Chest Radiography 2/25/2010jh

Xrays are electromagnetic waves that radiate in a tube from which electrical currents are passed. How it works: electrons strike a target and physically change which results in an emission of xrays. The xrays are emitted in all directions. They penetrate most matter and the picture they produce depends on the density of the object. (we will talk more about this in the next few slides) 2/25/2010jh

Different tissues in our body absorb X-rays in different amounts: CXR Different tissues in our body absorb X-rays in different amounts: Radiolucent- (see through) Black Radiopaque (dense) White Radiolucent: see through, black. This would be air in the lungs. It turns black because more of the xrays can pass completely through. Radiopaque: white, less rays pass through leaving the denser tissue white 2/25/2010jh

Densities CXR Bone Water Fat Air 2/25/2010jh Bone- very dense, so appears very white on an xray Water- not quite as dense as bone, so appears a little less white (lighter gray) Fat- less dense than water, appears dark gray Air- the least dense, appears black The patient and film should be approx. 6 feet away from the xray source for a proper image (we will discuss overexposure later on), portable films need to be taken about 4 feet away 2/25/2010jh

Placement of invasive lines Determine progression of Disease Indications Pulmonary work up ABG, PFT, CXR, H and P Diagnose Disease Determine Therapy Evaluate Tx Placement of invasive lines Determine progression of Disease Chest xrays are an important part of a pulmonary work up for a patient. Chest xrays help diagnose disease, determine therapy needed, evaluate treatments given, can determine placement of invasive lines, and determine the progression of disease. 2/25/2010jh

CXR Views PA the x-rays penetrate through the back of the patient on to the film Standard Standard CXR views are taken in two directions. PA and AP. PA= posterior to anterior Arms should be out of the way and patient’s should take a deep breath and hold it in if they can (sometimes, you will be asked to place the patient on an inspiratory hold on the ventilator). With this view, the heart will appear smaller than the AP view because the heart sits in the anterior portion of the chest. A standing lateral view is the other standard view taken. Typically, the patient places their left side against the cassette so the heart is smaller and you can see more of the lungs. 2/25/2010jh

CXR Views AP- the x-rays penetrate through the front of the patient on to the film PORTABLE Not usually done with standard xrays, but you will see it done as a portable xray because the patient is too sick to get out of bed or too sick to stand. Xray taken from anterior to posterior. Be sure to step out of the room or wear lead when your patient is being xrayed. The heart will appear larger in this view. It’s also usually more difficult to read as positioning and exposure of the xray will be less consistent (extra lines, bedding, etc. in the way, also patient often can’t follow commands like full inspiration on chest xray) 2/25/2010jh

CXR Views Lateral Decubitus Evaluate fluid in pleural space Must lay on the left or right side. Helps diagnose a pleural effusion (fluid will fall to gravity), or a smaller pneumothorax (air should rise). So, right pleural fluid= lay on right side. Right sided pneumo, place on the left side. (xray on next slide) 2/25/2010jh

Pleural Effusion Lateral decub. Xray. You can see how all the fluid buildup is on the right side. Other views: apical lordotic, looks from bottom up at 45 degree angle. Helps see the upper portion of the lungs. (TB, CA, etc.) Oblique view: 45 degrees from right or left side. Helps detect abnormalities. 2/25/2010jh

Croup (AP neck) www.uptodate.com/.../croup_steeple_sign.jpg There are two conditions that a neck xray is very helpful with diagnosis. It can be helpful with diagnosing upper airway issues such as croup and epiglottitis. With croup, you will see a classic steeple sign which will appear pointed the closer you get to the patient’s head. This is due to upper airway inflammation. www.uptodate.com/.../croup_steeple_sign.jpg 2/25/2010jh

Epiglottitis (Lateral) Will epiglottitis, you will see what we call a thumb sign because it looks like a thumb poked into the person’s neck. waent.org 2/25/2010jh

