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Chest x-ray reading
報告醫師: 李士毅醫師
指導醫師: 林榮祿醫師
Check List(1)
1.
2.
Check patient data, position, technical quality and normal anatomy.
Review systematically
o
o
o
Initial survey
Review skeletal structures of shoulder girdles and chest wall
Review mediastinum:
•
•
•
•
•
o
overall size and shape
trachea: position
margins: SVC, ascending aorta, right atrium, left subclavian artery, aortic arch,
main pulmonary artery, left ventricle
lines and stripes: paratracheal, paraspinal, paraesophageal (azygoesophageal),
paraaortic
retrosternal clear space
Review hila:
•
•
normal relationships
size
Check List(2)
o
Review lungs and pleura:
•
•
•
•
o
compare lung sizes
evaluate pulmonary vascular pattern: compare upper to lower lobe, right to left,
normal tapering to periphery
pulmonary parenchyma
pleural surfaces
– fissures - major and minor - if seen
– compare hemidiaphragms
– follow pleura around rib cage
Soft tissue including breast, companion shadow .
•
•
•
Review abdomen for bowel gas, organ size, abnormal calcifications, free air, etc.
Review soft tissues and spine of neck.
Review spine and rib cage: check alignment, disc space narrowing, lytic or
blastic regions, etc.
Check List
1.
Check patient data, position, technical quality and normal
anatomy.
Review systematically
2.
o
o
o
o
o
o
Initial survey
Review skeletal structures of shoulder girdles and chest wall
Review mediastinum
Review hila
Review lungs and pleura
Soft tissue including breast, companion shadow
1. Data base
1. Name
2. Date
- important for comparing prior exams
- Serial image
3. Position markers
- right(R) vs. left(L)
4. Type of film
5. Patients position
– supine, upright, lateral, etc.
6. Technical quality
1
2
3
(erect)
4
1
4
Introduction
• Serial image: Doubling time
– Point of disease(location/size)
– Make diagnosis easily
• Pneumonia
• Edema
• Tumor
Position
• Chest x-ray
–
–
–
–
–
–
–
P-A view
A-P
A-P supine
Lateral (Lt’/Rt’)
Lateral decubitus (Lt’/Rt’)
Lordotic
Oblique(Rt’/Lt’; post/anterior)
Position
• Speical position for special purpose
–
–
–
–
–
A-P supine: Ambulatory limit
A-P Lateral (Lt’/Rt’): Anatomy reading
Lateral decubitus: Effusion or thickening
Lordotic: Apical lesion
Oblique: Eliminate superimposed lesion
• Affect read result
- eg. redistritubion Phenomenon (slide 183)
P-A view
Rt’ Lateral view
Rt’ Lateral decubitus view
Technical quality
• Ideal KV exposure
– Key points
•
•
•
•
•
Apex
Retrocardiac lung marking
Trachea position
Spine
Scapula
– You can't find a subtle pneumothorax if there is patient motion
or the film is overexposed.
• 4 basic radiographic densities
Technical quality
• Ideal KV exposure
• 4 basic radiographic densities
–
–
–
–
Air
Fat
Water(soft tissue)
Bone(metal)
Normal Anatomy
• Anatomy & projection
– General anatomy
– Lobar anatomy
– Segmental anatomy
• The sihouette sign
Normal Anatomy
• Anatomy & projection
– General anatomy
•
•
•
•
•
•
•
•
•
•
Posterior process
Rib(Ant/Post)
Left 2/Right 4
Costothoracic ratio
Central trachea
Hilar: Lt>Rt
Lung field: Central> Peripheral/ Peripheral clear zone
Pleura: Linear
Diaphragm: Right >left/ Angle/Gastric pattern
Subcutaneous tissue
– Lobar anatomy
– Segmental anatomy
•
Normal Anatomy
Anatomy & projection
– General anatomy of lateral view
1. Right diaphragm
2. Left diaphragm
3. Spine
4. Scapula
5. Axiallary fold
6. Sternum
7. Subcutaneous tissue
8. Trachea
9. Aortic arch
10. Main bronchus
11. Pulmonary artery
12. Heart
13. Retrosternal clear space
14. Retrocardiac clear space
15. Costophrenic angle
16. Costocardiac angle
5
8
13
4
9
6
11
10
12
3
7
16 14
1
2
15
16
Normal Anatomy
• Anatomy & projection
– General anatomy
– Lobar anatomy
• Fissures
–
–
–
–
Def: Pleura surround by air
3 main(1 minor; 2 major)
3 accessory(Azygos; inferior & superior accessory)
If fissure do not appear a thin line?
