1. Chest X-rays Ash Kumar

2. 4 densities Air Fat Soft tissue Bone

3. Air Bone Soft tissue Fat

4. The silhouette sign When adjacent structures of different densities form a crisp silhouette Right heart border Above horizontal fissure Aortic knuckle Paraspinal line

5. How to present a chest X-ray!?

6. READ THE DETAILS (OUT LOUD) Mr Joe Bloggs 14/01/1956 1234567 Date: 17/01/2013 Time: 11.15am

7. P-O-R-P-I Projection Orientation Rotation Penetration Inspiration

8. Projection AP- Anteroposterior- the X-ray machine is in front of the patient and the X-ray film at the back - can be sitting or lying- this is usually marked by the radiographer- how PA- Posteroanterior- the X-ray machine is behind the patient and the X-ray film at the front Which one is “standard”? Which one do you see most often? If it is not marked, how do you know which projection it is? Why should you be careful about interpreting an AP CXR?

10. Orientation Left and right Usually marked by the radiographer

11. Rotation Identify the medial ends of the clavicles Select the vertebral process that lies between them The medial ends should be EQUIDISTANT from the spinous process

12. Penetration Look at the lower part of the cardiac shadow The vertebral bodies should only just be visible through the shadow Over penetrated Lungs fields appear falsely black you may miss low density lesions Under penetrated Lung fields appear falsely white

13. Penetration Look at the lower part of the cardiac shadow The vertebral bodies should only just be visible through the shadow

14. Inspiration Count the number of ribs above the diaphragm The midpoint of the right hemi-diaphragm should between the 5 th and 7 th ribs anteriorly

15. ABCDE Airway Breathing Cardiac shadow Diaphragm Everything else Review areas

16. Airway Trachea- bronchi- branch at carina Trachea passes to the right of the aorta What causes deviation of the trachea?

17. Breathing - Lung zones Describe lesions in the lungs using ZONES These do NOT equate to lobes

18. Breathing – describing a lesion in the lung 'Shadows, opacities, densities‘ Describe what you see…

19. Cardiothoracic ratio Cardio-thoracic ratio Heart size should be less than 50% of the thoracic cavity Only if the film is PA!

20. Diaphragm Why is the right hemidiaphragm higher than the left? Look at: the shape of the diaphragm the costophrenic angles the cardiophrenic angles

21. Everything else Artefacts Bones- fractures Hila- left lies slightly higher than the right Pleura- pleural thickening, pneumothorax, costophrenic angles Soft tissues- surgical emphysema

22. Review areas Apices- tumours, pneumothorax Bones- fractures Cardiac shadow- densities Diaphragm- look underneath it for a pneumoperitoneum Edge of the film

23. Ready for some cases!?

24. Mr AB, a 44 year old male, presents to his GP with anxiety, unexplained weight loss, a new fine tremor and intolerance to heat…

25. TRACHEAL DISPLACEMENT Thyroid enlargement Tracheal displacement to the left

26. Mrs CD, a 35 year old woman of Kenyan origin, presented to her GP with joint pain and a strange raised, red rash on her legs…

27. BILATERAL HILAR ENLARGEMENT

28. HILAR ENLARGEMENT Hila consist of blood vessels, bronchi and lymph nodes- any of these can be enlarged To detect hilar enlargement, COMPARE both sides and COMPARE to previous X-rays Bilateral hilar enlargement: Sarcoidosis - what else would you see? Pulmonary hypertension- what else would you see? Tumours-lymphoma, bronchial carcinoma, metastatic tumours Infection- TB Unilateral hilar enlargement: Neoplastic- bronchial carcinoma Infection- TB

29. Mr EF, a 70 year old male presented to A+E with a high temperature and a productive cough…

30. CONSOLIDATION

31. An area of white and dense lung Not uniform, no well demarcated border Pneumonia Alveolar spaces filled with pus and fluid, making them look white The larger airways retain air- this is an air bronchogram When should we do a follow-up X-ray for a patient diagnosed with pneumonia? Differentials for consolidation Cancer Airways full of cells Pulmonary oedema Airways full of fluid Fibrosis Compare with previous X-rays

32. Mr GH, a 72 year old male, presents with shortness of breath, weight loss and 55 pack year smoking history…

33. PULMONARY METASTESES

34. Mr IJ, a 70 year old man, presents with shortness of breath and a 50 pack year smoking history

35. COPD Black lung space Flattened hemi- diaphragms Bilateral hyperexpansion Bulla

36. COPD Associated with large lungs due to air trapping How many anterior/posterior ribs define a hyperexpanded lung? Flattened diaphragms Also due to hyper-expansion Darker/black lungs Decreased lung markings Peripheral “pruning” Bullae formation Air filled space, thin-walled, enlarge progressively “Narrow” heart Due to enlarged thorax

37. Mr KL, a 24 year old basketball player, presents with sudden onset shortness of breath and low blood pressure…

38. PNEUMOTHORAX Tracheal deviation Left lung compressed Right heart border moved to right side

39. PNEUMOTHORAX Primary pneumothorax- occurs without apparent cause Secondary pneumothorax- occurs in the presence of lung pathology Iatrogenic- pleural tap Trauma COPD (bulla) Infection Cystic fibrosis Connective tissue disorders- Marfan’s, Ehlers-Danlos Tension pneumothorax- the amount of air in the chest increases with every breath as a one-way valve is created What do you do if you see this on CXR?

40. Mr MN, a 78 year old smoker, presents feeling short of breath

41. LOBAR COLLAPSE Dense opacification

42. LOBAR COLLAPSE The mediastinum is pulled towards the area of collapse and the horizontal fissure is displaced Collapse happens when a part of the lung can not be ventilated Causes can be: Luminal Aspiration Mucous plugging Mural Bronchogenic carcinoma Extrinsic Adjacent mass

44. PLEURAL EFFUSION meniscus

45. PLEURAL EFFUSION Causes: Transudate <25g/l of protein FAILURES – heart, liver, renal due to increased venous pressure Hypoproteinaemia- cirrhosis, nephrotic syndrome, malabsorption Exudate >35g/l of protein Infection - TB Inflammation- rheumatoid arthritis Malignancy- bronchogenic carcinoma All due to increased leakiness of pleural capillaries

47. PNEUMOPERITONEUM

48. Technically means FREE air under the diaphragm Caused by perforation of the GI tract Iatrogenic e.g. open or laparoscopic surgery Gas forming infection e.g. C perfringens

49. HEART FAILURE

50. Alveolar shadowing- oedema (bats wings) Kerley B lines- oedema of the interlobular septa seen just above the costophrenic angle Cardiomegaly- LV enlargement Dilated upper lobe vessels- due to lower zone arteriolar vasoconstriction secondary to alveolar hypoxia Effusions

52. MASTECTOMY

54. RIB FRACTURES

55. Questions?

56. Sources Chest X-ray made easy 2 nd edition Radiologymasterclass.co.uk Radiopaedia.com robochest.com Oxford handbook of clinical medicine