1. Intro to the chest radiograph Matthew Bentz, MD OHSU Diagnostic Radiology Assistant Professor 2015

2. Goals for today Start with normal vs abnormal Try to develop a mental picture of normal See some commonly encountered and important chest radiograph findings

3. Teaching points 1)Name the 5 densities that are seen on standard radiographs 2)Choose and utilize a standardized way to view each radiograph 3)Locate the following anatomic structures: – Trachea, carina, subclavian artery and vein, SVC, cavoatrial junction 4)Name the 6 patterns seen on chest imaging

4. Blank x ray film

5. Under exposure & over exposure

6. Density – the key to x ray films

7. Tissue depth and density matter

8. Depth and density matter

9. Physics too – physical density and density to x rays both matter

10. Density Concept Organ boundaries are seen only when the densities are different between the tissues Examples: – Pulmonary vessels are sharply seen in normal lungs (Soft tissue – air interface) – Airways are not seen in normal lung (Air – Air interface)

11. Airways not visible in normal lungAirways visible in abnormal lung

12. Density is key! Converse is true also - If objects have, or develop, the same density, they will be inseparable on CXR

13. Density is key! Converse is true also - If objects have, or develop, the same density, they will be inseparable on CXR ?

14. Air Fat Densities Water/tissue Bone Metal Tissue appearance on x-rays

15. Teaching point #1 Name the 5 densities that are seen on standard radiographs Air Fat Densities Water/tissue Bone Metal

16. Conceptualize If you know what a cow looks like And you know the color purple You can recognize a purple cow, even if you’ve never see one

17. Quiz

18. Air Fat Densities Water/tissue Bone Metal

19. Quiz

20. Cartilage is water/soft tissue density Since it is the same density as the adjacent tissue, there is no visible boundary – i.e. cartilage is invisible on radiographs

21. Quiz #2

22. Quiz picture #3

23. “1 views is no views”

25. Titanic

26. Normal chest X ray

28. Pretty easy to spot

29. Really hard to spot

31. Are all the lines and tubes ok?

32. A brief digression into technique related issues

33. PA versus AP Examination Scapula Position Can Help AP View: 10% magnification

34. Patient body habitus

35. Rotation

36. Rotation: Medial Clavicles With Reference To The Spinous Process (Arrows) Rotated to RPO/LAO Rotated to LPO/RAO

37. Approaches to a CXR Alphabet method Between, inside, outside the lungs Top down Other – My approach: Abnormalities, right lung, left lung, compare the two lungs, trachea, mediastinum, heart, outside the lungs (including abdomen) and bones

38. Alphabet Air

39. Alphabet Air Bone

40. Alphabet Air Bone Cardiac

41. Alphabet Air Bone Cardiac Diaphragm

42. Alphabet Air Bone Cardiac Diaphragm Everything else

43. BIO Between Inside Outside

44. BIO Between Inside Outside

45. BIO Between Inside Outside

46. Top Down

47. My Method