- Ans: ?
– Segmental anatomy
• The sihouette sign
Normal Anatomy
• Anatomy & projection
– General anatomy
– Lobar anatomy
• Fissures
–
–
–
–
Def: Pleura surround by air
3 main(1 minor; 2 major)
3 accessory(Azygos; inferior & superior accessory)
If fissure do not appear a thin line
- Pneumonia(Bulging)
- Atelectasis (Deviation)
- Pleural effusion (Pseudotumor)
– Segmental anatomy
• The sihouette sign
Lobar anatomy
1
2
1
5
3-4-5
3-4-6
2
3-4
6
Normal Anatomy
• Anatomy & projection
• The sihouette sign
– Define
• Interface is invisible when two areas of similar
radiodensity touch.
– Position
Normal Anatomy
• Anatomy & projection
• The sihouette sign
– Define
– Location
•
•
•
•
Heart/Asending aorta
Desending aorta/Diaphragm
Airbronchogram
Incomplete border
Normal Anatomy
• Anatomy & projection
– General anatomy
– Lobar anatomy
– Segmental anatomy
• Rt’: 1-10
• Lt’ 1-10 (1+2, 7+8)
1
2
1
2
3
3
4
4
5
5
6
6
9
7
7
9
8
8
10
10
1+2
1+2
3
3
4
4
5
5
7 9
+
8 10
Check List
1.
Check patient data, position, technical quality and normal
anatomy.
Review systematically
2.
o
o
o
o
o
o
Initial survey
Review skeletal structures of shoulder girdles and chest wall
Review mediastinum
Review hila
Review lungs and pleura
Soft tissue including breast, companion shadow
Systematic review
• A-B-C-D-E-F-G-H or
• 
• Try interpret and understand what you see:
– D.D. normal v.s. abnormal?
Systematic review
• A-B-C-D-E-F-G-H
o
o
o
o
o
o
o
o
A: Airway
B: Bone
C: CV
D: Diaphragm
E: Extra-pulmonary
F: Lung field
G: Gastric bubble
H: Hilum/Hernia
Systematic review
•

o
o
o
o
o
o
Initial survey
Review skeletal structures of shoulder girdles and
chest wall
Review mediastinum
Review hila
Review lungs and pleura:
Soft tissue including breast, companion shadow. .
Check List
1.
Check patient data, position, technical quality and normal
anatomy.
Review systematically
2.
o
o
o
o
o
o
Initial survey
Review skeletal structures of shoulder girdles and chest wall
Review mediastinum
Review hila
Review lungs and pleura
Soft tissue including breast, companion shadow
Initial survey
1. General Body Size, Shape, and Symmetry
2. Sex
3. Age(cartilage/aortic arch
/asending aorta/Pulmonary trunk)
•
Infant/ child/ young adult/ elderly person
4. Foreign objects
•
•
tubes, IV lines, EKG leads, surgical drains, prosthesis
non-medical objects, bullets, shrapnel, glass, etc
Check List
1.
Check patient data, position, technical quality and normal
anatomy.
Review systematically
2.
o
o
o
o
o
o
Initial survey
Review skeletal structures of shoulder girdles and chest wall
Review mediastinum
Review hila
Review lungs and pleura
Soft tissue including breast, companion shadow
Skeletal structures
•
Overall size, shape, contour of each bone.
–
–
–
•
Joints
–
–
–
–
•
Density( mineralization)
Compare cortical thickness to medullary cavity,
trabecular pattern,
Erosions, fractures, any lytic or blastic regions.
Articular relationships
Joint spaces narrowed, widened
Calcification in the cartilages
Air in the joint space, abnormal fat pads
Refresh gross anatomy radiology
Neck and Cervical spines
• Overall(soft tissue)
– amounts
– calcifications,
– subcutaneous emphysema
• Trachea
– position
– size
• Cervical spine,
– alignment
– note any major congenital
abnormalities.
