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Learning Objectives Basic Radiology: Chest X-Ray Fundamentals · chest pain, and shortness of...
Transcript of Learning Objectives Basic Radiology: Chest X-Ray Fundamentals · chest pain, and shortness of...
Basic Radiology: Chest X-Ray Fundamentals
John Mabee, PhD, PA-C Adjunct Assistant Professor Clinical Family Medicine
Keck School of Medicine of USC Division of Physician Assistant Studies
Primary Care Physician Assistant Program
CAPA Conference – October 9, 2014
This workshop is geared toward the Primary Care PA. Upon completion of this workshop, the participant should be able to:
• List image & quality considerations of the chest x-ray study • Recognize basic normal thoracic radiographic anatomy • Perform a systematic review of the chest x-ray using an:
“A, B, C, D, E” approach • Identify & interpret common radiographic presentation of
pathology • Identify areas where pathology is commonly missed • Describe useful signs & hints
Learning Objectives
Exposure
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Underpenetrated
Image Quality
Overpenetrated
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Image Quality
Exposure
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Image Quality
Rotation
Bronchovascular structures seen thru heart T-spine disc spaces barely visible thru heart
Diaphragm: 8th-10th posterior or 5th-6th anterior rib
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Image Quality
Inspiration
PA view
Lateral View
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Sternum should be seen edge on Posteriorly, you should see 2 sets of ribs
Spine & lungs darken as you move caudally
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d
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Image Quality
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(4th rib)
(5-6th rib)
Anatomy
Trachea
RPA
LPA
CarinCarinCarinaaaCarinCaCarinCarinCarinaa aa
Anatomy
PA view
Lateral view
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= Left pulmonary artery
= Right pulmonary artery
R L
Trachea
Retrosternal space
CXR Interpretation
• One approach to reading a CXR:
- A: Airways
- B: Bones
- C: Cardiomediastinal silhouette
- D: Diaphragm
- E: Everything else (plus lungs!)
Normal
• A: Airways • B: Bones • C: Cardio-
mediastinal silhouette
• D: Diaphragm • E: Everything
else (+lungs)
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Selected Pathology & CXR Findings
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Bronchopneumonia Lobar Pneumonia
Pneumonia
library.med.utah.edu library.med.utah.edu
Inflammatory “infiltrate” (pus)
in alveoli consolidation of
airspaces
Pneumonia
Bronchopneumonia Lobar Pneumonia © Elseiver 2005 library.med.utah.edu
• “Infiltrate” • Airspaces filled with pus (pneumonia) or other fluid (inflammation, CA, blood)
• Usually no loss of lung volume
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Consolidation Silhouette Sign
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• Loss of the silhouette or lung/soft tissue interface caused by a mass or fluid in the normally air-filled lung
Silhouette Sign
RML
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Air Bronchogram
• Outline of airway tubes caused by filling of surrounding alveoli with fluid, cells or inflammatory exudates
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• A 35-year-old man comes to the emergency department for evaluation of fever, and productive cough for the past 4 days. Temperature is 39.4°C (103°F). Physical examination shows rales over the right lower anterior chest. Chest x-ray study is shown.
Case 1 Case 1
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Supine
+ silhouette sign
Focal area of consolidation by right heart
Sharp horizontal fissure Dx: Right middle lobe pneumonia
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Case 1 Supine Supine
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• A 58-year-old man is being evaluated in the intensive care unit. Two days ago, he was in a high speed car accident, and was treated for a closed right tibia and fibula fracture. Earlier today, he was intubated because of increasing dyspnea, tachypnea, and confusion. Chest x-ray study is shown.
Case 2
Case 2
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- Diffuse bilateral infiltrates - Appropriate positioning of ET tube [5 cm above carina or midway between clavicles & carina]
• Dx: ARDS
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Case 2
LVH & Pulmonary Edema
Alveolar Edema
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Cardiomegaly
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Normal: < 50% of thoracic diameter
Pulmonary Edema
• ↑ prominence of interstitial lines
• Kerley B (septal) lines
• Cephalization of the pulmonary vasculature
• Peribronchial cuffing
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Pulmonary Edema • “Bat wing" pattern & air bronchograms
radiologyassistant.nl Bilateral perihilar infiltrates
• A 58-year-old man is seen in the emergency department because of increasing dyspnea and orthopnea for the past 2 days. Pulse rate is 98/min, blood pressure is 132/84 mmHg, respirations are 22/min. Physical examination shows bilateral scattered rales, intermittent wheezes, and a S3. Chest x-ray study is shown.
Case 3
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Case 3
Cardiomegaly Prominent bilateral pulmonary vasculature Cephalization of vessels Kerley B lines Dx: - Heart failure - Pulmonary edema
Case 3
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Emphysema Dilated Airways library.med.utah.edu
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Emphysema
• Bilateral diffuse hyperinflation, flattening of diaphragms, ± bullae
• Narrowing of the cardiac silhouette
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• A 66-year-old woman is seen in the office for progressive shortness of breath for the past 2 months. She smokes 2 packs of cigarettes per day for the past 40 years. Physical examination shows pursed lip breathing, and mild curvature of the thoracic spine. Heart sounds are distant, but without murmur or gallop. Lung sounds are normal. Chest x-ray study is shown.
