, abnormal fat pads Refresh gross anatomy radiology 1. Overall size, shape, and contour(輪廓;輪廓線) of each bone. 2. Density or mineralization. 3. Compare cortical thickness to medullary cavity, trabecular pattern, look for erosions, fractures, any lytic or blastic regions. 4. At joints, are articular(關節的) relationships normal, joint spaces narrowed, widened, any calcification in the cartilages, air in the joint space, abnormal fat pads, etc.

Neck and Cervical spines Overall(soft tissue) amounts calcifications, subcutaneous emphysema Trachea position size Cervical spine, alignment note any major congenital abnormalities. Specific parts of the vertebra and disc spaces Checking erosions lytic or blastic lesions disc and synovial joint narrowing Other abnormalities. - Check overall amounts of soft tissue, presence of calcifications, subcutaneous emphysema, position and size of trachea. - For the cervical spine, check alignment(隊列,一直線) and note any major congenital abnormalities. - Then look at specific parts of the vertebra and disc spaces, checking for erosions, lytic or blastic lesions, disc and synovial joint narrowing or other abnormalities.

Thoracic spine and Rib cage Overall alignment- spine Symmetry - rib cage Double check bone density Two reminders at this point: Principle of general More detailed review in each section. concentrate on the skeletal detail “Look through" the mediastinum and lungs. - Two reminders at this point: >remember the principle of general to more detailed review in each section. >concentrate on the skeletal detail -- "look through" the mediastinum and lungs. - First check overall alignment of the spine and symmetry of the rib cage, double check bone density (this is a gross estimate).

Thoracic spine Specific parts(Each) Vertebra Disc spaces height integrity of cortical margins/pedicles/lamina presence of any lytic or sclerotic areas synovial joints(normal /narrowing /sclerosis spacing ) Compare frontal & lateral projections Specific parts(Each) Vertebra Disc spaces Compare frontal and lateral projections. Some check list items to watch for are: height of vertebral bodies and disc spaces, integrity of cortical margins around the bodies, pedicles, and lamina, presence of any lytic or sclerotic areas, normal spacing of synovial joints, versus narrowing or sclerosis

Thoracic spine Pedicle(根;肉莖;梗節) Transverse process Posterior process Intervertebral disc Intervertebral foramen Anterior longitudinal ligament Posterior longitudinal ligament Ligamentum flavum

Ribs 1. Posterior Rib 2. Anterior Rib

Ribs Compare Note calcified anterior cartilages Side to side, Cortical margins, Trabecular patterns. Note calcified anterior cartilages may obscure or mimic underlying lung lesions. 1. Posterior rib, 2.Ant rib - Compare individual ribs side to side, check specific parts, cortical margins, trabecular patterns. - Make a note if the anterior cartilages are calcified, frequently the first one does so irregularly and may obscure or mimic underlying lung lesions.

Lt/Rt SHOULDER GIRDLE 3 7 8 1 6 4 2 Aromion(肩峰) Coracoid(喙突狀的) Clavicle Humerus Acromio-clavicular joint Gleno-humeral joint Gleno-clavicular joint Sterno-clavicular joint

Check List Check patient data, position, technical quality and normal anatomy. Review systematically Initial survey Review skeletal structures of shoulder girdles and chest wall Review mediastinum Review hila Review lungs and pleura Soft tissue including breast, companion shadow Check patient name, position, technical quality. Initial survey Soft tissue including breast, chest wall, companion(同伴,伴侶;朋友) shadow. 4. Review soft tissues and skeletal structures of shoulder girdles and chest wall. 5. Review abdomen for bowel gas, organ size, abnormal calcifications, free air, etc. 6. Review soft tissues and spine of neck. 7. Review spine and rib cage: check alignment(隊列,一直線), disc space narrowing, lytic or blastic regions, etc. 8. Review mediastinum: - overall size and shape - trachea: position - margins: SVC, ascending aorta, right atrium, left subclavian artery, aortic arch, main pulmonary artery, left ventricle - lines and stripes: paratracheal, paraspinal, paraesophageal (azygoesophageal), paraaortic - retrosternal clear space

