Download to read offline
Chest X ray ap and pa view , findings in various diseases
- 1. Reading of chestX-Ray Chairperson: Dr. Shashidhar Khanapure sir Presenter: Sohan C. Kotigera
- 2. Contents • Introduction • Typesof chest xray – radiographic technique (chest projections) • Examination of films • Normal and pseudo abnormal chest x ray • Identification of lung pathology and other associated conditions
- 3. Introduction • Chest radiographyemploys the use of ionizing radiation of X rays to generate images of the chest. • The mean radiation dose to an adult from a chest radiograph is around 0.02 mSv for PA 0.08 mSv for a lateral view. • Together, this adds up to a background radiation equivalent of 10 days.
- 4. Chest projections • PAview • AP view • Lateral • Oblique view • Inspiration/ expiration PA view • Apical lordotic
- 5. PA view • Mostcommonly employed • View of choice (if feasible). • Rays originate from and pass through the chest from posterior anterior. • Adequate delineation of the lung parenchyma and other hilar and thoracic structures.
- 6. AP view • Donein moribund or bed ridden patients • Done in those who are unable to stand and/ or unable to follow instructions.
- 7. PA view andlateral view
- 8. Features of aPA view film • Medial end of the clavicle – equidistant from the vertebral column • Scapulae – off the lung fields • 10 posterior ribs above the diaphragm must be visible • Both CP angles must be present on the film
- 9. PA view APview Scapula in the periphery of the thorax Scapulae are seen over the lung fields Clavicles project over the lung fields Clavicles are present above the lung fields Posterior ribs are distinct Anterior ribs are distinct
- 12. 1st step in readinga film - Identification • Correct patient • Correct date and time of examination • Appropriate film
- 13. Commenting on theX-ray • RIPE 1. Rotation 2. Inspiration 3. Projection 4. Exposure
- 14. Commenting on anxray • ABCDE 1. Airway 2. Breathing – lungs 3. Cardiac – heart size and borders 4. Diaphragm – and CP angles 5. Everything else – ribs, devices etc.
- 15. Rotation • Medial endof each clavicle must be equidistant from the Spinous process • Spinous process must be vertically oriented to the vertebral bodies
- 18. Inspiration • 5-6 anteriorribs • Lung apices • CP angles • Lateral rib edges should be visible
- 21. Exposure • Well exposedfilm – 1. left hemi- diaphragm should be visible to the spine 2. vertebrae must be visible behind the heart
- 22. UNDER-PENETRATED OVER-EXPOSED Normal chestx-ray will appear to have diffuse infiltrates No adequate lung detail – can miss subtle/ early changes Left hemi diaphragm and left lung base are not visible properly Absence of peripheral vasculature No differentiation between the vertebral bodies and the intervertebral space Vertebral bodies are also seen extending into the abdominal region
- 25. Airway • Tracheal shift/deviation • Carina and its surrounding structures/contents • Hilum – the hilum is present at the centre of the film and consists of the pulmonary vasculature, thus asymmetry should raise the suspicion of a mass/ lesion/ enlarged lymph node.
- 28. Lungs • Lungs andthe concurrent pleura should be inspected for abnormalities and the best way to differentiate is to compare one side with the other which reveals a pathology. • the above mentioned technique falls short if there is symmetric B/L involvement.
- 29. Silhouette sign • Helpsin identification of the presence of a pathology and its location in the chest vis-à-vis other structures. STRUCTURE CONTACT WITH LUNG Upper right heart border Anterior segment of RUL Right heart border RML – medial Upper left heart border Anterior segment of LUL Left heart border Lingula Anterior hemidiaphram Lower lobes – anterior
- 34. Air bronchograms • Tubularoutline of the bronchi/ airway which is present because of the surrounding structures being inflamed or fluid filled. • Causes – interstitial disease, atelectasis, edema and most importantly – consolidation.
- 37. Consolidation • It isthe variation in the normal translucency which is seen in the lung fields due to the accumulation of substances. These substances include – Pus – pneumonia Cells – bronchiolar cell carcinoma Blood – contusion, pulmonary hemorrhage Water - aspiration
- 41. Collapse / atelectasis •This is due to the volume loss which occurs due to the alveolar collapse or failure. • Features of collapse – shift of fissures crowding of vessels increased opacity hilar shift elevation of hemidiaphram
- 44. ATELECTASIS PNEUMONIA Volume lossIncreased total volume is generally seen in cases of pneumonia Ipsilateral shift Contralateral shift Apex at hilum Apex not centered at the hilum Air bronchograms are seen in and occur in both of the conditions.
