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.Check patient data, position, technical quality and normal anatomy. 2.Review systematically

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. Check patient data, position, technical quality and normal anatomy.2. Review systematically

o Initial surveyo Review skeletal structures of shoulder girdles and chest wallo 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

o Review hila: • normal relationships

• size

Check List(2)

o 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 cageo 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 blast

ic regions, etc.

Check List

1. Check patient data, position, technical quality and normal anatomy.

2. Review systematicallyo Initial surveyo Review skeletal structures of shoulder girdles and chest wallo Review mediastinum o Review hilao Review lungs and pleura

o Soft tissue including breast, companion shadow

1. Data base1. 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

4

1

21

3

4

(erect)

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 decubitus view

Rt’ Lateral 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

• 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 diaphragm2. Left diaphragm3. Spine4. Scapula5. Axiallary fold6. Sternum7. Subcutaneous tissue8. Trachea9. Aortic arch10. Main bronchus11. Pulmonary artery12. Heart13. Retrosternal clear space14. Retrocardiac clear space15. Costophrenic angle16. Costocardiac angle

Normal Anatomy

8

12

3

4

5

6

7

9

11 10

13

12

14

15

16

16

• 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


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


Normal Anatomy

Lobar anatomy

1 21 2

3-4-5

3-45

3-4-6 6

• 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)

Normal Anatomy

11

2 2

33

4 4

55

66

797

9

8 108 10

1+2

3

3

1+2

44

5

5

7+8 10

9

Check List




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 A: Airway

o B: Bone

o C: CV

o D: Diaphragm

o E: Extra-pulmonary

o F: Lung field

o G: Gastric bubble

o H: Hilum/Hernia

Systematic review

o Initial surveyo Review skeletal structures of shoulder girdles and ch

est wallo Review mediastinumo Review hila

o Review lungs and pleura:

o Soft tissue including breast, companion shadow. .

Check List




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




• Overall size, shape, contour of each bone. – Density( mineralization) – Compare cortical thickness to medullary cavity, trabecu

lar pattern, – Erosions, fractures, any lytic or blastic regions.

• Joints– Articular relationships – Joint spaces narrowed, widened – Calcification in the cartilages– Air in the joint space, abnormal fat pads

• Refresh gross anatomy radiology

Skeletal structures

Neck and Cervical spines • Overall(soft tissue)

– amounts – calcifications, – subcutaneous emphysema

• Trachea– position – size

• Cervical spine, – alignment – note any major congenital abnormal

ities. • Specific parts of the vertebra and di

sc 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.

• 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

Thoracic spine

1. Posterior Rib

2. Anterior Rib

Ribs

Ribs

1. Posterior rib, 2.Ant rib• Compare

– Side to side,

– Cortical margins,

– Trabecular patterns.

• Note calcified anterior cartilages– may obscure or mimic un

derlying lung lesions.

Lt/Rt SHOULDER GIRDLE

1

2

3

4

7

6

8

Check List




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 path

ological lesion– Masses– otherwise






MEDIASTINUM






Anatomy

Project

Anatomy & project1. Carina

2. Left Main Stem Bronchus

3. Descending Aorta

4. Main Pulmonary Artery

5. Aorticopulmonary Window

6. Arch of Aorta

• 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.

MEDIASTINUM

1cm

4

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

I

II IV

I

II

III

Margins

Venography1. Right Brachiocephali

c 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

1cm

4

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

• 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 righ

t 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 Pratracheal stripe

Right paratracheal stripe(TOMOGRAM )

CT of Paratracheal stripe1. Asending aorta

2. Azygous vein

3. Esophagus

4. Desending aorta

5. Pulmonary trunk

Left Subclavian stripe• Width- normal 1.0-1.5 cm. • Inner margin- Air mucosal interface -mucos

al surface of the trachea, • Outer margin interface - Medi

al aspect of left upper lobe • Upper- outer edge

Level of the clavicle and will be able to follow it

• End- Bulge of the aortic arch.

Paraspinal stripe

• Sometimes(+) on the frontal view• Plural edge parallel to the lateral margins of the vertebr

al bodies.• Edge > millimeters beyond the vertebral bodies

• Should not be lumpy or bulging.

Pleural mediastinal interface1. 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, c

ontaining – 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

• 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

MEDIASTINUM

SUPERIOR MEDIASTINUM - PA

• Overall width for normal size, • Look for

– Masses– Calcifications– Free air.

• Detailed search for subtle distortion of – several major pleural mediastinal i

nterfaces.

• Not all of the following structures are seen on every film– Try to find them




• 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 pat

hological lesion– Masses– otherwise

HEART

1 Edge of superior vena cava

2. Right atrium 3. Aortic arch 4. Edge of main pulm

onary artery 5. Left atrial appenda

ge 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.

1. Trachea

2. Right Ventricle

3. Left Ventricle

4. Left Atrium

5. Right Pulmonary Artery

Lateral view of heart

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 artery1. 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 1. Trachea

2. Right Ventricle

3. Left Ventricle

4. Region of left Atrium


6. Left Pulmonary Artery

6

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 t

o the heart • Lung-air density, not soft tissu

e density. – Infants and young children

• Thymus fills this area.

• Check posterior sternal margin – Small masses: internal thoracic l

ymph node enlargement.

Check List8. Review hila:

– normal relationships – size

9. Review lungs and pleura: – compare lung sizes – evaluate pulmonary vascular pattern: compare upper t

o 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, 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.

Frontal view of the hila

Lateral view of the hila1. Trachea

2. Lower lobe bronchi (left and right superimposed)


Check List8. Review hila:


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


Lung size

• 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.

Lung


• Distribution- side to side – Compare right/left upper lobes and lower lobes f

or 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

• 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

PARENCHYMA

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, subcuta

neous 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 f

ree 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. Check patient name, position, technical quality. 2. Initial survey3. Soft tissue including breast, chest wall, companion shadow.

• 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. 4. 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 (azygoesophag

eal), paraaortic – retrosternal clear space

Check List (2)8. Review hila:


9. Review lungs and pleura: – compare lung sizes – evaluate pulmonary vascular pattern: compare upper t

o lower lobe, right to left, normal tapering to periphery – pulmonary parenchyma – pleural surfaces


Documents

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.Check patient data, position, technical quality and normal anatomy. 2.Review systematically

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.Check patient data, position, technical quality and normal anatomy. 2.Review systematically