Case 4
Case 4
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- Hyperinflation - Hyperlucency - Flattening of the diaphragm - Narrowing of the cardiac silhouette
• Dx: Emphysema
Case 4
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?
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Pulmonary Nodules & Masses
• Most common nodule ⇒ granuloma
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Hamartoma Squamous Cell CA Adenocarcinoma
Solitary Pulmonary Nodule
- Discrete, well-marginated round opacity < 3 cm diameter - Surrounded by lung parenchyma - Does not touch hilum or mediastinum - Ø adenopathy, atelectasis or pleural effusion
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?
Solitary Pulmonary Nodule
• Calcification pattern (if present):
Most likely benign
Suspicious
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• Anterior: - Thymic tumors - Lymphomas
• Middle: - Thyroid tumors - Lymphomas • Posterior: - Neurogenic tumors - Esophageal masses
Other possibilities: cysts, hemangiomas, lipomas + many more
Mediastinal divisions
Mediastinum
(retrosternal space)
Anterior Posterior
Middle
Mediastinal Lines radiologyassistant.nl
Mediastinum: 8 cm (supine)
Aortic Knob
Pulmonary Artery
Aorto- Pulmonary Window
Mediastinum
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Hodgkin Disease
Mass in aortopulmonary window Mass in retrosternal space
Mediastinum & Hila
Mediastinum – lines? Hila – dilated vessels or nodes?
Nodes – there are round densities where you don’t expect to see blood vessels
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Sarcoidosis
• A 68-year-old man is seen in the emergency department because of sharp tearing chest pain radiating to the upper back that began 1 hour ago. He is lightheaded, and has nausea. Pulse rate is 80/min, blood pressure is 200/110 mmHg, respirations are 18/min. Physical examination shows grade II/VI diastolic murmur over the aortic area, and diminished pulses in both lower extremities. Chest x-ray study is shown.
Case 5 Case 5
- Widened mediastinum > 8 cm
- Tracheal shift (right) • Dx: aortic dissection
Case 5
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Hemopneumothorax
Hemopneumothorax
• Violation of pleural space
• Loss of vascular markings
• Hyperlucent hemithorax
• Air-fluid level with hemothorax
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• A 27-year-old woman is evaluated in the emergency department for left-sided chest pain, and shortness of breath. During the primary survey, decreased breath sounds are heard over the left chest wall. Chest x-ray study is shown.
Case 6
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Case 6
- Visceral pleura edge is seen
- No vascular markings on outer lung field
- Air-fluid level behind left diaphragm
- Scoliosis! • Dx: Pneumothorax
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Pneumothorax: Size or %?*
a=apex-to-cupula distance (American): 3 cm b=interpleural distance @ hilum (British): 2 cm
≈ 50% pneumo
“Small” < 3 cm “Large” > 3cm
“Small” < 2 cm “Large” > 2cm
*MacDuff A, et al. Management of spontaneous pneumothorax: British Thoracic Society pleural disease guideline 2010. Thorax 2010 (Suppl 2):ii18-ii31.
Pleural Effusion radiologyassistant.nl
Fluid accumulation in the pleural cavity: - serous fluid [transudate or exudate] - pus (empyema) - blood (hemothorax) - lymph (chylothorax)
Pleural Effusion
• Fluid collection in pleural space → blunting of costophrenic ∠
• Minimum volume on XR: - ≈ 250 mL on PA view - ≈ 75 mL on lateral view
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Pleural Effusion • Lateral decubitus view → fluid “layering”
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Empyema
Pus
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• A 28-year-old man is seen in the office because of fever, chills, and productive cough for the past week. Over the past 2 days, he has developed left-sided chest pain, and progressive shortness of breath. Pulse rate is 110/min, blood pressure is 108/72 mmHg, respirations are 28/min, and temperature is 39.4°C (103°F). Physical examination shows decreased breath sounds over the lower ⅔’s of the left chest. Chest x-ray study is shown.
Case 7
Case 7 - Opacification (white out) of lower ⅔ of left hemithorax - Meniscus - Deviation of trachea & heart to right - Elevation of right horizontal fissure • Dx: Pleural effusion (empyema)
Case 7
Atelectasis • Collapse or incomplete expansion of
lung or lung segment • Characteristics: - ↑ opacity of airless lobe (+ volume loss) - displacement of fissures, hilar & cardiomediastinal structures toward side of collapse - elevation of ipsilateral hemidiaphragm - ↑ lucency of aerated lung - ± silhouette sign
Atelectasis Patterns
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ML
LUL
LLL
• RUL atelectasis - “ ” density - Right tracheal shift - ∅ retrosternal clear space on lateral view
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RUL
• RML atelectasis - Silhouette sign right heart - “ ” density on lateral view
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• RLL atelectasis - “ ” density right heart - Right tracheal shift - Elevation right diaphragm - “ ” density posterior CP ∠ on lateral view
en.wikipedia.org wikidoc.org
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• LUL atelectasis - General haze over left lung - ± left hilar mass - Left tracheal shift & elevated left diaphragm - ∅ retrosternal clear space
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radiologyassisLUL
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• LLL atelectasis - “ ” density left heart - Elevation left diaphragm - “ ” density posterior CP ∠ on lateral view
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LLL