Intro to CXR page 1 of 17 for Non-Radiologists
Introduction to CXRs For Non-Radiologists Introduction to CXRs For Non-Radiologists Objectives Disclaimer Physiology Review anatomy & physiology Physiology I am not Chest Radiologist Anatomy of the heart & lungs. Anatomy This is my first CXR lecture PA&Lat. Understand the significant PA&Lat. DualEnergy differences between: DualEnergy I do read CXRs daily PortableAP Upright PA and lateral views PortableAP Mostly from the ER Looking@CXR Portable supine AP view Looking@CXR Reading CXR is something Normal Recognize common Normal all radiologists should be PTX abnormalities: PTX able to do Pl.Effusion Pneumothorax Pl.Effusion Pneumonia Pleural Effusion Pneumonia Looking at CXR something Pul.Edema Pneumonia Pul.Edema ALL health care providers WOW Pulmonary Edema WOW should be willing to do www.schreibman.info Thanks to Carrie Bartels for 3D www.schreibman.info © 2013 Ken L Schreibman, PhD/MD processing and segmentation! Slide 1 of 99 © 2013 Ken L Schreibman, PhD/MD Slide 2 of 99
Introduction to CXRs For Non-Radiologists Introduction to CXRs For Non-Radiologists Terminology: “Chest” X-Ray (CXR) Terminology: Chest “X-Ray” (CXR) Physiology X-Rays pass thru Physiology This is a “Radiograph” Anatomy entire chest Anatomy Recall, “X-Rays” are: PA&Lat. Superficial tissues PA&Lat. EM Spectrum energy DualEnergy Skin, breasts, sub-q fat DualEnergy Very short wavelength PortableAP Muscles PortableAP About size of an atom Looking@CXR Intercostals Looking@CXR Man-made Normal Bones Normal Emitted by a tube… PTX Ribs, sternum, spine PTX …pass thru patient… Pl.Effusion Heart & Mediastinum Pl.Effusion …into a x-ray detector Pneumonia Trachea, Vessels, … Pneumonia Film (old school) Pul.Edema Lungs Pul.Edema CR plate WOW mostly air WOW DR unit www.schreibman.info www.schreibman.info A,M 38yoF © 2013 Ken L Schreibman, PhD/MD Slide 3 of 99 © 2013 Ken L Schreibman, PhD/MD Slide 4 of 99
Introduction to CXRs For Non-Radiologists IntroductionConvention: to CXRs We look at CXR likeFor we Non look-Radiologists at Pt… Radiographs Only Detect 4 Densities Face -to-Face Physiology Physiology Air = Black Tech’s marker, on detector, Anatomy Anatomy Right Lungs (Air-filled alveoli) near patient’s Left shoulder Aortic PA&Lat. PA&Lat. Aortic Arch DualEnergy Soft Tissues = Gray DualEnergy Arch Rare PortableAP Superficial tissues PortableAP Normal @ @ Variant Looking CXR Heart, Mediastinum Looking CXR (0.01%)* Normal Zipper= Normal Bones = Lighter Gray Clothed Cardiac Cardiac PTX PTX Apex Pl.Effusion Ribs, Spine Pl.Effusion Apex Pneumonia Pneumonia Metal = White Stomach Pul.Edema BicTM lighter = Pul.Edema Stomach WOW Outside/Inside patient Smoker WOW www.schreibman.info www.schreibman.info H,C 64yoM *wikipedia.org Q,J 23yoM © 2013 Ken L Schreibman, PhD/MD Slide 5 of 99 © 2013 Ken L Schreibman, PhD/MD Slide 6 of 99
©Ken L Schreibman, PhD/MD 8/9/13 www.schreibman.info Intro to CXR page 2 of 17 for Non-Radiologists
Introduction to CXRs For Non-Radiologists Introduction to CXRs For Non-Radiologists PowerPoint Model: Lungs PowerPoint Model: Lungs Physiology Bag of air Physiology 2 Lungs Trachea Anatomy Inhale: Fills Anatomy PA&Lat. PA&Lat. 3 Pipes RIGHT LEFT Bronchus Bronchus DualEnergy Exhale: Empties DualEnergy 2 Bronchi PortableAP (not completely) PortableAP “Main Stem Bronchi” Stem off Main Pipe: Carina Looking@CXR Pipes Looking@CXR Standard Normal Normal 1 Trachea Bronchus Meet at Convention: PTX Gr: “windpipe” PTX Look at CXR Pl.Effusion Pl.Effusion Carina like we’re Pneumonia Pneumonia looking at a Pul.Edema Pul.Edema patient, from WOW WOW the front www.schreibman.info etymonline.com www.schreibman.info © 2013 Ken L Schreibman, PhD/MD Slide 7 of 99 © 2013 Ken L Schreibman, PhD/MD Slide 8 of 99
