Download Brandy McKelvy, MD, FCCP Assistant Professor Division of

Brandy McKelvy, MD, FCCP
Assistant Professor
Division of Pulmonary, Critical Care and Sleep Medicine
Air
Fat
least opaque
most lucent
Black
Soft tissue
Bone
to
to
to
Metal
most opaque
least lucent
White
Anatomic
Air
Fat
Water
Bone
Metal
Example
Air
Mineral oil
Water
Tums tablets
Lead-bottom glass
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PA & Lateral
AP
Apical lordotic
Lateral decubitus
 Free flowing pleural effusions
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Up-right (erect) semi-erect & supine
 Supine increases medistinal size due to gravity
 Distribution of pleural fluid
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KUB vs abdominal series (3 views)
 Know what you are ordering!
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Inspiratory/expiratory films
 Number of ribs visible?
▪ Ideally 8-10 posterior ribs
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Posterior-Anterior (PA)
 Standard view & most reliable technique
 Erect films detect air under the diaphragm
Lateral view
 Done at the same time as the PA film
 Helps localize infiltrates, identify caridomegaly, effusions &
lymphadenopathy
 Posterior mediastinum and cost-phrenic recesses visible
Anterior-posterior (AP)
 Portable- patient is too ill to go to radiology, usually patient is
sitting upright in bed
 Poorer quality
 AP films may cause the mediastinum & heart to appear larger ( up
to 15% increase in mediastinal structures)
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Enlargement of the radiographic image of
an object relative to its actual size
Increased film-subject distance
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Super-imposition of structures in different planes
Resultant image = summation of opacities
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Two structures of the same radiopacity in contact –
their margins cannot be identified
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Pick one order of operations that you prefer
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You will not be a professional radiographer but
you should always look at your own films
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Start with:
 Reading the label on the chest film (what type of film)
 Reading the label of the film (correct patient)
 Assessing the quality of the film
 Identifying the radiographic technique
▪ AP/PA film, exposure, rotation, position (supine, sitting or
erect)
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Poor inspiration
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“Penetration”
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High diaphragms, crowded
lung markings
Disappearing thoracic
vertebral details through the
heart
Rotation
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Note equal distances from
the vertebral spines to the
medial ends of the clavicles
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Under penetrated: you will
not be able to see the
thoracic vertebrae
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Over penetration:
 Lungs are “too black”
 Unable to see lung markings
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Check for rotation
 Does the thoracic spine
align in the center of the
sternum and between the
clavicles?
 Are the clavicles level?
 Equal distant from sternum?
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Was film taken under full inspiration?
A good film will show:
 10 posterior ribs
 6 anterior ribs to qualify
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When x-ray beams pass through the anterior
chest on to the film under the patient, the
ribs closer to the film (posterior) are most
apparent
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Gastric bubble should be on the left
Aortic knob typically should be on the left
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Soft tissues- thickness, contours, presence of gas, masses
Bones- density, lesions, fractures
Lungs- look for abnormal densities, (opacity or luncency) or
pneumothorax
Pleura- thickening, calcification, effusion, or pneumothorax
Trachea- midline, or deviated, wall, lumen diameter
Mediastinum- width and contour, discreet masses
Heart- size and shape
Pulmonary vessels- artery or vein enlargement
Hila- position, masses, lymphadenopathy
Identify and check positioning of lines, tubes, and other invasive
devices
Foreign bodies- anything that should not normally be in the chest
Boundaries of the film
Costophrenic angle
Diaphragm
Heart
Aortic arch
Trachea
Hilum
Main carina
Stomach bubble
J. Ascending aorta
A.
B.
C.
D.
E.
F.
G.
H.
Costophrenic angle
Diaphragm
Heart
Aortic arch
Trachea
Hilum
Main carina
Stomach bubble
J. Ascending aorta
A.
B.
C.
D.
E.
F.
G.
H.