- 45. Pleural diseases • Pleuraleffusion • Pneumothorax • Pleural calcification or thickening • Pleural mass
- 46. Pleural effusions • Collectionof fluid can be – Transudative fluid – hydrothorax Pyothorax – pus Hemothorax – blood Chylothorax – chyle • Malignant – B/L pleural effusions – metastasis, lymphoma and SLE. Most common cause – cardiac in nature.
- 49. Pleural effusions • Rightsided – ascites heart failure liver abscess • Left sided – pancreatitis pericarditis aortic dissection
- 52. Radiological signs • Bluntingof the CP angles – most common and best indicator of the presence of effusions. • Shifting of the opacity based on change of position of the patient – best method to delineate minimal effusion with other conditions – poor exposure, diaphragmatic issues, consolidation
- 53. • Shifting ofthe opacity confirms the presence of effusion, however, it is not exclusive in nature as – loculated effusions pyothorax old/ capsulated haemothorax do not have any shifting of the fluid.
- 54. Pnuemothorax • Relatively simpleto differentiate • As air has the least radio opacity potential – blacking/ darkening of an area indicates the presence of air or gas • The films should ideally by in PA view and efforts must be made to obtain it in this position. • Care must be taken to rule out over exposure.
- 57. • Supine filmpneumothorax signs - • Ipsilaterla trans – radiancy • Deep finger like costo-phrenic sulcus laterally • Double diaphragm sign • Visualization of the undersurface of the heat and cardiac fat pads
- 59. Unilateral hyperlucent lung •Chest wall deficiency • Poland's syndrome • Mastectomy • Congenital pulmonary artery absence • Lobar collapse • Rotated film
- 61. Pleural calcification/ thickening •Asbestosis • Pancoast tumor • Metastasis • Old Tb • Pleuritis • Sarcoidosis
- 63. Cardia • Normal –heart should not occupy more than 50% of the thoracic width i.e. the CTR <0.5 • This comment must be made only in PA films.
- 66. Normal cardia butElevated CTR • Seen if deep inspiration cannot be taken – ascites obesity • Other anatomical defects- pectus excavatum straight back syndrome
- 67.
- 69. Measurement of themain pulmonary Artery • The line drawn tangentially from the left heart border to the aortic knuckle bisects the point of the MPA. • A value of 0 – 15mm towards the right heart border is normal with pulmonary hypertension leading to an overshooting of the line.
- 70. • If theMPA value is elevated then the cause of the cardiac enlargement can be pinned on right heart enlargement.
- 72. Pulmonary vasculature • Normal: Rightdescending pulmonary artery is less than 17mm lower lobe vessels are larger than the upper lobe vessels there is a gradual tapering of the diameter of the pulmonary vasculature from the centre to the periphery
- 74. Pulmonary venous hypertension •Pulmonary venous hypertension: increased RDPA diameter to more than 17mm upper lobe vessels are of a similar diameter as that of the lower lobes. This is also known as cephalisation of the vasculature. • Tapering of the vessels from the centre to the periphery ( normal, but its absence – other causes of the abnormal x-ray).
- 77. Pulmonary artery HTN •Pulmonary artery HTN: the RDPA is more than 17mm in diameter the lower lobe vessels are more prominent than the ones in the upper lobe rapid decrease in the size of the pulmonary vasculature from the centre to the periphery – also known as pruning sign
- 80. Pericardial effusion • Difficultto differentiate pericardial effusion from cardiomegaly • Often aided by the presence/ absence of the concurrent clinical signs.
- 83. Differentiating points • Distinctepicardial fat planes • Normal pulmonary vasculature despite cardiomegaly • Obliteration of the retro – sternal space • Water bottle appearance of the enlarged cardiac silhouette
- 85. Diaphragm • Normally thediaphragm is of the same radio opacity as that of the liver. • Main points to be seen is if the diaphragm has gas under it – indicative of pneumoperitoneum, or if there’s another pathology located superiorly to the diaphragm making it undetectable.
- 86. Diaphragm • Eventeration – dueto the absence of a part of a muscle of the diaphragm which is instead replaced with a connective tissue membrane. • Hemidiaphram is not visualized • Multicystic mass in the chest • Mediastinal shift to the opposite side.
- 89. Diaphragm • Diaphragmatic hernia: bochdaleksand morgagnian’s • Hiatal hernia: appearance is of a soft tissue lesion present just behind the heart • Trauma: affects left side of the diaphragm 3 times more commonly than the right – mostly due to the buffeting action of the liver.