Introduction to CXRs For Non-Radiologists Introduction to CXRs For Non-Radiologists How Do The Lungs Work? Thought Experiment Physiology The lungs don’t “work” (just bags of air) Physiology Balloon tied to a Straw Anatomy Anatomy Atmospheric Pressure PA&Lat. Lungs inflate passively PA&Lat. Sealed inside glass jar DualEnergy DualEnergy Only way air gets into balloon in response to pressure gradients - - PortableAP Carina Pressure > Lung Pressure PortableAP is via end of straw outside jar Looking@CXR Rescue Breathing Looking@CXR Jar has sealed rubber bottom Normal On a ventilator + Normal Pulling down on bottom… PTX PTX - - Pl.Effusion Tracheal Tube - Pl.Effusion Increases size of sealed jar Pneumonia Lung Pressure < Carina Pressure Pneumonia Decreases pressure in jar (PV=nrT) Pul.Edema Negative pressure outside the lungs Pul.Edema Jar Pressure < Atmospheric WOW Created by the DIAPHRAGM WOW Balloon Inflates! www.schreibman.info www.schreibman.info © 2013 Ken L Schreibman, PhD/MD Slide 9 of 99 © 2013 Ken L Schreibman, PhD/MD Slide 10 of 99
Introduction to CXRs For Non-RadiologistsAir enters Introduction to CXRs For Non-Radiologists Lungs Work The Same via… Lungs Fill Pleural Space Physiology 2 Lungs (bags of air) Physiology Not much in Thorax Lung Lung Anatomy Nose/ Anatomy Apex Apex Tracheobronchial tree Mouth Lungs: Fill the Thorax PA&Lat. PA&Lat. From Apices DualEnergy Sealed within Thorax DualEnergy Costo-Phrenic Angle (CPA) PortableAP Chest Wall (layers) - - PortableAP “Costo”: Ribs @ @ “Phrenic”: Diaphragm Looking CXR Skin/Sub-Q Looking CXR Media- Normal Ribs, Intercostal A/N/Muscles Normal Tracheobronchial Tree stinum PTX Inner Pleural Lining PTX Bronchioles branch off Pl.Effusion Diaphragm – Domed - - Pl.Effusion Heart Heart Pneumonia When it contracts it flattens Pneumonia Vessels (Mediastinum) CPA CPA Pul.Edema Increases intra-thoracic volume Pul.Edema Connect lungs to heart WOW Decreases intra-pleural pressure WOW Connect heart to whole body www.schreibman.info www.schreibman.info © 2013 Ken L Schreibman, PhD/MD Slide 11 of 99 © 2013 Ken L Schreibman, PhD/MD Slide 12 of 99
©Ken L Schreibman, PhD/MD 8/9/13 www.schreibman.info Intro to CXR page 3 of 17 for Non-Radiologists
Introduction to CXRs For Non-Radiologists Introduction to CXRs For Non-Radiologists Gas Exchange Diffusion Physiology Physiology All human cells require O2, emit CO2 Way of moving things for free (No energy expense) Anatomy Anatomy Related to a Fundamental Force: Entropy PA&Lat. Red Blood Cells (RBC) transport gas PA&Lat. Hemoglobin molecule (Hgb) Things become disorderly DualEnergy DualEnergy It takes a lot less energy to knock down Jenga tower… PortableAP PortableAP Occurs at capillaries Diffusion: Things move from high concentration (ordered) Looking@CXR Diameter = 1 RBC (5µm) Looking@CXR to lower concentrations (disordered) Normal Normal Tissue Cell CO CO Walls: Very thin, semipermeable membranes 2 2 CO2 CO PTX PTX CO2 2 I have more CO2 than you. CO2 CO2 CO 2 CO2 CO Here’s some of mine Pl.Effusion Permits Diffusion of gasses Pl.Effusion 2 Pneumonia Pneumonia O RBC 2 RBC O O 2 I have more O2 than you. Pul.Edema Capillary 1 RBC Pul.Edema Capillary 12 RBC Thin Walls O O2 Thin Walls 2 O2 Here’s some of mine WOW WOW www.schreibman.info www.schreibman.info © 2013 Ken L Schreibman, PhD/MD Slide 13 of 99 © 2013 Ken L Schreibman, PhD/MD Slide 14 of 99
Introduction to CXRs For Non-Radiologists Introduction to CXRs For Non-Radiologists Gas Exchange: Alveoli Gas Exchange: Alveoli Physiology alveolus [L]: Physiology Anatomy C Anatomy C A “little cavity” C PA&Lat. C PA&Lat. I have plenty of O C C 2 I have very little CO2 DualEnergy Air sacs C DualEnergy C Room Air is 21% O2 Room Air is 0.04% CO2 C C O O O2 PortableAP Bronchioles C PortableAP 2 O2 2 O2 @ C @ Looking CXR C Looking CXR O O O O2 2 2 O2 Looks like C C 2 O Normal Normal 2 bunch of grapes. O2 O2 O2 PTX PTX O2 Lungs O Pl.Effusion Interstitial spaces Pl.Effusion 2 Diffusion! O2 Pneumonia Outside alveoli Pneumonia CO2 RBC CO2 CO I need O2 Pul.Edema Capillaries Pul.Edema 2 CO2 Capillary 11 CO RBCRBC Thin Walls 2 CO2 WOW Where gas exchange occurs WOW CO 2 I need to get rid of CO2 www.schreibman.info www.schreibman.info © 2013 Ken L Schreibman, PhD/MD Slide 15 of 99 © 2013 Ken L Schreibman, PhD/MD Slide 16 of 99