Mediastinum Define Key is knowledge of anatomical relationships and Area between the lung Water density Surrounded two air filled lungs and Intersected by the air filled trachea and major bronchi. Key is knowledge of anatomical relationships and how structures project on a radiograph. CT and MRI is helpful. Interfaces of air-soft tissue margins may be distorted by pathological lesion Masses otherwise - An enormous amount of information about the mediastinum can be extracted from plain films; the key is a thorough knowledge of anatomical relationships and how structures are likely to project on a radiograph. - Use of cross-sections from CT and MRI will supplement this section. - Understand on plain films the mediastinum projects as a water density surrounded by the two air filled lungs and intersected(橫斷面)by the air filled trachea and major bronchi. - The interfaces of these air-soft tissue margins may be distorted by pathological processes, usually masses, that otherwise would be hidden in the mediastinum.

Mediastinum Define Key is knowledge of anatomical relationships and Area between the lung Water density Surrounded two air filled lungs and Intersected by the air filled trachea and major bronchi. Key is knowledge of anatomical relationships and how structures project on a radiograph. CT and MRI is helpful. Interfaces of air-soft tissue margins may be distorted by pathological lesion Masses otherwise - An enormous amount of information about the mediastinum can be extracted from plain films; the key is a thorough knowledge of anatomical relationships and how structures are likely to project on a radiograph. - Use of cross-sections from CT and MRI will supplement this section. - Understand on plain films the mediastinum projects as a water density surrounded by the two air filled lungs and intersected(橫斷面)by the air filled trachea and major bronchi. - The interfaces of these air-soft tissue margins may be distorted by pathological processes, usually masses, that otherwise would be hidden in the mediastinum.

MEDIASTINUM

Mediastinum Define Key is knowledge of anatomical relationships and Area between the lung Water density Surrounded two air filled lungs and Intersected by the air filled trachea and major bronchi. Key is knowledge of anatomical relationships and how structures project on a radiograph. CT and MRI is helpful. Interfaces of air-soft tissue margins may be distorted by pathological lesion Masses otherwise - An enormous amount of information about the mediastinum can be extracted from plain films; the key is a thorough knowledge of anatomical relationships and how structures are likely to project on a radiograph. - Use of cross-sections from CT and MRI will supplement this section. - Understand on plain films the mediastinum projects as a water density surrounded by the two air filled lungs and intersected(橫斷面)by the air filled trachea and major bronchi. - The interfaces of these air-soft tissue margins may be distorted by pathological processes, usually masses, that otherwise would be hidden in the mediastinum.

Anatomy

Project * Aortopulmonary window

Anatomy & project 1. Carina 2. Left Main Stem Bronchus 3. Descending Aorta 4. Main Pulmonary Artery 5. Aorticopulmonary Window 6. Arch of Aorta

Lateral landmarks on chest radiographs Although it is not uncommon to find the lateral chest film displayed with the body either looking left or right, depending on which side of the patient was closest to the film, it is most sensible to present the lateral the film always in some fixed manner to the viewer so that consistent visual pattern recognition can be achieved. A favored direction is as if the patient were being viewed through the left lateral chest wall, so that the image appears as if the patient is facing the viewer's left. This film orientation provides an assessment of the overall heart size which should show a space anteriorly below the sternum if the right cardiac chambers are not enlarged. The dome of the diaphragm will appear convex upward. - The dome that can be seen to extend most anteriorly is identified as the right diaphragm. - The left diaphragmatic dome merges with undersurface of the heart, a tissue of the same density, and therefore tends to disappear anteriorly. Another marker of the left diaphragm is the gastric air bubble which should most closely approach the boundary of the left diaphragm if the patient has normal cardiac situs.   The trachea should be readily visible to the carina. Where there are slight amounts of fluid in the

MEDIASTINUM Anatomy dividing region SUPERIOR MEDIASTINUM Mediastinum Begins - root of the neck and Ends - line drawn T-4 vertebrae --- sternomandible junction. line skims the top of the aortic arch. T Mediastinum Begins - this line End- diaphragm Further divided into three regions Anterior Middle Posterior. - Although there are several methods of dividing the mediastinum into regions, this program will continue with the system taught in gross anatomy. - The superior mediastinum begins at the root of the neck and ends caudally at a line drawn between T-4 vertebrae and the sternomanubrial junction. Usually that line skims(在...表面凝結) the top of the aortic arch. The area between this line and the diaphragm is further divided into three regions, anterior, middle, and posterior. - Basically, the heart and pericardium form the middle section, everything anterior to the heart is the anterior region, and everything posterior to the heart back to the spine is the posterior mediastinum.

