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Chest Radiograph ,[object Object],For Interns ,[object Object],Reported by: Cristal Ann G. Laquindanum,[object Object],		     ASMPH Class of 2012,[object Object]
References,[object Object],Brant and Helm’s,[object Object],Paul and Juhls,[object Object],Learningradiology.com,[object Object],Clinical Radiology Made Ridiculously Simple,[object Object],School lectures,[object Object]
Outline,[object Object],Normal Chest Radiograph – adult and pediatric,[object Object],Requirement for chest xray film,[object Object],Anatomy,[object Object],Common pathologies – pleural effusion, pneumothorax, pneumonia, PTB,[object Object]
BACKTO*radiology*BASICS,[object Object]
More dense = More Xrays = WHITER / radioopaque,[object Object],Less dense = Less Xrays = BLACKER / radiolucent,[object Object]
Is it good enough? ,[object Object],Recognizing a TECHNICALLY ADEQUATE chest radiograph,[object Object]
Penetration ,[object Object],Inspiration,[object Object],Rotation,[object Object],Magnification,[object Object],Angulation,[object Object],Factors to Evaluate: ,[object Object]
Penetration,[object Object],You should be able to see the thoracic spine through the heart ,[object Object]
Underpenetration,[object Object],> Left hemidiaphragm may not be visible on the frontal film; left lung base may appear opaque,[object Object],> Pulmonary markings may appear more prominent,[object Object],Overpenetration,[object Object],> Lung markings may seem decreased or absent,[object Object]
Inspiration,[object Object]
Rotation,[object Object],If the spinous process of the vertebral body is equidistant  from the medial ends of each clavicle, there is NO rotation,[object Object]
If the spinous process appears closer to the right clavicle (redarrow), the patient is rotated toward their own left side,[object Object],If the spinous process appears closer to the left clavicle (redarrow), the patient is rotated toward their own right side,[object Object]
Severe rotation may make the pulmonary arteries appear larger on the side farther from the film,[object Object]
Magnification,[object Object],vs,[object Object],PA ,[object Object],AP ,[object Object]
AP ,[object Object],AP vs PA ,[object Object]
PA ,[object Object],AP vs PA ,[object Object]
Angulation,[object Object],If the x-ray beam is angled toward the head (mostly because the patient is semi-recumbent), the film so obtained is called an “apical lordotic” view	,[object Object]
Clavicles,[object Object],Unusually shaped heart,[object Object]
Penetration see spine through the heart,[object Object],Inspiration at least 8-9 posterior ribs,[object Object],Rotation spinous process between clavicles,[object Object],Magnification AP films will slightly magnify the heart,[object Object],Angulation clavicle over 3rd rib,[object Object],Factors to Evaluate: ,[object Object]
How to read a Chest Xray:,[object Object], Basics,[object Object], Technically Adequate,[object Object],☐	 Anatomy,[object Object]
Chest Radiograph for Interns
Chest Radiograph for Interns
Trachea,[object Object],Upper Lobes,[object Object],Aortic knob,[object Object],Left ,[object Object],Pulmonary Artery,[object Object],Right,[object Object],Atrium,[object Object],Left ,[object Object],Ventricle,[object Object],Lower Lobes,[object Object]
Chest Radiograph for Interns
Trachea,[object Object],Upper Lobes,[object Object],Aortic knob,[object Object],Carina,[object Object],Left ,[object Object],Pulmonary Artery,[object Object],Right,[object Object],Atrium,[object Object],Left ,[object Object],Ventricle,[object Object],Lower Lobes,[object Object],Costophrenic Angle,[object Object],Gastric bubble,[object Object]
Upper lobes,[object Object],Right,[object Object],middle lobe,[object Object],Lower lobes,[object Object],Lingula,[object Object]
RADIOLOGY,[object Object]
Airway  (trachea),[object Object],Bones (clavicles, ribs),[object Object],Cardiomediastinalsilhoutte,[object Object],Diaphragms (and the costophrenic angles) ,[object Object],Everything Else (lung fields, soft tissues, tubes, lines, wires, devices, etc),[object Object]
Airway  (trachea),[object Object]
Chest Radiograph for Interns
Bones (clavicles, ribs),[object Object]
Chest Radiograph for Interns
Cardiomediastinalsilhoutte,[object Object]
Cardiomediastinalsilhoutte,[object Object]
Diaphragms (and the costophrenic angles) ,[object Object]
Diaphragms (and the costophrenic angles) ,[object Object]
Everything Else (lung fields, soft tissues, tubes, lines, wires, devices, etc),[object Object]
Chest Radiograph for Interns
Lungs more radiolucent,[object Object],Thymus is often large,,[object Object],Widening of superior mediastinum,[object Object],Ribs angulate downward,[object Object],Heart is globular and large,[object Object],Left ventricle more prominent with age,[object Object],Diaphragm is higher,[object Object],Left > Right,[object Object]