- 91. Diaphragm • There isoften associated eventeration of abdominal contents into the thorax seen in the X-ray • There is also seen – collar sign where there is a constriction at the site of the tear from where the organ has protruded into the thoracic cavity. • NG tube above the diaphragmatic level on the left side is also another indicator of the same.
- 92. Costo phrenic angels •Normal – clearly visible CP angels • Loss – fluid or blunting
- 95. Aortic knuckle • Archingback over the left main bronchus • Reduced definition of the knuckle is seen in case of aneurysm,
- 99. Aorto pulmonary window •Space between the arch of the aorta and the pulmonary arteries. • Space can be lost in case of mediastinal Lymphadenopathy/ malignancy.
- 101. Other important thingsto note in a chest x ray • Bones • Soft tissue – hematoma etc. • Medical devices – pacemakers, NG tube, artificial valves.
- 102. Mediastinum • The mediastinumis conventionally divided into superior and inferior sections. • Inferior – anterior, middle and posterior segments. • 2/3 of the heart lies in the left side of the chest and 1/3 lies on the right. • Left border – left atrium and left ventricle • Right border – right atrium alone
- 103. Devices • Central line •ET tube • Thoracostomy tube • Pacemaker • Nasogastric tube
- 110. Normal looking abnormalx-rays • Mediastinal mass • Breast tissue vs. lung opacities • Cervical ribs • Small pneumothorax
- 113. Normal x raysin the presence of underlying pathology • Pulmonary thrombo-embolism • Asthma • Croup • Viral pneumonia
- 114.
- 115. Coin lesion • Carcinoma •Hamartoma • Metastasis • Granuloma • TB Rare: hydatid cyst, abscess, hematoma, adenoma
- 117. Multiple coin lesions •Metastasis • Septic emboli • Abscesses • Multiple emboli Rare: wegeners granulomatosis, rheumatoid lung
- 120. Cavitatory lesions • TB •Hydatid • Carcinoma • Septic infarct Uncommon: lymphoma, hematoma, bullae, pneumatocoele
- 123. Apical involvement inchest x-ray • TB • Pancoasts tumor • Metastases • Pleural thickening • Extra pleural disease
- 126. Peribronchial thickening • Chronicbronchitis • Asthma • Edema • Bronchiectasis • Cystic fibrosis
- 127. Diffuse pulmonary infiltrates •Acute: ARDS Aspiration hemorrhage cardiogenic edema
- 128. Diffuse pulmonary infiltrates •Chronic: TB aspergillosis sarcoidosis silicosis
- 131. Diffuse pulmonary infiltrates Upperlobe Lower lobe S – silicosis C – coal workers pneumoconisois H – histiocytosis A - AS R – radiation T - TB R - RA A - Asbestosis S – Scleroderma I – iodiopathic O – other – bleomycin, amiodarone etc.
- 132. Miliary opacities • Miliarypattern: sarcoidosis, metastasis, Tb, silicosis, pneumoconiosis • Dense nodules: silicosis, hemosiderosis, metal, microlithiasis
- 135. CP angle mass •Fat pad – post pregnancy, obesity, steroids • Pericardial cyst • Pericardial tumor
- 136. Hyper inflated lungs BilateralUnilateral Apparent unilateral COPD Foreign body Rotated film Asthma Pneumothorax Increased density on opposite side Alpha 1 AT deficiency Pulmonary embolus (large) Absent breast – mastectomy Aspergillosis Lung cyst Absent pectoral muscle Bronchiolistis Unilateral emphysema Scoliosis Cystic fibrosis Post lobectomy
- 139. Specific x rayfeatures
- 140. CCF • Cardiomegaly • Pulmonarycongestion UL>/= LL • Prominent lymphatics – blurring of hilar vessels • Visible lymphatics – kerly A and B lines • Diffuse patchy opacities
- 142. Pulmonary edema • Kerley’slines • Diffuse reticular pattern • Sub pleural thickening and edema
- 145. Mind Map 1. Typesof CXR 2. Choice of CXR based on patient Identification of the CXR Differentiating points for different views and significance RIPE ABCDE Commenting on the normal and abnormal parts of the X-RAY in a sequential fashion Characteristic CXR DD for commonly seen lesions Use of CXR for device related matters Importance of and the advantages of an old and cheap investigation
- 146. Source • Chest X-raymade easy – D karthikeyan Deepa Chegu
- 147.