4 1cm

Mediastinum Overall size and shape Trachea: position Margins Lines and stripes Retrosternal clear space Check patient name, position, technical quality. Initial survey Soft tissue including breast, chest wall, companion(同伴,伴侶;朋友) shadow. 4. Review soft tissues and skeletal structures of shoulder girdles and chest wall. 5. Review abdomen for bowel gas, organ size, abnormal calcifications, free air, etc. 6. Review soft tissues and spine of neck. 7. Review spine and rib cage: check alignment(隊列,一直線), disc space narrowing, lytic or blastic regions, etc. 8. Review mediastinum: - overall size and shape - trachea: position - margins: SVC, ascending aorta, right atrium, left subclavian artery, aortic arch, main pulmonary artery, left ventricle - lines and stripes: paratracheal, paraspinal, paraesophageal (azygoesophageal), paraaortic - retrosternal clear space

Mediastinum Overall size and shape Trachea- position Margins SVC- Ascending aorta Right atrium Left subclavian artery- Aortic arch Main pulmonary artery Left antrium Left ventricle Lines and stripes Retrosternal clear space Check patient name, position, technical quality. Initial survey Soft tissue including breast, chest wall, companion(同伴,伴侶;朋友) shadow. 4. Review soft tissues and skeletal structures of shoulder girdles and chest wall. 5. Review abdomen for bowel gas, organ size, abnormal calcifications, free air, etc. 6. Review soft tissues and spine of neck. 7. Review spine and rib cage: check alignment(隊列,一直線), disc space narrowing, lytic or blastic regions, etc. 8. Review mediastinum: - overall size and shape - trachea: position - margins: SVC, ascending aorta, right atrium, left subclavian artery, aortic arch, main pulmonary artery, left ventricle - lines and stripes: paratracheal, paraspinal, paraesophageal (azygoesophageal), paraaortic - retrosternal clear space

Margins I I II III II * Aortopulmonary window IV

* Aortopulmonary window

Venography 1. Right Brachiocephalic Vein 2. Superior Vena Cava 3. Left Brachiocephalic Vein

Axial plan of computer tomography Right Brachiocepahlic Artery Superior Vena Cava Right Paratracheal Stripe Esophagus Left Subclavian Artery Left Common Carotid Artery Left Brachiocephalic Vein

4 1cm

Mediastinum Overall size and shape Trachea: position Margins Lines and stripes Paratracheal Paraspinal Paraesophageal (azygoesophageal) Paraaortic Retrosternal clear space Strip(條,帶;細長片)

Edge of Superior vena cave (SVC) Seen PA(AP) view only Often only a portion Never bulge into the lung with a convex border. - Seen PA(AP) view only, and depending how laterally it projects, its right edge may cast a subtle line on the film. - Sometimes the entire edge is seen, often only a portion, but it should not bulge into the lung with a convex border.

Right Pratracheal stripe

Right Pratracheal stripe Normal- < 5 mm, usually 2-3 mm. Important marker for subtle adenopathy. Distal end - formed by azygous vein Distended vein, stripe > 1 cm. Medial margin -soft tissue interface /right mucosal surface of trachea. Outer margin -begins medial end of clavicle/formed by plural surface of right upper lobe (RUL). Normal structures in soft tissue density between air trachea and the RUL Right wall of the trachea Nerves Fat Lymph nodes Pleura of the RUL. Azygous vein - anteriorly to empty into the posterior surface of the SVC.  Normal- < 5 mm, usually 2-3 mm. Important marker for subtle(精妙的) adenopathy. 3. The distal end of the stripe is formed by the azygous vein, and if the vein is distended, that portion of the stripe may normally be up to 1 cm wide. 4. The medial margin of the stripe is the air-soft tissue interface along the right mucosal surface of the trachea. 5. The outer margin of the stripe begins around the level of the medial end of the clavicle and is formed by the plural surface of the right upper lobe (RUL) against the mediastinum. 6. The only structures normally at that level to give soft tissue density between the air filled trachea and the RUL are the right wall of the trachea, nerves, some fat, lymph nodes, and pleura of the RUL. 7. The stripe ends where the RUL bronchus sweeps under the azygous vein as the latter arches anteriorly to empty into the posterior surface of the SVC. 