Introduction to CXRs For Non-Radiologists Introduction to CXRs For Non-Radiologists Circulatory System The Heart: 4 Chambers Physiology Transports O2-rich RBCs Physiology Arteries carry blood from Heart Anatomy Lungs Whole Body Anatomy Thick walls (>120mmHg) PA&Lat. PA&Lat. LA O2 RBC Whole O2 Whole O DualEnergy 12 RBC Body DualEnergy O O O2 Body PortableAP 2 2 PortableAP Vena RA Looking@CXR Heart Looking@CXR Cava Normal Normal Lungs CO RBC2 CO PTX 2 PTX CO Lungs 12 RBCCO 2 CO2 CO2 Pl.Effusion CO2 Pl.Effusion Left Pneumonia Pneumonia Veins carry Right Ventricle Ventricle Pul.Edema Transports CO2-rich RBCs Pul.Edema blood to Heart Thin Wall Thick Wall WOW Lungs Whole Body WOW Thin walls (<10mmHg) <20mmHg >120mmHg www.schreibman.info www.schreibman.info © 2013 Ken L Schreibman, PhD/MD Slide 17 of 99 © 2013 Ken L Schreibman, PhD/MD Slide 18 of 99
©Ken L Schreibman, PhD/MD 8/9/13 www.schreibman.info Intro to CXR page 4 of 17 for Non-Radiologists
Introduction to CXRs For Non-Radiologists Introduction to CXRs For Non-Radiologists Cardio-Pulmonary System Left Ventricle (LV) Physiology Heart & Lungs intertwined Physiology Workhorse of the heart Anatomy also vessels, bronchi Anatomy Thick muscular wall PA&Lat. Anatomy of blood PA&Lat. Pump blood entire body DualEnergy filled structures can DualEnergy Generate pressure >120mmHg PortableAP be well demonstrated PortableAP 5½ FEET of H2O! Looking@CXR with CT-Angiography Looking@CXR It doesn’t look like much here Normal CT obtained immediately Normal because this is a CTA, showing LV Cardiac PTX after IV contrast bolus PTX only the contrast in the blood Basic 3D processing… INSIDE the chamber of the LV. Apex Pl.Effusion All blood/contrast filled Pl.Effusion Pneumonia structures (heart, vessels) Pneumonia Radiograph – LV: have same density… Pul.Edema and with technologists skilled in segmentation Pul.Edema left cardiac border WOW Similar to bone density processing we can add artificial colors! WOW cardiac apex www.schreibman.info www.schreibman.info © 2013 Ken L Schreibman, PhD/MD Slide 19 of 99 © 2013 Ken L Schreibman, PhD/MD Slide 20 of 99
Introduction to CXRs For Non-Radiologists Introduction to CXRs For Non-Radiologists Red Blood: LV Aorta Body Blue Blood: Body RA RV PulArt Physiology Great Vessels: Right Subclavian Left Common Carotid Physiology Right Ventricle (RV) Right Common Carotid Left Subclavian Anatomy Innominate Anatomy Wraps around LV PA&Lat. Aorta PA&Lat. Arch Thin muscular wall DualEnergy Thick wall, 3 layers Ascending DualEnergy PortableAP PortableAP Only needs to pump blood PA Intima (inner layer) Aorta Descending to adjacent lungs (20mmHg) Looking@CXR Tear Dissection Aorta Looking@CXR Normal Media (muscle, elastic fibers) LV LV Normal Pulmonary Artery (PA) RV LV PTX Tear Aneurysm PTX Carries blood from RV Pl.Effusion Adventitia (outer, supportive layer) Pl.Effusion to both lungs Pneumonia Tear ALL THREE Aortic Laceration Pneumonia Can’t see of this with CXR Only artery to carry Pul.Edema Pul.Edema deoxygenated blood WOW Need to use: CT, MR, US AnteriorOblique view WOW Oblique view www.schreibman.info www.schreibman.info © 2013 Ken L Schreibman, PhD/MD Slide 21 of 99 © 2013 Ken L Schreibman, PhD/MD Slide 22 of 99