• Specific parts of the vertebra and
disc spaces
• Checking
–
–
–
–
erosions
lytic or blastic lesions
disc and synovial joint narrowing
Other abnormalities.
Thoracic spine and Rib cage
•
•
•
•
Overall alignment- spine
Symmetry - rib cage
Double check bone density
Two reminders at this point:
– Principle of general
• More detailed review in each
section.
– concentrate on the skeletal
detail
• “Look through" the
mediastinum and lungs.
Thoracic spine
• Specific parts(Each)
– Vertebra
– Disc spaces
•
•
•
•
height
integrity of cortical margins/pedicles/lamina
presence of any lytic or sclerotic areas
synovial joints(normal /narrowing /sclerosis spacing )
• Compare frontal & lateral projections
Thoracic spine
Ribs
1. Posterior Rib
2. Anterior Rib
Ribs
1. Posterior rib, 2.Ant rib
• Compare
– Side to side,
– Cortical margins,
– Trabecular patterns.
• Note calcified anterior
cartilages
– may obscure or mimic
underlying lung lesions.
Lt/Rt SHOULDER GIRDLE
3
7
1
8
6
4
2
Check List
1.
Check patient data, position, technical quality and normal
anatomy.
Review systematically
2.
o
o
o
o
o
o
Initial survey
Review skeletal structures of shoulder girdles and chest wall
Review mediastinum
Review hila
Review lungs and pleura
Soft tissue including breast, companion shadow
Mediastinum
• Define
– Area between the lung
– Water density
• Surrounded two air filled lungs and
• Intersected by the air filled trachea and major bronchi.
• Key is knowledge of anatomical relationships and
how structures project on a radiograph.
• CT and MRI is helpful.
• Interfaces of air-soft tissue margins may be distorted by
pathological lesion
– Masses
– otherwise
Mediastinum
• Define
– Area between the lung
– Water density
• Surrounded two air filled lungs and
• Intersected by the air filled trachea and major bronchi.
• Key is knowledge of anatomical relationships and
how structures project on a radiograph.
• CT and MRI is helpful.
• Interfaces of air-soft tissue margins may be distorted by
pathological lesion
– Masses
– otherwise
MEDIASTINUM
Mediastinum
• Define
– Area between the lung
– Water density
• Surrounded two air filled lungs and
• Intersected by the air filled trachea and major bronchi.
• Key is knowledge of anatomical relationships and
how structures project on a radiograph.
• CT and MRI is helpful.
• Interfaces of air-soft tissue margins may be distorted by
pathological lesion
– Masses
– otherwise
Anatomy
Project
Anatomy & project
1. Carina
2. Left Main Stem
Bronchus
3. Descending Aorta
4. Main Pulmonary
Artery
5. Aorticopulmonary
Window
6. Arch of Aorta
MEDIASTINUM
• Anatomy dividing region
– SUPERIOR MEDIASTINUM
• Begins - root of the neck and
• Ends - line drawn T-4 vertebrae --- sternomandible junction.
– line skims the top of the aortic arch. T
– Mediastinum
• Begins - this line
• End- diaphragm
• Further divided into three regions
– Anterior
– Middle
– Posterior.
4
1cm
Mediastinum
•
•
•
•
•
Overall size and shape
Trachea: position
Margins
Lines and stripes
Retrosternal clear space
Mediastinum
•
•
•
Overall size and shape
Trachea- position
Margins
•
•
•
•
•
•
•
•
SVC- Ascending aorta
Right atrium
Left subclavian artery- Aortic arch
Main pulmonary artery
Left antrium
Left ventricle
Lines and stripes
Retrosternal clear space
Margins
I
I
II
III
II
IV
Venography
1. Right
Brachiocephalic Vein
2. Superior Vena Cava
3. Left Brachiocephalic
Vein
Axial plan of computer
tomography
1. Right Brachiocepahlic
Artery
2. Superior Vena Cava
3. Right Paratracheal Stripe
4. Esophagus
5. Left Subclavian Artery
6. Left Common Carotid
Artery
7. Left Brachiocephalic Vein
4
1cm
Mediastinum
•
•
•
•
Overall size and shape
Trachea: position
Margins
Lines and stripes
•
•
•
•
•
Paratracheal
Paraspinal
Paraesophageal (azygoesophageal)
Paraaortic
Retrosternal clear space
Edge of Superior vena cave (SVC)
• Seen PA(AP) view only
• Often only a portion
• Never bulge into the lung
with a convex border.