Right paratracheal stripe(TOMOGRAM ) Tomography- Purpose: Body planes free of superimposition(重疊;添上). ABC+ABC +ABC +ABC +ABC +ABC +ABCABBBBBBBC

CT of Paratracheal stripe 1. Asending aorta 2. Azygous vein 3. Esophagus 4. Desending aorta 5. Pulmonary trunk

Left Subclavian stripe Width- normal 1.0-1.5 cm. Inner margin- Air mucosal interface -mucosal surface of the trachea, Outer margin interface - Medial aspect of left upper lobe Upper- outer edge Level of the clavicle and will be able to follow it End- Bulge of the aortic arch. The normal width is 1.0-1.5 cm. Its inner margin is the air mucosal interface along the left mucosal surface of the trachea, and its outer margin is the interface of the medial aspect of the left upper lobe against the lateral margin of the left subclavian artery. You usually will pick up the outer edge of the stripe at the level of the clavicle and will be able to follow it down to the bulge of the aortic arch.

Paraspinal stripe

Sometimes(+) on the frontal view Plural edge parallel to the lateral margins of the vertebral bodies. Edge > millimeters beyond the vertebral bodies Should not be lumpy or bulging. Sometimes(+) on the frontal view Plural edge parallel to the lateral margins of the vertebral bodies. Edge > millimeters beyond the vertebral bodies, and should not be lumpy or bulging. (The paraspinal edges are not visible on this image.)

Pleural mediastinal interface Superior Vena Cava Right Paratracheal Stripe Left Subclavian Stripe

Azygoesophageal line or Paraesophageal line

On the forntal view only Formed by the right lower lobe & Mediastinum, containing Esophagus Azygous vein. Overlies the thoracic spine Near the midline Fairly straight, vertically. Bulges convex to lung S/p mediastinal mass, eg. subcarinal lymph nodes Enlarged left atrium. - This is seen on the forntal view only and is formed by the right lower lobe where it meets the portion of the mediastinum containing the esophagus and the azygous vein. - It usually overlies the thoracic spine, at or near the midline, and is usually fairly straight, vertically. - If it bulges convex toward the lung, be suspicious of a mediastinal mass, usually subcarinal lymph nodes or an enlarged left atrium.

CT of the Azygoesophageal line 1. Esophagus 2. Azygous Vein 3. Descending Aorta

Lateral view of tracheal wall Posterior tracheal < 4mm

MEDIASTINUM Overall size/ shape on PA & lateral views Look for Decide if it is normal & age. Look for Obvious masses Calcifications Double check for foreign projects Tubes Electrical leads Pacemaker Artificial valves

MEDIASTINUM Evidence of Look trachea/major bronchus Mediastinal shift Entire or Section of it. Look trachea/major bronchus Size Position Intraluminal masses

SUPERIOR MEDIASTINUM - PA Overall width for normal size, Look for Masses Calcifications Free air. Detailed search for subtle distortion of several major pleural mediastinal interfaces. Not all of the following structures are seen on every film Try to find them

Mediastinum Define Key is knowledge of anatomical relationships and Area between the lung Water density Surrounded two air filled lungs and Intersected by the air filled trachea and major bronchi. Key is knowledge of anatomical relationships and how structures project on a radiograph. CT and MRI is helpful. Interfaces of air-soft tissue margins may be distorted by pathological lesion Masses otherwise - An enormous amount of information about the mediastinum can be extracted from plain films; the key is a thorough knowledge of anatomical relationships and how structures are likely to project on a radiograph. - Use of cross-sections from CT and MRI will supplement this section. - Understand on plain films the mediastinum projects as a water density surrounded by the two air filled lungs and intersected(橫斷面)by the air filled trachea and major bronchi. - The interfaces of these air-soft tissue margins may be distorted by pathological processes, usually masses, that otherwise would be hidden in the mediastinum.