Introduction to CXRs For Non-Radiologists Introduction to CXRs For Non-Radiologists Blue Blood: Body RA RV PulArt Cardio-Pulmonary System Physiology Right Atrium (RA) Physiology Pulmonary Veins (PV) Anatomy Forms right heart Anatomy PA&Lat. PA&Lat. Carry blood border on CXR lungs to LA DualEnergy DualEnergy PA PortableAP Right Ventricle (RV) PA PortableAP PV PV Looking@CXR Wraps around LV Looking@CXR PV Physiology requires heart & lungs RLAV PV Normal Does doesn’t RV LV Normal LV PTX contribute to heart RA PTX work together RA Pl.Effusion Pl.Effusion Anatomy places heart & lungs shadow on frontal adjacent so PA & PV can be short Only veins w/ Pneumonia radiograph Pneumonia oxygenated Pul.Edema Pul.Edema A lot of air & blood filled structures blood WOW Anterior view WOW in the tight intra-thoracic space Posterior view www.schreibman.info www.schreibman.info © 2013 Ken L Schreibman, PhD/MD Slide 23 of 99 © 2013 Ken L Schreibman,There’s PhD/MD a lot to look at on CXR! Slide 24 of 99
©Ken L Schreibman, PhD/MD 8/9/13 www.schreibman.info Intro to CXR page 5 of 17 for Non-Radiologists
Introduction to CXRs For Non-Radiologists Introduction to CXRs For Non-Radiologists Upright PA Chest Radiograph Upright PA Chest Radiograph Physiology Standing Upright Physiology PA is Standard Anatomy This is a big deal Anatomy X-rays enter Posteriorly, PA&Lat. PA&Lat. DualEnergy Permits full lung inflation DualEnergy X-rays exit Anteriorly PortableAP Can’t fully inflate laying/sitting PortableAP Hence X-rays travel
Looking@CXR Makes use of gravity Looking@CXR PosteriorAnterior, “PA” Normal More blood flows bases Normal Detector is Anterior PTX Pleural effusions CP angles PTX X-ray Allows patient to abduct Detector Pneumothoraces apices Pl.Effusion CR plate Pl.Effusion tube scapulae away from chest Pneumonia Pulls scapulae away Pneumonia Minimizes heart magnification Pul.Edema DR array Patient hugs detector Pul.Edema WOW Grid WOW www.schreibman.info www.schreibman.info © 2013 Ken L Schreibman, PhD/MD Marty age 13 Slide 25 of 99 © 2013 Ken L Schreibman, PhD/MD Slide 26 of 99
Introduction to CXRs For Non-Radiologists Introduction to CXRs For Non-Radiologists Shadow-graphic Magnification Radiographic Magnification Physiology As my hand gets further from Physiology PA AP Anatomy the wall, the shadow gets larger Anatomy Projection Projection PA&Lat. PA&Lat. Minimizes Increases DualEnergy DualEnergy heart-detector heart-detector PortableAP PortableAP distance distance Looking@CXR Looking@CXR Normal Flashlight Normal PTX PTX X-rays D X-rays D Pl.Effusion Pl.Effusion Heart is E Heart is E Similarly, as body parts get T T Pneumonia Pneumonia Minimizes anterior in E Increases anterior in E chest C chest C Pul.Edema further from the detector, their Pul.Edema heart T heart T O O WOW radiographic shadow get larger WOW magnification R magnification R www.schreibman.info www.schreibman.info © 2013 Ken L Schreibman, PhD/MD Slide 27 of 99 © 2013 Ken L Schreibman, PhD/MD Slide 28 of 99
Introduction to CXRs For Non-Radiologists Introduction to CXRs For Non-Radiologists PA CXR is Backward Importance of Scapular Abduction Physiology Physiology Pneumo- Can’t see Anatomy Anatomy thorax! the PTX! PA&Lat. PA&Lat. DualEnergy DualEnergy Edge PortableAP PortableAP Marty’s Lung Looking@CXR Left Looking@CXR Scapula Normal Shoulder Normal well Apex Scapulae PTX PTX abducted Scapulaoverlap Pl.Effusion Pl.Effusion away lungs from lung overlaps Pneumonia Pneumonia lung Pul.Edema Shot looking at patient’s back… Pul.Edema WOW Hung looking at patient’s front WOW Outpatient Clinic 1 hour later, Emergency Room www.schreibman.info S,M 8yoM www.schreibman.info D,M 21yoF © 2013 Ken L Schreibman, PhD/MD Slide 29 of 99 © 2013 Ken L Schreibman, PhD/MD Slide 30 of 99
©Ken L Schreibman, PhD/MD 8/9/13 www.schreibman.info Intro to CXR page 6 of 17 for Non-Radiologists