Right Pratracheal stripe
Right Pratracheal stripe
• Normal- < 5 mm,
usually 2-3 mm.
– Important marker for subtle adenopathy.
• Distal end - formed by azygous vein
– Distended vein, stripe > 1 cm.
• Medial margin -soft tissue interface /right mucosal surface of trachea.
• Outer margin -begins medial end of clavicle/formed by plural surface of right
upper lobe (RUL).
• Normal structures in soft tissue density between air trachea and the RUL
–
–
–
–
–
Right wall of the trachea
Nerves
Fat
Lymph nodes
Pleura of the RUL.
• Azygous vein - anteriorly to empty into the posterior surface of the SVC.
Right paratracheal
stripe(TOMOGRAM )
CT of Paratracheal stripe
1. Asending aorta
2. Azygous vein
3. Esophagus
4. Desending aorta
5. Pulmonary trunk
Left Subclavian stripe
• Width- normal 1.0-1.5 cm.
• Inner marginAir mucosal interface mucosal surface of the trachea,
• Outer margin interface Medial aspect of left upper
lobe
• Upper- outer edge
Level of the clavicle and will
be able to follow it
• EndBulge of the aortic arch.
Paraspinal stripe
• Sometimes(+) on the frontal view
• Plural edge parallel to the lateral margins of the
vertebral bodies.
• Edge > millimeters beyond the vertebral bodies
• Should not be lumpy or bulging.
Pleural mediastinal interface
1. Superior Vena Cava
2. Right Paratracheal
Stripe
3. Left Subclavian Stripe
Azygoesophageal line or
Paraesophageal line
• On the forntal view only
• Formed by the right lower lobe & Mediastinum,
containing
– Esophagus
– Azygous vein.
• Overlies the thoracic spine
– Near the midline
– Fairly straight, vertically.
• Bulges convex to lung
– S/p mediastinal mass, eg.
• subcarinal lymph nodes
• Enlarged left atrium.
CT of the Azygoesophageal line
• 1. Esophagus
• 2. Azygous Vein
• 3. Descending Aorta
Lateral view of tracheal wall
• Posterior tracheal
< 4mm
MEDIASTINUM
• Overall size/ shape on PA & lateral views
– Decide if it is normal & age.
• Look for
– Obvious masses
– Calcifications
– Double check for foreign projects
•
•
•
•
Tubes
Electrical leads
Pacemaker
Artificial valves
MEDIASTINUM
• Evidence of
– Mediastinal shift
• Entire or
• Section of it.
• Look trachea/major bronchus
– Size
– Position
– Intraluminal masses
SUPERIOR MEDIASTINUM PA• Overall width for normal size,
• Look for
– Masses
– Calcifications
– Free air.
• Detailed search for subtle
distortion of
– several major pleural mediastinal
interfaces.
• Not all of the following
structures are seen on every
film
– Try to find them
Mediastinum
• Define
– Area between the lung
– Water density
• Surrounded two air filled lungs and
• Intersected by the air filled trachea and major bronchi.
• Key is knowledge of anatomical relationships and
how structures project on a radiograph.
• CT and MRI is helpful.
• Interfaces of air-soft tissue margins may be distorted by
pathological lesion
– Masses
– otherwise
HEART
1 Edge of superior
vena cava
2. Right atrium
3. Aortic arch
4. Edge of main
pulmonary artery
5. Left atrial
appendage
6. Left ventricle
•
•
•
•
•
Superimposed on the frontal view.
The major structure is the heart.
Pericardium and heart is inseparable on plain film views.
Review the heart for overall size and shape.
Rough yardstick - cardiac-thoracic ratio
– Widest diameter of the heart /widest width of the thoracic cage( inner aspect
of rib to rib).
– > 50%
• Check
–
–
–
–
–
Calcifications
Pneumopericardium
Pneumomediastinum
Sutures
Prosthetic valves etc.,
• You may have overlooked on the general survey of the entire mediastinum.
Lateral view of heart
1. Trachea
2. Right Ventricle
3. Left Ventricle
4. Left Atrium
5. Right Pulmonary
Artery
Aorta
• Try tracking
– Root
– Distal descending aorta.