HEART 1 Edge of superior vena cava 2. Right atrium 3. Aortic arch 4. Edge of main pulmonary artery 5. Left atrial appendage 6. Left ventricle

Superimposed on the frontal view. The major structure is the heart. Pericardium and heart is inseparable on plain film views. Review the heart for overall size and shape. Rough yardstick - cardiac-thoracic ratio Widest diameter of the heart /widest width of the thoracic cage( inner aspect of rib to rib). > 50% Check Calcifications Pneumopericardium Pneumomediastinum Sutures Prosthetic valves etc., You may have overlooked on the general survey of the entire mediastinum. 1. Superimposed on the frontal view. 2. The major structure is the heart. 3. Pericardium and heart is inseparable on plain film views. 4. Review the heart for overall size and shape. 5. Rough yardstick(衡量標準,) for size on the frontal film is the ratio of the widest diameter of the heart to the widest width of the thoracic cage as measured from inner aspect of rib to rib. 6. This cardiac-thoracic ratio should be less than 50% (see inset for a graphic illustration of ratio measurements). 7. Look carefully for calcifications, pneumopericardium, pneumomediastinum, sutures, prosthetic valves etc., that you may have overlooked on the general survey of the entire mediastinum.

Gross anatomy - coronal section of the chest

Lateral view of heart 1. Trachea 2. Right Ventricle 3. Left Ventricle 4. Left Atrium 5. Right Pulmonary Artery

Aorta

Young adult - hidden in the mediastinum Try tracking Root Distal descending aorta. Young adult - hidden in the mediastinum Older - swing to the right to cast a soft tissue bulge. Arch- always be seen make sure left to distal trachea Pushes trachea slightly to the right actually . Check aortic calcifications and size. Left lateral border of descending aorta abuts the left lung (column of dots on the pt's. left, on the annotated image). Lateral view- aorta is usually not seen.  1.Try tracking Root Distal descending aorta. 2. Young adult - hidden in the mediastinum Older - swing to the right to cast a soft tissue bulge. 3. The arch should always be seen, make sure it is to the left of the distal trachea and actually pushes the distal trachea slightly to the right. 4. Check for aortic calcifications and size. The left lateral border of the descending aorta abuts(鄰接;毗連;緊靠) the left lung (column of dots on the pt's. left, on the annotated(有註釋的) image). [The other column of dots is not the right side of the aorta, but instead is the paraesophageal line - see below.] 5. On the lateral view the aorta is usually not seen. 

Pulmonary artery 1. Carina 2. Left Main Stem Bronchus 3. Descending Aorta 4. Main Pulmonary Artery 5. Aorticopulmonary Window 6. Arch of Aorta

"middle mogul" - when convex Main pulmonary artery Straight or Convex (most commonly in young females). "middle mogul" - when convex Upper "mogul" - aortic knob Lower mogul - left ventricle. Left pulmonary artery- branching of main pulmonary artery Right pulmonary artery- Proximal- not seen, ( buried in the mediastinum) Branches can see ( as the right hilum) - On the frontal view, the only part of the main pulmonary artery seen is the left lateral border where it meets the left lung. It can be relatively straight or convex (most commonly in young females). - When convex(凸面的), it forms a "middle mogul(大人物)" just above the heart. - The upper "mogul" is the aortic knob, the lower mogul is the left ventricle. - The left pulmonary artery is directly behind the main pulmonary artery, and is visible on frontal films as a branching structure

Blood vesseles in the lung

Pulmonary arteries, Lateral view 1. Trachea 2. Right Ventricle 3. Left Ventricle 4. Region of left Atrium 5. Right Pulmonary Artery 6. Left Pulmonary Artery 6

Pulmonary artery Right pulmonary artery Left pulmonary artery Ovoid branching structure- easily seen, Just anterior to the air column of the trachea and main bronchi. Left pulmonary artery Never seen as clearly as the right Unless markedly enlarged. Curved shadow, similar to the aorta just behind the air column

Normal PA view of the chest Normal PA view of the chest. This is the most common presentation of an otherwise uncomplicated pulmonary embolus.