CAT Scans V / Q scans Angiography Fluoroscopy Other Evaluations 2/25/2010jh

The use of computers with tomography results in very fine detail. Computed Tomography The use of computers with tomography results in very fine detail. The cost of CT is much higher than that of a conventional chest x-ray TOMOGRAPHY: The use of imagery in sections- 2mm sections. Lung tumors—most often evaluated with CT. It helps us see tissues that often don’t show up on xray. Adding contrast can make it even more clear. Chronic interstitial lung Occupational lung disease (pulmonary fibrosis caused from inhaling dusts, pollutants, etc) CT can identify changes seen in the pleura and lung tissue. Pneumonias—certain lung infections that also involve the pleura may be evaluated with CT. Smaller infections or hilar infections are easier to see on CT. Chronic obstructive pulmonary disease (COPD) CT not used in most COPD patients but may prove useful when severe emphysematous blebs are present. 2/25/2010jh

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Done to evaluate the patient suspected of having a pulmonary embolism Angiography Done to evaluate the patient suspected of having a pulmonary embolism 2/25/2010jh

Used to determine pulmonary embolism Angiography An angiography is an x-ray of an artery or arteries in the body. Used to determine pulmonary embolism In order to actually see the arteries, a special dye, referred to as a contrast dye, is injected through the artery (done by threading a catheter in through a vein and injecting the dye near the SVC so it can reach the arteries-pulmonary angiography). Once the dye is flowing through the artery, an x-ray can be taken to determine whether or not blood is flowing normally through the vessel. An angiography can help to identify tumors, blood clots or atherosclerotic plaque that may be partially blocking blood flow Generally only done if V/Q scan and CT scan can’t determine diagnosis and patient is at high risk. CT angiography does not require feeding a catheter into the body so it is used more frequently 2/25/2010jh

Fluoroscopy Live X ray An x-ray procedure that makes it possible to see internal organs in motion. Fluoroscopy uses x-ray to produce real-time video images. Murrugun The Mystic - Sword Swallowing Fluoroscopy - YouTube After the x-rays pass through the patient, instead of using film, they are captured by a device called an image intensifier and converted into light. The light is then captured by a TV camera and displayed on a video monitor. Used to evaluate diaphragm functions Used during bronchoscopy with Biopsy 2/25/2010jh

Check the quality of the film Check position Check inspiration Evaluating Chest X rays… Be systematic: Check the quality of the film Check position Check inspiration Check Technique Check Name!!! Evaluate lung fields More details to follow… 2/25/2010jh

The ABC’s of X-ray A – Airways B – Bones C – Cardiac (silhouette) D – Diaphragm More details to follow 2/25/2010jh

E – ETT F – Fissures G – Gastric H – Hilum The ABC’s of X-ray E – ETT F – Fissures G – Gastric H – Hilum Hilum (The region of each lung where the bronchi, blood vessels, and nerves enter and leave the lungs) 2/25/2010jh

X-ray Evaluation Place the chest film on the view box as if the patient were facing the clinician i.e., the right side of the patient’s chest is on the clinician’s left, Cardiac shadow on left side of chest X-rays are often marked R or L http://www.youtube.com/watch?v=qAjEJZ-mQvQ 2/25/2010jh

Was film taken under full inspiration? -10 ribs should be visible Film Quality Was film taken under full inspiration? -10 ribs should be visible 2/25/2010jh

Count 10 ribs (don’t forget the ribs at the very bottom) 2/25/2010jh

2/25/2010jh Anatomical landmarks The airways are just barely visible with the slightly darker markings down the center 2/25/2010jh

Quality (cont.) Check to see if the film over or under penetrated Properly penetrated chest radiograph is one which the vertebral bodies can be seen Vertebral bodies should be just barely visible. If they can be seen easily, it’s over exposed. If they can’t be seen at all, underexposed. 2/25/2010jh

An under-penetrated chest x-ray does not differentiate the vertebral bodies from the intervertebral spaces An over-penetrated film shows the intervertebral spaces very distinctly 2/25/2010jh

Quality (cont) Check for rotation Does the thoracic spine align in the center of the sternum and between the clavicles? Are the clavicles level? 2/25/2010jh

