Med Students Lecture Series Chest University Hospitals Case Medical Center Department of Radiology

Factors in evaluation for a technically adequate chest x-ray

Factors in evaluation for a technically adequate chest x-ray Penetration Inspiration Rotation Magnification Angulation

Penetration Should be able to faintly see the thoracic spine through the heart shadow Underpenetration Will not be able to see the spine through the heart Introduced Errors Left lung base may be opaque Pulmonary markings may be more prominent Overpenetration Lung markings will seem decreased or absent

Penetration NORMAL UNDERPENETRATED OVERPENETRATED http://images.radiopaedia.org/images/220869/76052f7902246ff862f52f5d3cd9cd.jpg http://www.med-ed.virginia.edu/courses/rad/cxr/web%20images/penet-underexposed.jpg http://img185.imageshack.us/img185/451/26183645.gif NORMAL UNDERPENETRATED OVERPENETRATED

Inspiration Assess by counting the number of posterior ribs Excellent inspiration – 10 posterior ribs Hospitalized patients – 8 to 9 posterior ribs Poor inspiration Compresses and crowds the lung markings http://www.learningradiology.com/medstudents/recognizingseries/Recognizing%20Adequate-2012/Recognizing%20Adequate-2012.html

Rotation Evaluate the medial end of each clavicle Rotation may alter the contours of the heart, great vessels, hila and hemidiaphragm NORMAL

Rotation http://www.learningradiology.com/medstudents/recognizingseries/Recognizing%20Adequate-2012/Recognizing%20Adequate-2012.html

Magnification The closer an object is to the surface being imaged, the more true to its actual size the resultant image will be PA chest x-ray – heart is an anterior (closer to the imaging surface) – will be more true to size AP chest x-ray – heart is posterior structure - magnified http://www.learningradiology.com/medstudents/recognizingseries/recogadequateflashpage.htm

Magnification http://www.learningradiology.com/medstudents/recognizingseries/recogadequateflashpage.htm

Angulation X-ray beam should pass horizontally for an erect chest x-ray Hospitalized patients - May not be able to sit upright X-ray beam will be directed toward the patient’s head  APICAL LORDOTIC VIEW

Angulation

Factors in evaluation for a technically adequate chest x-ray Penetration Inspiration Rotation Magnification Angulation

Basic Densities Conventional Radiography Air Fat Fluid/Soft-Tissue Calcium Metal NORMAL

Basic Densities Conventional Radiography Air Fat Fluid/Soft-Tissue Calcium Metal Air NORMAL

Basic Densities Conventional Radiography Air Fat Fluid/Soft-Tissue Calcium Metal Fat NORMAL

Basic Densities Conventional Radiography Air Fat Fluid/Soft-Tissue Calcium Metal Soft tissue NORMAL

Basic Densities Conventional Radiography Air Fat Fluid/Soft-Tissue Calcium Metal Calcium NORMAL

Basic Densities Conventional Radiography Air Fat Fluid/Soft-Tissue Calcium Metal Metal NORMAL

Opacified Hemithorax Large pleural effusion Atelectasis Pneumonia of the entire lung Pneumonia of an entire lung Pneumonectomy http://www.swansea-radiology.co.uk/images/case_study42_image1.jpg

Mediastinal Shift – Right sided hemithorax Opacified Hemithorax Mediastinal Shift – Right sided hemithorax Heart Trachea Right Hemidiaphram Pleural Effusion Leftward Left Disappears Pneumonia No shift Midline May disappear Atelectasis Rightward Right Upward Pneumonectomy

Pleural Effusion Transudative Exudative Congestive Heart Failure Hypoalbuminemia Cirrhosis Nephrotic Syndrome Empyema pus Hemothorax fluid hematocrit > 50% blood Chylothorax increased TG or cholesterol

Pleural Effusion Different Appearances of Pleural Effusions Subpulmonic Effusion Blunting of the Costophrenic Angles The Meniscus Sign Loculated Effusions Fissural Pseudotumors Laminar Effusions Hydropneumothorax

Pleural Effusion Subpulmonic Effusion http://www.vcuthoracicimaging.com/Historyanswer.aspx?qid=44&fid=1 Free flowing - Below the diaphragm Frontal – highest point of the hemidiaphragm is displaced laterally Lateral – curved hemidiaphragm has an abrupt change when it meets the major fissure – becomes flat anteriorly

BLUNTING OF THE COSTOPHRENIC ANGLE Pleural Effusion BLUNTING OF THE COSTOPHRENIC ANGLE http://openi.nlm.nih.gov/imgs/rescaled512/3167139_kjae-61-166-g001.png Normal Amount of Pleural fluid – 2 to 10mL fluid Lateral Projection – Posterior Costophrenic Angle – 75mL fluid Frontal Projection – Lateral Costophrenic Angle – 300mL fluid

Pleural Effusion MENISCUS SIGN http://www.learningradiology.com/medstudents/recognizingseries/recogeffusionflashpage.htm Pleural fluid appears to rise higher along the edges of the thorax Meniscus Shape medially and laterally  Upside down “U”