Aorticopulmonary window (AP WINDOW)

Double check area - for subtle mediastinal masses. Between Aortic arch Left pulmonary artery Residual portion Ligamentum arteriosum left recurrent laryngeal nerve Should concave or straight border. Mediastinal mass(+) Lung pushed laterally  border becomes convex. - Double check area This is another area radiologists for subtle mediastinal masses. It is seen on the frontal view (line of white dots) and is formed by a portion of the upper lobe sitting in the space immediately lateral to the area between the aortic arch and left pulmonary artery (remember ligamentum arteriosum and left recurrent laryngeal nerve?). - The AP window should have a concave or straight border. If there is a mediastinal mass in the AP window region, the lung will be pushed laterally and the border becomes convex.

MISCELLANEOUS Lateral view Check posterior sternal margin Adult anterior mediastinum cephalad to the heart Lung-air density, not soft tissue density. Infants and young children Thymus fills this area. Check posterior sternal margin Small masses: internal thoracic lymph node enlargement.

Check List Review hila: Review lungs and pleura: normal relationships size Review lungs and pleura: compare lung sizes evaluate pulmonary vascular pattern: compare upper to lower lobe, right to left, normal tapering to periphery pulmonary parenchyma pleural surfaces fissures - major and minor - if seen compare hemidiaphragms follow pleura around rib cage

Frontal view of the hila

Frontal view of the hila Frontal view, hilar shadows most left pulmonary arteries. right pulmonary arteries. Bronchi(with the arteries) Radiolucent. Pulmonary veins Not clearly seen they are behind the widest parts of the heart, inferior to the hila, where they converge into the left atrium. Left pulmonary artery always more superior > right,  left hilum higher. Calcified lymph nodes may be visible within the hilar shadows. 

Lateral view of the hila 1. Trachea 2. Lower lobe bronchi (left and right superimposed) 3. Right Pulmonary Artery

Check List Review hila: Review lungs and pleura: normal relationships size Review lungs and pleura: compare lung sizes evaluate pulmonary vascular pattern compare upper to lower lobe, right to left, normal tapering to periphery pulmonary parenchyma pleural surfaces fissures - major and minor - if seen compare hemidiaphragms follow pleura around rib cage

Lung size

Lung Compare overall size of one lung bilateral, Also a double check on your earlier look at the rib cage size. Look for major areas of abnormal lucency/or density Train your eyes to look through the heart and upper abdomen to lung posterior to these areas.

Blood vesseles in the lung

Blood vesseles in the lung Distribution- side to side Compare right/left upper lobes and lower lobes for roughly equal. Distribution- upper to a lower Vessel in the same middle zone of the lung. Upright person- pressure differential lower lobe vessel wider (i.e., larger) If same size or reversed in size, Redistribution of flow has occurred. Phenomenon does not apply, if the person is semi-recumbent or supine. 

Blood vesseles of lung

PARENCHYMA

PARENCHYMA Large abnormalities/small lesion Masses Infiltrates calcifications Compare- side to side at a time. Now ignore the bone but lung. 3 areas easily overlooked: Behind the calcified anterior first rib cartilage, Behind the heart Behind the diaphragm

LATERAL VIEW OF THE LUNG Help to look Posterior costophrenic recess Anterior mediastinum. Lateral view is your great chance to look at the lung in the posterior costophrenic recess and anterior mediastinum.

Pleura PA view Lateral view Minor fissue thickness and location minor fissures major fissures (even if you do not see them in their entirety which you rarely will).

AP VIEW OF THE PLEURA Follow the pleural surface around the lung periphery making the following observations. On the frontal view, the apex of the hemidiaphragms should be in the mid third of each hemithorax with the right hemidiaphragm usually 2-2.5 cm higher than the left. The costophrenic angles laterally should be sharp. The lung should abut right up against the inner margins of the rib cage. If the pleural space is widened by fluid or mass, the lung will be pushed away by soft tissue density. Also check for pleural calcifications, and presence of pneumothorax. 

LATERAL VIEW OF THE PLEURA ,follow the pleura into the posterior costophrenic recess along the inner aspect of the posterior ribs, if possible. Recheck Posterior sternal margin.