Introduction to CXRs For Non-Radiologists Introduction to CXRs For Non-Radiologists Upright Lateral Chest Radiograph Importance of Arm Elevation Physiology Importance of Physiology Arms Can barely Now we Anatomy multiple views Anatomy not elevated even see With good arm can see PA&Lat. Pt standing PA&Lat. the heart elevation… heart… DualEnergy Lungs inflated DualEnergy & lung in PortableAP Left side next PortableAP front of it Looking@CXR to the detector Looking@CXR Normal Minimize heart Normal PTX magnification PTX Pl.Effusion Tradition: Hung Pl.Effusion Pneumonia backwards Pneumonia Pul.Edema Arms Pul.Edema WOW Elevated! WOW Initial Lateral View Repeat Lateral View www.schreibman.info S,M 8yoM www.schreibman.info D,R 37yoM © 2013 Ken L Schreibman, PhD/MD Slide 31 of 99 © 2013 Ken L Schreibman, PhD/MD Slide 32 of 99
Introduction to CXRs For Non-Radiologists Introduction to CXRs For Non-Radiologists Importance of Lateral View CXR is NOT a Simple Exam Physiology Physiology Requires patient able to: Anatomy Anatomy PA&Lat. PA&Lat. Stand upright Obvious density Sitting in a chair is not the same DualEnergy DualEnergy Propped up on a cart, not the same PortableAP Behind heart = PortableAP Looking@CXR LLL Pneumonia! Looking@CXR Elevate their arms, abduct scapulae Normal Normal Take in a big breath, hold it 1 second PTX PTX Requires technologist to: Pl.Effusion Pl.Effusion Make sure patient is optimally positioned Pneumonia Pneumonia Pul.Edema Subtle density Pul.Edema Look at images to access optimal quality WOW Overlaps heart WOW Repeat images as needed www.schreibman.info S,M 8yoM www.schreibman.info © 2013 Ken L Schreibman, PhD/MD Slide 33 of 99 © 2013 Ken L Schreibman, PhD/MD Slide 34 of 99
Introduction to CXRs For Non-Radiologists Introduction to CXRs For Non-Radiologists Dual Energy CXR: Separate Lungs/Bones Digital Radiography Physiology The lungs are hard to see on CXR as they are nearly radiolucent, Physiology CR (Computed Radiography) Anatomy compared to the overlying bones which are relatively radiopaque. Anatomy Wouldn’t it be nice if we could remove calcified ribs on a CXR… Similar to old-fashioned film radiography PA&Lat. generating a 2nd CXR of the lungs without the overlying ribs… PA&Lat. rd Technologist places a cassette under the patent DualEnergy and even generate a 3 CXR showing just calcified structures! DualEnergy Contains photostimulable phosphor plate, rather than film PortableAP PortableAP Runs cassette through IIP (Image Information Processor) Looking@CXR Looking@CXR Laser scanner, rather than darkroom chemical developer Normal Normal Used for bones, abdomen, portables PTX PTX Pl.Effusion Pl.Effusion DR (Direct Radiography) Pneumonia Pneumonia Similar to modern digital camera Pul.Edema Pul.Edema Captures directly to image detector, no cassette Can take 2 images, rapidly, at 2 energies (DE) WOW At UW, our standard PA CXR is Dual Energy WOW www.schreibman.info S,J 58yoM www.schreibman.info First only text slide © 2013 Ken L Schreibman, PhD/MD Requires investment in dedicatedSlide DR 35 unit of 99 © 2013 Ken L Schreibman, PhD/MD Slide 36 of 99
©Ken L Schreibman, PhD/MD 8/9/13 www.schreibman.info Intro to CXR page 7 of 17 for Non-Radiologists
Introduction to CXRs For Non-Radiologists Introduction to CXRs For Non-Radiologists CR: Can use old film equipment CR: Film, cassettes, dark room replaced Physiology Outpatient CR room Physiology Anatomy Same film equipment Anatomy PA&Lat. PA&Lat. DualEnergy Same X-ray tube DualEnergy PortableAP Same PortableAP Same art Looking@CXR cassette Looking@CXR Normal Same holder Normal PTX cassette PTX Pl.Effusion holder Pl.Effusion IIP Pneumonia Pneumonia plate Pul.Edema Pul.Edema reader WOW WOW CR cassettes containing the phosphor plates www.schreibman.info www.schreibman.info © 2013 Ken L Schreibman, PhD/MD Slide 37 of 99 © 2013 Ken L Schreibman, PhD/MD Slide 38 of 99