• Young adult - hidden in the mediastinum
Older - swing to the right to cast a soft tissue bulge.
• Arch- always be seen
– make sure left to distal trachea
– Pushes trachea slightly to the right actually .
• Check aortic calcifications and size.
• Left lateral border of descending aorta
– abuts the left lung (column of dots on the pt's. left, on the
annotated image).
• Lateral view- aorta is usually not seen.
Pulmonary artery
1. Carina
2. Left Main Stem
Bronchus
3. Descending Aorta
4. Main Pulmonary
Artery
5. Aorticopulmonary
Window
6. Arch of Aorta
• Main pulmonary artery
– Straight or
– Convex (most commonly in young females).
• "middle mogul" - when convex
– Upper "mogul" - aortic knob
– Lower mogul - left ventricle.
• Left pulmonary artery- branching of main
pulmonary artery
• Right pulmonary artery– Proximal- not seen, ( buried in the mediastinum)
– Branches can see ( as the right hilum)
Blood vesseles in the lung
Pulmonary arteries, Lateral view
6
1. Trachea
2. Right Ventricle
3. Left Ventricle
4. Region of left Atrium
5. Right Pulmonary
Artery
6. Left Pulmonary Artery
Pulmonary artery
• Right pulmonary artery
– Ovoid branching structure- easily seen,
– Just anterior to the air column of the trachea and main
bronchi.
• Left pulmonary artery
–
–
–
–
Never seen as clearly as the right
Unless markedly enlarged.
Curved shadow, similar to the aorta
just behind the air column
Aorticopulmonary window
(AP WINDOW)
• Double check area - for subtle mediastinal
masses.
• Between
– Aortic arch
– Left pulmonary artery
– Residual portion
• Ligamentum arteriosum
• left recurrent laryngeal nerve
• Should concave or straight border.
– Mediastinal mass(+)
• Lung pushed laterally  border becomes convex.
MISCELLANEOUS
• Lateral view
– Adult
• anterior mediastinum cephalad
to the heart
• Lung-air density, not soft tissue
density.
– Infants and young children
• Thymus fills this area.
• Check posterior sternal
margin
– Small masses: internal thoracic
lymph node enlargement.
Check List
8. Review hila:
–
–
normal relationships
size
9. Review lungs and pleura:
–
–
–
–
compare lung sizes
evaluate pulmonary vascular pattern: compare upper
to lower lobe, right to left, normal tapering to
periphery
pulmonary parenchyma
pleural surfaces
•
•
•
fissures - major and minor - if seen
compare hemidiaphragms
follow pleura around rib cage
Frontal view of the hila
Frontal view of the hila
• Frontal view, hilar shadows most
– left pulmonary arteries.
– right pulmonary arteries.
• Bronchi(with the arteries)
– Radiolucent.
• Pulmonary veins
– Not clearly seen
• they are behind the widest parts of the heart, inferior to the hila,
where they converge into the left atrium.
• Left pulmonary artery always more superior > right,
 left hilum higher.
• Calcified lymph nodes may be visible within the
hilar shadows.
Lateral view of the hila
1. Trachea
2. Lower lobe bronchi
(left and right
superimposed)
3. Right Pulmonary
Artery
Check List
8. Review hila:
–
–
normal relationships
size
9. Review lungs and pleura:
–
–
compare lung sizes
evaluate pulmonary vascular pattern
•
–
–
compare upper to lower lobe, right to left, normal tapering to
periphery
pulmonary parenchyma
pleural surfaces
•
•
•
fissures - major and minor - if seen
compare hemidiaphragms
follow pleura around rib cage
Lung size
Lung
• Compare overall size of one lung bilateral,
• Also a double check on your earlier look at
the rib cage size.
• Look for major areas of abnormal lucency/or
density
• Train your eyes to look through the heart
and upper abdomen to lung posterior to these
areas.
Blood vesseles in the lung
Blood vesseles in the lung
• Distribution- side to side
– Compare right/left upper lobes and lower lobes
for roughly equal.
• Distribution- upper to a lower
– Vessel in the same middle zone of the lung.
• Upright person- pressure differential
– lower lobe vessel wider (i.e., larger)
– If same size or reversed in size,
• Redistribution of flow has occurred.