Soft tissues Overall Following Calcifications Bony defect Soft tissue companion shadow for the clavicle Supraclavicular LAP 1. Soft tissues look again at overall amount, then check for the following: calcifications, obvious mass effect, abnormal air collections (called subcutaneous emphysema), and soft tissue companion shadow for the clavicle (this is a normal but variable finding). 2. Bones look at each bone for the following items (notice again the progression from general to increasingly specific detail throughout the review). If your anatomic memory is hazy, refresh with a review of the gross anatomy radiology review program.

Lt/Rt CHEST WALL Overall thickness, subcutaneous emphysema, calcification. Muscle-fat planes (sharp, distinct; dots). - Look for overall thickness, subcutaneous emphysema, calcification. - Look for sharp, distinct muscle fat planes as illustrated on the annotated image (dots).

BREAST TISSUE Symmetry (Normal variation – Standing(PA view) + unequal pressure against the film holder) Notice lung density changes (lung area +/- soft tissue of the breast ) - In males and females, some asymmetry can occur from standing with unequal pressure against the film holder. - Notice how the apparent lung density changes from the lung area covered by the soft tissue of the breast to the lung area inferior to the breast.

ABDOMEN Highly variable look for following Gastric and bowel gas Amount/ location( normal? ) Organ size liver, spleen, kidneys Free peritoneal air Position will change location of free air. Calcifications and masses can they be localized to a specific structure. - The visibility of structures is highly variable but look for the following even if you see very few on any one exam. - Gastric and bowel gas - Is amount and location normal? - Check for organ size of liver, spleen, and kidneys if visible. - Check for free peritoneal air - Remember position of patient will change location of free air. - Look for calcifications and masses - can they be localized to a specific structure.

Final Notes

This completes an introduction into the beginnings of chest review. Be aware there are many more detailed observations to learn in the future. Go through the sections until you understand the anatomy, and then start practicing a continuous review looking at a full frontal and lateral view. When you have developed a review system that works for you (remember the order here is only a guide) go to the next section that has the check off list type of review. Many people find it helpful to talk their way through the film, the eye-brain-mouth loop does work. Finally look at films on a variety of normal people of all ages, sizes, and both sexes to develop a data base of normal references. Practice the review sequence that works best for you until it is automatic, and then you can concentrate on the diagnostic findings. 

Check List (1) Check patient name, position, technical quality. Initial survey Soft tissue including breast, chest wall, companion shadow. Review soft tissues and skeletal structures of shoulder girdles and chest wall. Review abdomen for bowel gas, organ size, abnormal calcifications, free air, etc. Review soft tissues and spine of neck. Review spine and rib cage: check alignment, disc space narrowing, lytic or blastic regions, etc. Review mediastinum: overall size and shape trachea: position margins: SVC, ascending aorta, right atrium, left subclavian artery, aortic arch, main pulmonary artery, left ventricle lines and stripes: paratracheal, paraspinal, paraesophageal (azygoesophageal), paraaortic retrosternal clear space Check patient name, position, technical quality. Initial survey Soft tissue including breast, chest wall, companion(同伴,伴侶;朋友) shadow. 4. Review soft tissues and skeletal structures of shoulder girdles and chest wall. 5. Review abdomen for bowel gas, organ size, abnormal calcifications, free air, etc. 6. Review soft tissues and spine of neck. 7. Review spine and rib cage: check alignment(隊列,一直線), disc space narrowing, lytic or blastic regions, etc. 8. Review mediastinum: - overall size and shape - trachea: position - margins: SVC, ascending aorta, right atrium, left subclavian artery, aortic arch, main pulmonary artery, left ventricle - lines and stripes: paratracheal, paraspinal, paraesophageal (azygoesophageal), paraaortic - retrosternal clear space

Check List (2) Review hila: Review lungs and pleura: normal relationships size Review lungs and pleura: compare lung sizes evaluate pulmonary vascular pattern: compare upper to lower lobe, right to left, normal tapering to periphery pulmonary parenchyma pleural surfaces fissures - major and minor - if seen compare hemidiaphragms follow pleura around rib cage