Introduction to CXRs For Non-Radiologists Introduction to CXRs For Non-Radiologists DR: Requires all new equipment Dual Energy CXR: Helps See Pneumonia Physiology Outpatient DR room Physiology Standard PA view Technically:Dual Energy Lung Perfect! view Anatomy Anatomy PA&Lat. It looks a lot like the CR room PA&Lat. Lungs: Well Inflated DualEnergy DualEnergy Patient: Not Rotated Scapulae: Abducted PortableAP PortableAP Looking@CXR New DR New dual energy Looking@CXR Normal detector X-ray tube Normal PTX built into PTX Pl.Effusion upright chest Pl.Effusion Pneumonia unit New DR detector Pneumonia Pul.Edema built into table Pul.Edema Hard to see subtle density WOW WOW overlapping ribs… www.schreibman.info www.schreibman.info D,K 63yoM © 2013 Ken L Schreibman, PhD/MD Slide 39 of 99 © 2013 Ken L Schreibman, PhD/MD Slide 40 of 99
Introduction to CXRs For Non-Radiologists Introduction to CXRs For Non-Radiologists Dual Energy CXR: Helps See Nodules Dual Energy CXR: Shows Ca++ Nodules Physiology Standard view Lung view Ca++ view Lung view Physiology Standard view Lung view Ca++ view Anatomy Anatomy PA&Lat. PA&Lat. DualEnergy DualEnergy PortableAP PortableAP Looking@CXR Looking@CXR Tiny Hard to Easy to Normal Normal Nodule see see PTX ? !!! PTX Nipple Pl.Effusion Marker Pl.Effusion Calcified Pneumonia Scapula Better Pneumonia Granuloma Pul.Edema overlaps scapula Pul.Edema Nipple WOW lungs abduction WOW Marker www.schreibman.info A,S 75yoM www.schreibman.info L,T 61yoM © 2013 Ken L Schreibman, PhD/MD Slide 41 of 99 © 2013 Ken L Schreibman, PhD/MD Slide 42 of 99
©Ken L Schreibman, PhD/MD 8/9/13 www.schreibman.info Intro to CXR page 8 of 17 for Non-Radiologists
Introduction to CXRs For Non-Radiologists Introduction to CXRs For Non-Radiologists Portable Supine AP CXR Supine AP: Can’t make use of Gravity Physiology Used in cases when patient cannot Physiology Supine AP Upright PA Anatomy stand for upright PA & Lateral views Anatomy Vertical beam PTX rises above PA&Lat. PA&Lat. PARALLEL to gravity normal lung DualEnergy DualEnergy PortableAP PortableAP PTX layers Horizontal PTX Looking@CXR Looking@CXR anterior to beam Normal Normal Normal Lung normal lung PERPEN- Normal Pl.Ef. DICULAR Lung PTX PTX to gravity Pl.Effusion Pl.Effusion Pl.Ef. Pneumonia Pneumonia Pleural Effusion layers out Pleural Effusion flows Pul.Edema Pul.Edema posterior to normal lung below normal lung WOW WOW www.schreibman.info www.schreibman.info © 2013 Ken L Schreibman, PhD/MD Slide 43 of 99 © 2013 Ken L Schreibman, PhD/MD Complex Slide Warning Slide 44 of 99
Introduction to CXRs For Non-Radiologists Introduction to CXRs For Non-Radiologists Problems with Supine AP vs PA Portable AP CXR Never Fully Upright Physiology X-ray beam not perpendicular to gravity Physiology Anatomy Hard to see PTX air rising anteriorly Anatomy PA&Lat. Hard to see pleural effusions layering out posteriorly PA&Lat. DualEnergy Hard to assess increased blood flow to upper lobes DualEnergy PortableAP Lungs never well inflated PortableAP Looking@CXR Looking@CXR Normal No lateral view Normal PTX No dual energy PTX Pl.Effusion Hard to abduct scapulae Pl.Effusion Pneumonia Pneumonia Pul.Edema Heart is magnified Pul.Edema WOW Harder to assess heart size (cardiomegaly) WOW www.schreibman.info Second only text slide www.schreibman.info A,R 76yoM © 2013 Ken L Schreibman, PhD/MD Slide 45 of 99 © 2013 Ken L Schreibman, PhD/MD Slide 46 of 99
Introduction to CXRs For Non-Radiologists Introduction to CXRs For Non-Radiologists Portable AP vs Upright PA Portable AP vs Upright PA Physiology Semi-upright AP Upright PA Physiology Semi-upright AP Upright PA Anatomy Heart looks big Lungs better inflated Anatomy PA&Lat. Lots of pulmonary Heart less magnified PA&Lat. interstitial markings Normal pulmonary DualEnergy Extending to periphery! markings DualEnergy PortableAP PortableAP Looking@CXR Looking@CXR Normal Normal PTX PTX Pl.Effusion Pl.Effusion Pneumonia Pneumonia Dx: Resembles Pul.Edema Pulmonary Edema? Pul.Edema WOW Rec: Upright PA & Lat. Dx: Normal WOW www.schreibman.info C,C 54yoF www.schreibman.info O,T 54yoM © 2013 Ken L Schreibman, PhD/MD Slide 47 of 99 © 2013 Ken L Schreibman, PhD/MD Slide 48 of 99