Pathologies,[object Object],Pleural effusion,[object Object],Atelectasis,[object Object],Pneumothorax,[object Object],Pneumonia,[object Object],Pulmonary Tuberculosis,[object Object]
Pleural Effusion,[object Object],complete opacification of the right mid and lower zones is due to fluid in the pleural cavity,[object Object],meniscus sign -  concavity of the fluid level due to surface tension with the pleura,[object Object],Blunting of costophrenic angle may be due to a small pleural effusion or focal pleural thickening.,[object Object],May coexist with pneumothorax or entrapped within fissures mimicking a tumor.,[object Object],Right pleural effusion in a patient with nephrotic syndrome,[object Object],The flattened and laterally displaced curvature of the right hemidiaphragm indicates presence of subpulmonic pleural fluid,[object Object]
Pleural Effusion,[object Object],Patient cannot stand? ,[object Object],lateral decubitus,[object Object],Ultrasound or CT thorax as alternative modalities for early detection of small pleural effusion. ,[object Object],Ultrasound advantage: no radiation; can be used to guide drainage,[object Object],CT advantage: evaluate the underlying lung and mediastinal structures to identify the cause of the effusion,[object Object]
Pneumothorax,[object Object],Pneumothorax represents abnormal air accumulation within pleural cavity. This may be due to trauma (accidental or iatrogenic), underlying pulmonary disease (e.g. asthma) or idiopathic in origin,[object Object],Erect chest radiograph in full expiration is diagnostic in majority of cases,[object Object],If the patient is unable to stand erect, lateral decubitus view may be helpful,[object Object]
Pneumothorax,[object Object],Radiologic Findings:,[object Object],Contralateral mediastinalshift,[object Object],Depression of ipsilateralhemi-diaphragm,[object Object],Compressive atelectasis of adjacent normal lung,[object Object],presence of significant increased intrathoracic pressure,[object Object],Role of imaging in patients with pneumothorax:,[object Object],1. Confirm the clinical diagnosis,[object Object],2. Assess extent of pneumothorax ,[object Object],3. Detect signs of tension,[object Object],4. Follow-up examination to monitor resolution of pneumothorax after drainage,[object Object]
The right lung (white open arrows) has been pushed medially. The mediastinum is shifted to the left (black arrow). This appearance is typical of tension pneumothorax.,[object Object], Magnified view of a PA chest radiograph of a right pneumothorax. The visceral pleura (arrow heads) is seen as a thin white line. ,[object Object]
Pneumonia,[object Object],Role of imaging in patients with pneumonia,[object Object],1. Confirm the clinical diagnosis,[object Object],2. Detect possible complications such as pleural effusion / empyema or lung abscess if clinically not responsive to appropriate antibiotic treatment,[object Object],3. Follow-up CXR to monitor response to treatment ,[object Object],may take 4-6 weeks for consolidative changes to resolve,[object Object],Radiologic improvement usually lags behind clinical improvement,[object Object],If radiologic signs still present after adequate treatment, underlying predisposing factors have to be excluded (e.g. central obstructive carcinoma in elderly patients),[object Object]
Pneumonia,[object Object],[object Object]
Visualization of air in the intrapulmonary bronchi
Abnormal
Denotes a pulmonary lesion/consolidation (excludes a pleural or mediastinal lesion)
Seen in pneumonia, pulmonary edema or pulmonary infarct Silhouette ,[object Object],sign,[object Object]
Pneumonia,[object Object],Pneumonia caused by certain organisms may produce characteristic radiologic features,[object Object],Unilateral lobar involvement in streptococcus infection,[object Object],Bilateral patchy involvement sometimes with cavitation in staphylococcus pneumonia,[object Object],Upper lobe involvement with cavitation in pulmonary TB,[object Object],Bilateral symmetrical perihilar distribution which progresses rapidly over 3-5 days in PCP pneumonia in immunocompromised patients,[object Object]
Bilateral patchy involvement sometimes with cavitation in staphylococcus pneumonia,[object Object]
Chest Radiograph for Interns
Upper lobe involvement with cavitation in pulmonary TB,[object Object]
Bilateral symmetrical perihilar distributionPCP pneumonia in immunocompromisedpatients,[object Object]
Pulmonary Tuberculosis,[object Object],Radiologic Findings in PTB,[object Object],Cavitation and air-fluid level- the opacity represents caseous necrosis in tuberculosis,[object Object],Enlarged hilum– representinggranulomatous inflammation of lymph nodes, usually in primary TB,[object Object],Fibrocalcificchanges in lung apex usually representing healing of previous TB infection,[object Object],Multi-focal air-space opacities representing bronchogenic spread of infection,[object Object],Tiny miliary nodules in both lungs representing miliary TB due to haematogenous spread of infection,[object Object]