See how the spine looks a little twisted? Doesn’t look quite right… 2/25/2010jh

Verify Right and Left sides Gastric bubble should be on the left. Heart should be on the left 2/25/2010jh

Verify Left and Right 2/25/2010jh Gastric bubble is on the left side of the patient as well as the heart 2/25/2010jh

Now you are ready Look at the diaphragm: abnormal elevation Margins should be sharp (the right hemidiaphragm is usually slightly higher than the left) Elevated right hemidiaphragm 2/25/2010jh

Silhouette-margins should be sharp Check the Heart Size Shape Silhouette-margins should be sharp Diameter (>1/2 thoracic diameter is enlarged heart) Remember: AP views make heart appear larger than it actually is. If the silhouette sign is blurry, it is a sign that there may be some lung consolidation 2/25/2010jh

Cardiac Silhouette R Atrium Superior Vena Cava Pulmonary Valve R Ventricle 3. Apex of L Ventricle Superior Vena Cava Inferior Vena Cava 6. Tricuspid Valve Pulmonary Valve Pulmonary Trunk 9. R PA 10. L PA 2/25/2010jh

In this xray, the heart is taking up more than half of the thoracic cage. This is most likely heart failure due to the vascular congestion as well 2/25/2010jh

Check the Costophrenic angles Margins should be sharp 2/25/2010jh

Loss of Sharp Costophrenic Angles Often the cause of a pleural effusion 2/25/2010jh

Finally, Check the Lung Fields Infiltrates Increased interstitial markings Masses Absence of normal margins Air bronchograms Increased vascularity 2/25/2010jh

Air Bronchogram Air bronchogram (Black arrowheads pointing to air bronchogram) Bronchi beyond 3-4 order of branching is not recognizable in CXR, because of loss of thickness and no contrast between intra bronchial  air and surrounding alveoli containing air. In pneumonia the disease is primarily in the alveoli. Bronchi are patent. Air in the alveoli is replaced by inflammatory exudate. Now bronchi containing air is visible because of the contrast provided by liquid density induced by inflammatory exudate. This Xray is also overexposed a little (super dark lung fields and can easily see the vertebrae) 2/25/2010jh

Atelectasis Can be compressive or obstructive 2/25/2010jh Compressive- another problems pushes on the lung collapsing part or all of it. (pneumo/hemothorax is a common cause) Obstructive-caused by blockage of an airway so ventilation. of that area is absent. (tumor, mucus plugs, etc.) Picture: atelectasis (complete, right lung) 2/25/2010jh

Pneumothorax When air enters the pleural space. Either from chest wall or from lung Often causes atelectasis. Can you see the tracheal and cardiac shift? 2/25/2010jh

Hyperinflation Often due to obstructive lung disease Increased A/P diameter, flattening of diaphragm, large airspace. See how flat the diaphragm is? Large spaces between ribs? 2/25/2010jh

Interstitial Lung disease Fibrotic changes, you may see large hilar and paratracheal lymph nodes, calcified nodules, honeycomb cavities in lungs, air bronchograms. 2/25/2010jh

Congestive Heart Failure Large heart Fluid collection in vasculature and gravity dependent portions Kerly’s B lines 2/25/2010jh

Congestive heart failure Kerly B. Little horizontal lines. Also notice the consolidation in the vascular markings. (this heart doesn’t look too bad actually) 2/25/2010jh

Pleural Effusion Sometimes a meniscus sign too (fluid filled between the lung and chest wall, forms an opaque white crescent). You will talk about this more in advanced patient assesment. Can also increase egophony (spoken voice increases in intensity and sounds nasal), diminished breath sounds in that area, dull percussion in that area. 2/25/2010jh

Consolidation Copious mucus production that fills the lung tissue. Right middle lobe consolidation 2/25/2010jh

Interpretation: pneumothorax on the right side (tension) 2/25/2010jh

What do you see? Air bronchograms left upper lobe. Consolidation through left side. Okay inflation. Overexposed xray. Gastric bubble on left side. Heart is most likely pushed over. 2/25/2010jh

Hyperinflation, flat diaphragm, narrow heart. 2/25/2010jh