©Ken L Schreibman, PhD/MD 8/9/13 www.schreibman.info Intro to CXR page 9 of 17 for Non-Radiologists
Introduction to CXRs For Non-Radiologists Introduction to CXRs For Non-Radiologists Portable AP vs Upright PA Portable AP vs Upright PA & Lat Physiology Supine AP Upright PA Physiology Semi-upright AP Upright PA Lateral Anatomy Anatomy Dual Energy PA&Lat. PA&Lat. Lung view DualEnergy DualEnergy PortableAP PortableAP Looking@CXR Looking@CXR Normal Normal PTX PTX Pl.Effusion Pl.Effusion Pneumonia OK to travel to DR Pneumonia Lungs very underinflated Lungs well inflated Pul.Edema Chest room with EKG Pul.Edema Dx: Negative? Density R heart border WOW electrodes attached WOW Rec: Upright PA & Lat. Dx: RLL Pneumonia www.schreibman.info K,R 50yoM www.schreibman.info J,K 63yoM © 2013 Ken L Schreibman, PhD/MD Slide 49 of 99 © 2013 Ken L Schreibman, PhD/MD Slide 50 of 99
Introduction to CXRs For Non-Radiologists Introduction to CXRs For Non-Radiologists What is the Portable AP CXR Good For? What is the Portable AP CXR Good For? Physiology Physiology In the ER trauma room Left lung much Anatomy Anatomy Is there a LARGE pneumothorax? better inflated PA&Lat. ET PA&Lat. Is the Chest Tube in the right place? DualEnergy Carina DualEnergy Chest PortableAP CL PortableAP Tube Looking@CXR Looking@CXR Edge Normal NG in Left Normal Left PTX Bronchus! PTX Lung Pl.Effusion Checking tubes and lines Pl.Effusion Pneumonia Is Endo Tracheal (ET) Tube above the carina? Pneumonia Pul.Edema Is the Central Line (CL) in the SVC? Pul.Edema Pneumo- WOW Is the Naso Gastric (NG) Tube stomach? WOW thorax! After placing Chest Tube www.schreibman.info C,W 83yoM www.schreibman.info M,M 75yoM © 2013 Ken L Schreibman, PhD/MD Slide 51 of 99 © 2013 Ken L Schreibman, PhD/MD Slide 52 of 99
Introduction to CXRs For Non-Radiologists Introduction to CXRs For Non-Radiologists What is the Portable AP CXR Good For? Break… then Key things to look for… Physiology Physiology Anatomy Anatomy PA&Lat. PA&Lat. DualEnergy DualEnergy PortableAP PortableAP Looking@CXR Air space Looking@CXR Normal Large Right density Normal PTX Pleural Eff. throughout PTX Left Lower Pl.Effusion In the ER trauma room Pl.Effusion Pneumonia Is there a LARGE pleural effusion? Lobe Pneumonia Pul.Edema Is there a LARGE pulmonary density? (Pneumonia, Contusion) Pul.Edema WOW Should get Upright PA & Lateral whenever possible WOW www.schreibman.info K,C 64yoF G,S 40yoM www.schreibman.info S,J 12yM © 2013 Ken L Schreibman, PhD/MD Slide 53 of 99 © 2013 Ken L Schreibman, PhD/MD Slide 54 of 99
©Ken L Schreibman, PhD/MD 8/9/13 www.schreibman.info Intro to CXR page 10 of 17 for Non-Radiologists
Introduction to CXRs For Non-Radiologists Introduction to CXRs For Non-Radiologists Schreibman’s Says… Is the Patient fully upright? Physiology 1st Rule of Radiology: Physiology PA view Lateral view Anatomy Anatomy PA&Lat. Know what you’re looking at! PA&Lat. DualEnergy Is this the correct study? (YOU check every time) DualEnergy PortableAP Correct Patient PortableAP Correct Date/Time Looking@CXR Looking@CXR Right Stomach bubble Stomach bubble Correct Study (CXR ≠ CT ≠ MR ≠ US) Right Normal Normal hemidiaphragm under Left hemidia. under Left PTX Correct Body part PTX hemidiaphragm hemidiaphragm Pl.Effusion Is this a good study? (This takes experience) Pl.Effusion Pneumonia Is it upright PA & lateral, or portable supine AP? Pneumonia Pul.Edema Is this a good quality study? Pul.Edema Air-Fluid Air-Fluid WOW Patient well positioned? Lungs well inflated? WOW Level Level www.schreibman.info Third only text slide www.schreibman.info M,S 20yoF © 2013 Ken L Schreibman, PhD/MD Slide 55 of 99 © 2013 Ken L Schreibman, PhD/MD Slide 56 of 99