Chest Radiograph for Interns
Chest Radiograph for Interns
CASE PRESENTATION,[object Object]
AM, 5year old female ,[object Object],CC: fever and cough,[object Object],HPI: 6 days PTC – on and off fever (Tmax 39) + headache,[object Object],3 days PTC – abdominal pain, consult done and was given Cefaclor and Ventolin expectorant,[object Object],Morning PTC – symptoms persisted, one episode of post-tussive vomiting, decreased appetite  admission,[object Object],HISTORY,[object Object]
PAST MEDICAL HISTORY,[object Object],TMC – Dengue and UTI – Oct 2010,[object Object],VRMC – Pneumonia 2006,[object Object],BIRTH HISTORY,[object Object],Born full term via NSD to a 30 year old G2P2 (2002) ,[object Object],no fetomaternal complications,[object Object],VACCINATION HISTORY,[object Object],Only BCG, DPT, HepB, MMR x1, no HiB,[object Object]
NUTRITIONAL HISTORY,[object Object],Breastfed until 2 months, on milk formula until 15 months,[object Object],Weaning at  months, food preference fish,[object Object],FAMILY HISTORY ,[object Object],unremarkable,[object Object]
BP 90/60 , RR 30 , HR 118 , Temp 39.5 ,[object Object],Harsh breath sounds, equal chest expansion, rales R>L, no wheezes, no alar flaring, no retractions,[object Object],Hyperactive bowel sounds, epigastric tenderness,[object Object],Tachycardic, normal rhythm,[object Object],PHYSICAL EXAMINATION,[object Object]
PCAP C ,[object Object],IMPRESSION ,[object Object]
CBC - normal,[object Object],Chest Xray (PA/Lat),[object Object],DIAGNOSTICS,[object Object]

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Chest Radiograph for Interns

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  • 48. Visualization of air in the intrapulmonary bronchi
  • 50. Denotes a pulmonary lesion/consolidation (excludes a pleural or mediastinal lesion)
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Notas del editor

  1. The less dense an object is, the fewer xrays it absorbs, and the blacker it wll appearAir attenuates very little of the xray beam, allowing nearly full force of the beam to blacken the image. Fat, and soft tissues attenuate interediate amounts of the xray beam , resulting in proportional degrees of image blackening (shades of gray) radiation than thin structures iBone, metal, and radiographic contrast agents attenuate a large proportion of the xray beam, allowing very little radiation through to blacken the image. Thus, bone and metallic objects and structures opacified by xray contrast agents appear white on radiographs. Bone is densest naturally occurring tissue. It absorbs the greatest amount of xray and appears white on radiographs.Metal is even denser than bone and essentially absorbs all xrays, but unless you have bullets or artifical hip replacements, metal doesn’t naturally occur in humans
  2. Underpenetration – mimic or hide true disease of left lower lung field (lower lobe pneumonia, left pleural effusion)Overpenetration – mistakenly think patient has emphysema or pneumothorax; pulmonary nodule may be invisible
  3. In an AP film, the heart is farther from the film and is more magnifiedPortable chest x-rays are almost always done AP
  4. In an AP film, the heart is farther from the film and is more magnifiedPortable chest x-rays are almost always done AP
  5. Anterior structures (like the clavicles) will be projected higher on the film than posterior structures
  6. A film which is apical lordotic (beam is angled up toward head) will have an unusually shaped heart and the sharp border of the left hemidiaphragm will be absentAnterior structures (like the clavicles) will be projected higher on the film than posterior structureshis projectionresults in clear visualization of the lung apices because the clavicle and first rib are projected above the pulmonary apex
  7. Right – minor fissure separates upper and middle lobe. Major fissure middle lobe and lower lobeRight upper lobe – anterior apical and posteriorMiddle lobe – medial and lateralRight lower lobe – anterior, lateral, posterior and medialLeft – upper and lower lobes by left major fissure Left upper lobe is analogous to the combined right upper and middle , anterior, apicoposterior, superior and inferior lingular segmentsLeft lower lobe – anteromedial, lateral and posterior
  8. Airways, including hilaradenopathy or enlargementBreast shadowsBones, e.g. rib fractures and lytic bone lesionsCardiac silhoutte, detecting cardiac enlargementCostophrenic angles, including pleural effusionsDiaphragm, e.g. evidence of free airEdges, e.g. apices for fibrosis, pneumothorax, pleural thickening or plaquesExtrathoracic tissuesFields (lung parenchyma), being evidence of alveolar fillingFailure, e.g. alveolar air space disease with prominent vascularity with or without pleural effusions