Pleural Effusion LOCULATED EFFUSIONS http://openi.nlm.nih.gov/imgs/rescaled512/2700481_ATM-04-75-g040.png Result of limited mobility of the pleural effusion often by adhesions old empyema or hemothorax Unusual shapes – do not change appearance with changing positions Difficult to drain non communicating pockets

FISSURAL PSUEDOTUMORS Pleural Effusion FISSURAL PSUEDOTUMORS http://www.learningradiology.com/caseofweek/caseoftheweekpix2/cow159sidebyside.jpg Sharply marginated collections of pleural fluid  Lenticular shape Interlobar pulmonary fissure – minor fissure is the most common Subpleural location Not free-flowing

Pleural Effusion LAMINAR EFFUSIONS NORMAL EFFUSION http://o.quizlet.com/acYbmkEAPuH9JnanyKn7uQ_m.jpg Thin band-like density along the lateral chest wall Near costophrenic angle Not free-flowing

Pleural Effusion HYDROPNEUMOTHORAX http://api.ning.com/files/rQyHlaA8eUZY04Eo0AvfKUrBmlTlr9PH-sPJ0IWgEorhSrx3rv8GQnfhKiIsnc4vsgvJWw2layetc4PPpOkj08FVrWyIhW0X/1.2.840.113564.10.1.48834858645158166241631765811922122914628.jpg?width=732&height=600 Both Air (Pneumothorax) and Fluid in the Pleural space Air-Fluid Level Etiology – Trauma, Surgery, Bronchopleural Fistula

Pneumonia Consolidation of the lung produced by inflammatory exudate General Characteristic - More dense than surrounding aerated lung Patterns: Lobar Segmental Interstitial Round Cavitary

Pneumonia Lobar pneumonia http://www.freewebs.com/kundipaediatrics/xray.JPG http://www.learningradiology.com/lectures/chestlectures/Pneumonias-2012/Pneumonias-2012.html Prototype – pneumococcal pneumonia: Streptococcus pneumoniae Homogeneous consolidation of affected lobe with air bronchograms Sharp margins at the edge of a lobe – interlobar fissure Silhouette sign – where consolidation contacts heart, aorta, or diaphragm

Pneumonia SEGMENTAL pneumonia http://www.learningradiology.com/lectures/chestlectures/Pneumonias-2012/Pneumonias-2012.html Prototype – bronchopneumonia – Staphylococcus aureus Spreads via the tracheobronchial trachea Patchy airspace disease – involving several segments simultaneously Margins are fluffy and indistinct, No air-bronchograms

INTERSTITIAL pneumonia http://robochest.com/WebHelp/Images/Interstitial/pjp.jpg Prototype – Viral pneumonia Mycoplasma pneumonia, Pneumocystis (AIDS) Involves airway walls and alveolar septa - Reticular interstitial disease Diffuse spread throughout the lungs

Pneumonia ROUND pneumonia http://images.radiopaedia.org/images/454292/c32b79e12b2355b1730f977ea57985.jpg Mostly children – Haemophilus influenzae, Streptococcus, Pneumococcus Spherical shape – may resemble a mass Lower lobes

Pneumonia CAVITARY pneumonia http://www.learningradiology.com/lectures/chestlectures/Pulmonary%20Tuberculosis-2012/Pulmonary%20Tuberculosis-2012.html http://tjgmd99.files.wordpress.com/2010/05/cavitary-tb.jpg Prototype – Mycobacterium tuberculosis Other organisms – Stahylococcal pneumonia, Klebsiella, Coccidiodomycosis Usually occurs with post primary TB – reactivation TB upper lobe predominance, thin-walled, no air-fluid levels

Pneumothorax Air within the pleural space – between the parietal and visceral pleura Types Simple no shift of mediastinal structures Tension shift of mediastinum AWAY from pneumothorax cardiopulmonary compromise Causes Spontaneous Rupture of an apical, subpleural bleb or bulla Tall, thin males – ages 20-40 Traumatic Traumatic or iatrogenic

Pneumothorax Signs Visualization of the visceral pleural line Convex curve of the visceral pleural line Paralleling the contour of the chest wall Absence of lung marking Beyond the visceral pleural line Deep sulcus sign Air-fluid level in the pleural space Hydropneumothorax  previously discussed

Pneumothorax Visible visceral pleural line Convex visceral pleural line Absence of lung markings http://www.learningradiology.com/medstudents/recognizingseries/pneumothoraxflashpage.htm http://www.nejm.org/na101/home/literatum/publisher/mms/journals/content/nejm/2010/nejm_2010.362.issue-12/nejmicm0901473/production/images/large/nejmicm0901473_f1.jpeg

Pneumothorax Deep sulcus sign Important for supine films http://images.radiopaedia.org/images/547159/ca7ec009730443cc9ec80260efc51a.jpg http://www.nejm.org/na101/home/literatum/publisher/mms/journals/content/nejm/2012/nejm_2012.366.issue-6/nejmicm1105315/production/images/large/nejmicm1105315_f1.jpeg

Please read the supplemental article on mediastinal masses Questions? Please read the supplemental article on mediastinal masses Chest quiz will be administered on Thursday at 11:30AM before conference Major Text Reference for Power Point: Learning Radiology: Recognizing the Basics By William Herring