DOI: 10.1378/chest.130.2.350 2006;130;350-361 Chest Schwaibold ...
M-4 Conf Intro Chest
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Transcript of M-4 Conf Intro Chest
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CHEST INTRODUCTION
Technical Adequacy
In trying to determine if pathology is present in a chest radiograph
several factors have to be considered in the overall judgment of theradiograph to determine if the visual findings are pathologic or in
part are related to the radiograph itself.
Factors to be considered on all chest x-rays include:
Inspiration
Penetration
Rotation
Angulation
Orientation
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Inspiration: The volume of air in the hemithorax
will affect the configuration of the heart with
question of cardiac enlargement with a shallowlevel of inspiration. The vascular pattern in the
lung fields will be accentuated with a shallow
inspiration since the same amount of blood flow isnow distributed to a smaller volume of lung.
The level of inspiration can be estimated by
counting ribs. Visualization of nine posterior ribs,
or seven anterior ribs on an upright PA radiograph
projecting above the diaphragm would indicate a
satisfactory inspiration.
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Inspiration Expiration
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Inspiration
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Expiration
4
NOTE CHANGE IN HEART SIZE ANDVASCULARITY DUE TO EXPIRATION.
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Penetration: Refers to adequate photons traversing
the patient to expose the radiograph. This is oftenlimited in patients of large size such that there is
poor visualization of structures in the lower lung
fields and in a retro-cardiac location. The lack of
penetration renders the area whiter than with an
adequate film and can simulate pneumonia or
effusion. In an ideal radiograph the thoracic spine
should be barely perceptual viewing through thecardiac silhouette. The soft tissues at the shoulder
can also give an estimate of the relative degree of
penetration of the film.
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PenetrationCASE #1
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IS THE DIFFERENCE DUE TO CHF OR PENETRATION?
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PenetrationCASE #2
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DID YOU SEE THE NODULE ON
THE PREVIOUS FILM?
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Rotation of the patient distorts mediastinal anatomyand makes assessment of cardiac chambers and the
hilar structures especially difficult. Chest wall
tissue also contributes to increased density over thelower lobe fields simulating disease. Rotation of the
radiograph is assessed by judging the position of the
clavicle heads and the thoracic spinous process.
Ideally the clavicle heads should be equidistant fromthe spinous process.
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Rotation
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DISTORTED MEDIASTINUM DUE
TO TORTOUS AORTA AND
ROTATION.
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Orientation: In this we are making reference to the position
of the patient and the xray beam. A PA radiograph is
obtained with the x-ray traversing the patient from posterior
to anterior and striking the film. Similarly an APradiograph is positioned with the xray traversing the patient
from anterior to posterior striking the film. The cardiac
border or silhouette will appear larger on an AP radiograph
due to the magnification effect of the more anteriorly
located heart relative to the film.
Typically portable radiographs are obtained AP, as the
patient is not able to stand. Standing radiographs in thedepartment are typically obtained PA with a corresponding
lateral radiograph. The PA and lateral radiograph best
demonstrate the actual cardiac size with minimal
magnification compared to the AP exam.
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Orientation
PAAP
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PA
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AP
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Angulation: With the patient in a more
lordotic projection the clavicles will project
superiorly relative to the upper thorax again
causing some distortion of the normal
mediastinal anatomy. With the lordoticprojection of the ribs assume a more
horizontal orientation. Occasionally a lordotic
xray can be obtained intentionally to bettervisualize structures in the thoracic apex
obscured by overlying boney structures.
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Angulation
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PA
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AP LORDOTIC
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EXAMPLE OF
GOOD
INSPIRATION
PENETRATION
ROTATION
ORIENTATION
ANGULATION
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WAS THIS FILM TAKEN
IN THE UPRIGHT
POSITION?
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WHATS MISSING ?
The Rt. Shoulder!