Chest Xrays Dr Faezeh Sakhinia FY2

Aims Basics of CXR interpretation OSCE approach Images with explanation Quiz!!

Initial Approach Details: Correct patient Correct date Correct examination (CXR) Correct view AP/PA Supine/portable/lateral On an AP CXR the heart often appears larger than it is – so you can’t really comment on the heart size in these examples. AP: ?EMERGENCY FILM

Projections PA AP LATERAL

Picture Quality Rotation Inspiration Picture Exposure (Penetration) Rotation – medial clavicle ends equidistant from spinous process Inspiration – 5-6 anterior ribs in MCL or 8-10 posterior ribs above diaphragm, poor inspiration?hyperexpanded? Picture – straight vs oblique, entire lung fields, scapulae outside lung fields Exposure (Penetration) – IV disc spaces, spinous processes , left hemidiaphragm visible through cardiac shadow.

Order of View Airway– is it deviated? Breathing – Lungs Circulation – Heart (normal<½ cardiothoracic ratio in PA view) Diaphragm – R>L by ~ 1 intercostal space, cardiophrenic and costophrenic angles Extras – pneumoperitoneum? air under the skin (surgical emphysema), fractures, lines (NG,ECG, chest drains, pacemaker) ‘C3, C4, C5 keeps the diaphragm alive’

OSCE Approach OSCE Example: “This is a plain chest xray of John Smith in a PA view. The film is adequately exposed and orientated.” The main findings are: Starting off with the airways....

Normal Xray

Pleural Effusion Meniscus Uniformly white Exudate/transudate Case: Clinical information Life long smoker Weight loss and increasing shortness of breath Diagnosis Large left pleural effusion Underlying bronchogenic carcinoma

Consolidation with Air Bronchograms Clinical information The patient had a high temperature and a productive cough Diagnosis Pneumonia - consolidation with pus Differential diagnosis of consolidation Pneumonia - airways full of pus Cancer - airways full of cells Pulmonary haemorrhage - airways full of blood Pulmonary oedema - airways full of fluid

COPD Chest xrays demonstrates very marked hyperinflation of both lungs. Over 11 posterior ribs are seen, the diaphragms are flattened and there is enlargement of the retrosternal airspace.  Pulmonary vasculature not terribly distorted, although there is some prominence of the pulmonary arteries.  

Pneumothorax Tension pneumothorax This is the one not to miss. If you cannot diagnose a tension pneumothorax at medical finals you won't find an examiner who will defend you. The left hemithorax is black due to air in the pleural cavity. Signs of tension The left lung is completely compressed (arrowheads). The trachea is pushed to the right (arrow) The heart is shifted to the contralateral side - note right heart border is pushed to the right (red line) The left hemidiaphragm is depressed (orange line) Remember If you diagnose a tension pneumothorax clinically - do not request an X-ray - TREAT THE PATIENT!

Left Lower Lobe Collapse The tracheal deviation seen in this chest x-ray is due to left lower lobe collapse. This has a classical appearance of a 'double left heart border,' or a 'sail sign' (orange). The second heart border (curved arrow) is due to the dense edge of the collapsed left lower lobe, which has been squashed into a triangle or sail shape. Note that the left hemidiaphragm cannot be followed all the way to the spine. This is because the left lower lobe sits directly on top of the diaphragm, and as it no longer contains air, it is of the same soft tissue density as the diaphragm and therefore blends into it.

Left Upper Lobe Collapse Note the following appearances Trachea deviated to the left Right heart border not visible - indicating mediastinal shift to the left Volume loss of the left hemithorax 'Veil-like' opacification of the left hemithorax obscuring the left heart border - characteristic of left upper lobe collapse Ovoid density at the left hilum CT confirmed a large left hilar mass, which occluded the left upper lobe bronchus. Note the left hemidiaphragm is still visible - indicating sparing of the left lower lobe The left lower lobe has increased in volume to compensate for the volume loss and can be seen wrapping round the medial side of the collapsed upper lobe (red line). This is known as the 'Luftsichel' (air crescent) sign .

Right Lower Lobe Collapse This chest x-ray shows tracheal deviation to the right. There is no pleural effusion on the left, and there is overall volume loss of the right hemithorax, compared with the left. The mediastinum is therefore PULLED to the right. Bronchoscopy showed a cancer occluding the right lower lobe bronchus. The x-ray shows right lower lobe collapse (ringed). Although the mass itself is not seen clearly, collapse of a lung lobe in an adult should raise the suspicion of a malignant process.

Right Upper Lobe Collapse There is volume loss of the right upper lobe. The right upper zone has become dense due to lobar collapse. The volume loss has displaced the trachea which is PULLED to the right, and the horizontal fissure (arrow) has been PULLED upwards Right upper lobe collapse is hardly ever caused by plugging of mucous or foreign bodies. The presence of right upper lobe collapse in an adult should therefore immediately raise the suspicion of an underlying malignant process occluding the right main bronchus.

Lung Cancer 'cannon ball lesions’ : Lesions of 2-3cm diameter usually 

Heart failure Signs of heart failure Cardiomegaly CTR = 18/30 Upper zone vessel enlargement (1) - a sign of pulmonary venous hypertension Pulmonary oedema (2) - bilateral increased lung markings (classically peri-hilar and shaped like bats wings - more widespread in this case) Septal (Kerley B) lines (3) - See next picture Pleural effusions (4) Clinical information Worsening exercise tolerance Chronic uncontrolled hypertension Rapid onset of shortness of breath Atrial fibrillation Diagnosis Left ventricular failure with pulmonary oedema Septal lines (Kerley B lines) Costophrenic angle Horizontal lines reaching the lung edge Septal lines - a specific sign of pulmonary oedema Differential diagnosis Occasionally conditions that cause lymphatic obstruction may cause septal lines - such as sarcoidosis or lymphangitis carcinomatosa

QUIZ!!! Easy......Odd!

Consolidation & Collapse (pneumonia)

Pneumothorax (COPD)

Mastectomy

Dextocardia with Situs Inversus Be careful it could be a mistake with labelling On clinical examination the apex beat was found on the RIGHT, confirming dextrocardia.

Valve Replacements The aortic valve is above the red line and the mitral valve lies below it.

Nipple Ring!

If you can answer these...a career in radiology is for you!!!

Pneumonectomy Pneumonectomy The trachea, hila and mediastinum are deviated to the left. Are they PUSHED or PULLED? This patient has had a pneumonectomy (removal of the left lung) to treat a lung cancer. Note the left main bronchus is abruptly cut off (arrowhead). The left hemithorax is filled by the heart and great vessels which have moved to the fill the space vacated by the removed lung. The right lung has expanded to fill the space vacated by the heart.

Surgical Emphysema Secondary to Chest Drain Drain/surgical emphysema Surgical emphysema (subcutaneous trapped air) is a complication of chest drain insertion, or sometimes of the pneumothorax itself. Surgical emphysema can form because of poor technique during drain insertion or because of displacement of the drain such that a side hole near the end of the drain lies within the subcutaneous tissues. Surgical emphysema has the clinical characteristic of feeling like 'rice crispies' or 'bubble wrap' on palpation.

Asbestos Related Pleural Plaques Bilateral well defined irregular shadows that are as dense as the bones Peripheral pleural thickening Clinical information Chronic mild shortness of breath Retired dock worker with clear history of asbestos exposure Diagnosis Bilateral calcified asbestos related pleural plaques

Quiz Done...and Relax!!!

Summary

Thank You!!