1. Right Atrium
2. R Ventricle
3. Apex of L
Ventricle
4. Superior Vena
Cava
5. Inferior Vena
Cava
6. Tricuspid Valve
7. Pulmonary
Valve
8. Pulmonary
Trunk
9. Right PA
10. Left PA
Cardio/thoracic ratio
should be < 50%
The hila – the large blood
vessels going to and from
the lung at the root of
each lung where it meets
the heart
 Check for elevation,
location, symmetry,
lymph nodes, enlarged
vessels, masses
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Increased
 Pulmonary arterial HTN
▪ Pruning
 Pulmonary venous HTN
▪ Pulmonary edema
▪ No pruning
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Decreased
 Pulmonary embolism
 Hypovolemia
Right side
1. SVC
2. Ascending
aorta
3. Right
Atrium (RA)
Left side
4. LSCA
5. Aortic knob
6. Left PA
7. Left atrium
8. Left ventricle
5. Aortic arch
2. Ascending
aorta
9.Right
Ventricle
6.Pulmonary
trunk
7. Left
atrium
8. Left
Ventricle
Superior
Anterior
Middle
Posterior
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Anterior mediastinal masses
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Middle mediastinum
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Thymoma
Thyroid
Teratomas
“Terrible lymph-nodes”(lymphoma)
Lymph nodes
Esophagus
Aorta
Duplication cysts, bronchogenic cysts
Hiatal hernia
Posterior mediastinum
 Neurogenic tumors
 Spinal mass
 Chest wall masses
lymphoma
thymoma
thryroid
Right upper lobe
Right middle lobe
Left upper lobe
Lingula
Right lower lobe
Left lower lobe
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Loss of lung volume
Anatomy shifts towards atelectasis
Linear, smooth, wedge-shaped
Apex of opacity starts at hilum
Air bronchograms or lack of air
Sharp edges
Volume loss
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Normal lung volume
No anatomical shift
Consolidation/infiltrates
Irregular margins
Coalesce of infiltrates
Air bronchograms
Blood, pus, water, protein, tumor all look the
same on chest-x-ray
Focal vs Diffuse
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Infiltrates will occupy 1 of 3 spaces:
 Alveoli
▪
▪
▪
▪
▪
“Fluffy”, irregular
Confluence
Air-bronchograms
Silhouette sign
Acinar nodules
 Supporting structures
▪ The interstitium or the lymphatics
▪
▪
▪
▪
Reticular i.e. “lacy” infiltrates
Nodules
Lymphatics spread of tumor
Interstitial fibrosis
 The blood vessels
Alveolar-filling, or “airspace” disease:
“Pointillist” patterns
Air bronchograms
RML consolidation
Right Upper Lobe Infiltrate
Multi-lobar opacities
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“Always” diffuse
Linear
Reticular
Nodular/miliary
Honey -combing
Curly B lines – fluid in the intra-lobular septae
A. Generalized interstitial thickening = linear (“reticular”)
B. Discrete interstitial thickening = nodules
C. Interstitial & alveolar filling = silhouette
Curly B lines
Curly B lines
Cardiogenic vs non-cardiogenic pulmonary edema?
Bat-wing
ARDS
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Nodules
 Solitary or multiple
 Solitary pulmonary nodule
 Size
▪ 1-2 mm, micronodular (miliary)
▪ 2 mm- 3.0 cm
 Calcified or non-calcified
 Margins? Cavitation?
 Doubling time? How long has it been present?
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Masses > 3 cm
Renal Cell Carcinoma
Testicular cancer
TB/HIV
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No walls
 Emphysema
 Bullea >1 cm
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Thin walled
 Pneumatocels
 Aircysts (LAM, EG, PLCH)
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Thick walled
 Honey combing
 With Air-fluid levels
▪ Lung abscess, septic emboli, TB, tumors
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Bronchiectasis
Aspergillus cavity
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Pleural effusions
 Free flowing
 Loculated
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Pleural calcifications
Pleural line
 Pneumothorax?
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Right hemi-diaphragm always slightly higher than the left
Bilateral elevated hemi-diaphragms:
 Increased intra-abdominal pressure, increased airway pressures
 Bilateral phrenic nerve palsy
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Unilateral elevated hemi-diaphragm
 Unilateral phrenic nerve palsy
 Volume loss
▪ Atelectasis
▪ Lobectomy
 Intra-abdominal mass
 Sub-pulmonic effusion
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Herniation thru the diaphragm
Look under the diaphragm
Chest tube port outside chest wall