• Phenomenon does not apply, if the person is
semi-recumbent or supine.
Blood vesseles of lung
PARENCHYMA
PARENCHYMA
• Large abnormalities/small lesion
– Masses
– Infiltrates
– calcifications
• Compare- side to side at a time.
• Now ignore the bone but lung.
• 3 areas easily overlooked:
– Behind the calcified anterior first rib cartilage,
– Behind the heart
– Behind the diaphragm
LATERAL VIEW OF THE LUNG
• Lateral view
– Help to look
• Posterior
costophrenic recess
• Anterior
mediastinum.
Pleura
• PA view
– Minor fissue thickness and location
• Lateral view
– minor fissures
– major fissures
(even if you do not see them in their entirety which you rarely will).
AP VIEW OF THE PLEURA
•
•
•
•
•
•
Follow the pleural surface around
the lung periphery making the
following observations.
On the frontal view, the apex of
the hemidiaphragms should be in
the mid third of each hemithorax
with the right hemidiaphragm
usually 2-2.5 cm higher than the
left.
The costophrenic angles laterally
should be sharp.
The lung should abut right up
against the inner margins of the
rib cage.
If the pleural space is widened by
fluid or mass, the lung will be
pushed away by soft tissue density.
Also check for pleural
calcifications, and presence of
pneumothorax.
LATERAL VIEW OF THE PLEURA
• Lateral view
– ,follow the pleura into the
posterior costophrenic
recess
– along the inner aspect of
the posterior ribs, if
possible.
• Recheck Posterior
sternal margin.
Soft tissues
1. Overall
2. Following
–
–
–
Calcifications
Bony defect
Soft tissue companion shadow for the clavicle
•
Supraclavicular LAP
Lt/Rt CHEST WALL
• Overall thickness,
subcutaneous emphysema,
calcification.
• Muscle-fat planes (sharp,
distinct; dots).
BREAST TISSUE
• Symmetry
(Normal variation –
Standing(PA view) +
unequal pressure against the film holder)
• Notice lung density
changes
(lung area +/- soft tissue of
the breast )
ABDOMEN
• Highly variable
• look for following
– Gastric and bowel gas
• Amount/ location( normal? )
– Organ size
• liver, spleen, kidneys
– Free peritoneal air
• Position will change location of
free air.
– Calcifications and masses
• can they be localized to a
specific structure.
Final Notes
• This completes an introduction into the beginnings of chest
review.
• Be aware there are many more detailed observations to
learn in the future.
• Go through the sections until you understand the anatomy,
and then start practicing a continuous review looking at a
full frontal and lateral view.
• When you have developed a review system that works for
you (remember the order here is only a guide) go to the next
section that has the check off list type of review.
• Many people find it helpful to talk their way through the
film, the eye-brain-mouth loop does work.
• Finally look at films on a variety of normal people of all ages,
sizes, and both sexes to develop a data base of normal
references.
• Practice the review sequence that works best for you until it
is automatic, and then you can concentrate on the diagnostic
findings.
Check List (1)
1.
2.
3.
Check patient name, position, technical quality.
Initial survey
Soft tissue including breast, chest wall, companion shadow.
•
•
•
•
4.
Review soft tissues and skeletal structures of shoulder girdles and chest
wall.
Review abdomen for bowel gas, organ size, abnormal calcifications, free air,
etc.
Review soft tissues and spine of neck.
Review spine and rib cage: check alignment, disc space narrowing, lytic or
blastic regions, etc.
Review mediastinum:
–
–
–
–
–
overall size and shape
trachea: position
margins: SVC, ascending aorta, right atrium, left subclavian artery, aortic
arch, main pulmonary artery, left ventricle
lines and stripes: paratracheal, paraspinal, paraesophageal
(azygoesophageal), paraaortic
retrosternal clear space
Check List (2)
8. Review hila:
–
–
normal relationships
size
9. Review lungs and pleura:
–
–
–
–
compare lung sizes
evaluate pulmonary vascular pattern: compare upper
to lower lobe, right to left, normal tapering to
periphery
pulmonary parenchyma
pleural surfaces
•
•
•
fissures - major and minor - if seen
compare hemidiaphragms
follow pleura around rib cage