  9. Airways, including hilaradenopathy or enlargementBreast shadowsBones, e.g. rib fractures and lytic bone lesionsCardiac silhoutte, detecting cardiac enlargementCostophrenic angles, including pleural effusionsDiaphragm, e.g. evidence of free airEdges, e.g. apices for fibrosis, pneumothorax, pleural thickening or plaquesExtrathoracic tissuesFields (lung parenchyma), being evidence of alveolar fillingFailure, e.g. alveolar air space disease with prominent vascularity with or without pleural effusions
  10. Airways, including hilaradenopathy or enlargementBreast shadowsBones, e.g. rib fractures and lytic bone lesionsCardiac silhoutte, detecting cardiac enlargementCostophrenic angles, including pleural effusionsDiaphragm, e.g. evidence of free airEdges, e.g. apices for fibrosis, pneumothorax, pleural thickening or plaquesExtrathoracic tissuesFields (lung parenchyma), being evidence of alveolar fillingFailure, e.g. alveolar air space disease with prominent vascularity with or without pleural effusions
  11. DeviationFBET Tube
  12. Airways, including hilaradenopathy or enlargementBreast shadowsBones, e.g. rib fractures and lytic bone lesionsCardiac silhoutte, detecting cardiac enlargementCostophrenic angles, including pleural effusionsDiaphragm, e.g. evidence of free airEdges, e.g. apices for fibrosis, pneumothorax, pleural thickening or plaquesExtrathoracic tissuesFields (lung parenchyma), being evidence of alveolar fillingFailure, e.g. alveolar air space disease with prominent vascularity with or without pleural effusions
  13. Airways, including hilaradenopathy or enlargementBreast shadowsBones, e.g. rib fractures and lytic bone lesionsCardiac silhoutte, detecting cardiac enlargementCostophrenic angles, including pleural effusionsDiaphragm, e.g. evidence of free airEdges, e.g. apices for fibrosis, pneumothorax, pleural thickening or plaquesExtrathoracic tissuesFields (lung parenchyma), being evidence of alveolar fillingFailure, e.g. alveolar air space disease with prominent vascularity with or without pleural effusions
  14. Airways, including hilaradenopathy or enlargementBreast shadowsBones, e.g. rib fractures and lytic bone lesionsCardiac silhoutte, detecting cardiac enlargementCostophrenic angles, including pleural effusionsDiaphragm, e.g. evidence of free airEdges, e.g. apices for fibrosis, pneumothorax, pleural thickening or plaquesExtrathoracic tissuesFields (lung parenchyma), being evidence of alveolar fillingFailure, e.g. alveolar air space disease with prominent vascularity with or without pleural effusions
  15. Airways, including hilaradenopathy or enlargementBreast shadowsBones, e.g. rib fractures and lytic bone lesionsCardiac silhoutte, detecting cardiac enlargementCostophrenic angles, including pleural effusionsDiaphragm, e.g. evidence of free airEdges, e.g. apices for fibrosis, pneumothorax, pleural thickening or plaquesExtrathoracic tissuesFields (lung parenchyma), being evidence of alveolar fillingFailure, e.g. alveolar air space disease with prominent vascularity with or without pleural effusions
  16. Newborn infantAP diameter of the thorax is greater compared with the tranverse diameter than in adultsDiaphragm is higher, vertical diameter of the thoracic cavity relatively less than in the adultWith growth, chest becomes narrower and ribs gradually angulate downward from horizontal position Thymus is often large enough in early infancy to produce widening of the superior mediastinum -bilobed structure located in the anterior mediastinum that can cause considerable confusion simulate cardiomegaly, upper-lobe pneumonia, and atelectasis. Additionally, it can appear as a pathologic mass if it is aberrant in locationHeart is globular and is relatively large in comparison with the diameter of the chest than in adultsLeft ventricle becomes more prominent with age, resulting in downward displacement of the apex, and the relatively heart size gradually decreasesLungs more radiolucent than in the adult because the pulmonary interstitium usually is not visible., tracheal bifurcation gradually descends and reaches the adult level (T5) at about 10 yrs old The hilar shadows are relatively high and usually are situated at the level of the third thoracic vertebra.Diaphragm tends to be higher in infancy and childhood than in adult life; opposite to adult that left hemidiaphragm higher than the right (stomach is distended with air)
  17. Two substances of the same density, in direct contact, cannot be differentiated from each other on x-rayCommon locationsLower lobes-diaphragmsRight heart border – RMLLeft heart border – LingulaLeft diaphragm – Heart (on lateral view)