Introduction to CXRs For Non-Radiologists Introduction to CXRs For Non-Radiologists Air Below Diaphragm Air Below RIGHT Diaphragm Physiology Common below LEFT Physiology Anatomy Stomach Anatomy PA&Lat. Colon (Splenic flexure) PA&Lat. DualEnergy Uncommon below RIGHT DualEnergy That’s where the liver lives PortableAP Rarely (0.1%) loop of colon PortableAP Looking@CXR (hepatic flexure) Looking@CXR Normal Chilaiditi’s (“Ky-La-Ditty”) Normal PTX Free air below diaphragm PTX is Abnormal Liver Colon Free Air! Pl.Effusion Pl.Effusion Colon Pneumonia Recent (past week) surgery, Stomach Pneumonia laparoscopy Colon Pul.Edema Bowel Perforation! Pul.Edema WOW (Pneumoperitoneum) WOW …19 days later www.schreibman.info learningradiology.com B,C 57yoF www.schreibman.info L,A 77yoF © 2013 Ken L Schreibman, PhD/MD Slide 57 of 99 © 2013 Ken L Schreibman, PhD/MD Slide 58 of 99
Introduction to CXRs For Non-Radiologists Introduction to CXRs For Non-Radiologists AreIs thethe PatientLungs fully included?upright? Are Lungs Well Inflated? Physiology From Apices Physiology Patient is instructed: InspirationExpiration 1 Apex Apex 2 Anatomy To CP Angles Anatomy “Breathe in… hold it…” 4 3 Tech shoots picture PA&Lat. on Lateral! PA&Lat. 5 DualEnergy DualEnergy “… and breathe…” 6 PortableAP PortableAP We want lungs 7 Looking@CXR Looking@CXR maximally inflated 8 Normal Normal 9 PTX PTX L L Old Radiology Lore: 10 Pl.Effusion R Pl.Effusion The lungs are well inflated CPA CPAL 11 Pneumonia CPA R CPA CPA Pneumonia if you can see 10 ribs. Pul.Edema R Pul.Edema (I can’t find a reference) WOW CPA WOW www.schreibman.info W,D 28yoM www.schreibman.info G,J 47yoM © 2013 Ken L Schreibman, PhD/MD Slide 59 of 99 © 2013 Ken L Schreibman, PhD/MD Slide 60 of 99
©Ken L Schreibman, PhD/MD 8/9/13 www.schreibman.info Intro to CXR page 11 of 17 for Non-Radiologists
Introduction to CXRs For Non-Radiologists Introduction to CXRs For Non-Radiologists Good Inspiration (even on Portable Supine AP) “Atelectasis” Physiology Physiology [Gr] ἀτελής: “incomplete” + Anatomy Anatomy ἔκτασις: “extension” PA&Lat. PA&Lat. DualEnergy DualEnergy Incomplete expansion PortableAP PortableAP Sub-segmental Looking@CXR Looking@CXR Entire segment/lobe Right Normal Normal Entire lung Upper Lobe PTX Density LLL PTX Can be caused by: Atelectasis Pl.Effusion Pl.Effusion Under inflation Pneumonia? With better inflation, Pneumonia Mass? density nearly resolves. Pneumonia Airway obstruction (pneumonia) Pul.Edema Pul.Edema Pneumothorax WOW It was just Atelectasis! WOW Atelectasis ≠ Pneumothorax www.schreibman.info C,J 70yoM www.schreibman.info wikipedia.org G,M 62yoF © 2013 Ken L Schreibman, PhD/MD Slide 61 of 99 © 2013 Ken L Schreibman, PhD/MD Slide 62 of 99
Introduction to CXRs For Non-Radiologists Introduction to CXRs For Non-Radiologists Lung Anatomy: Lobes & Fissures AreIsAre thethe Lungs PatientLungsOverinflated! Well fully Inflated? included?upright? (COPD?) PhysiologyRight Lung Left Lung Physiology AnatomyMajor Major Anatomy FissurePA&Lat. RUL Fissure PA&Lat. DualEnergyRUL Minor LUL LUL DualEnergy Minor Fissure PortableAP Fissure PortableAP Looking@CXRR ML Looking@CXR Normal RML Normal PTXR LL LLL PTX Pl.Effusion RLL Pl.Effusion Pneumonia Pneumonia Pul.Edema LLL Pul.Edema WOW WOW Diaphragm relatively flat… rather than domed www.schreibman.info V,A 19yoF *[L] “little tongue” www.schreibman.info L,J 81yoF © 2013 Ken L Schreibman, PhD/MD Slide 63 of 99 © 2013 Ken L Schreibman, PhD/MD Slide 64 of 99
Introduction to CXRs For Non-Radiologists Introduction to CXRs For Non-Radiologists Look for sharp margins Look behind heart/diaphragm Physiology Heart borders Physiology Try to see lung marking Anatomy Anatomy behind heart/diaphragm PA&Lat. Diaphragm PA&Lat. A lot of May need to re-window disease DualEnergy CPAs DualEnergy occurs PortableAP “Should be sharp enough to PortableAP back @ @ Looking CXR pick your teeth!” Jannette Collins Looking CXR here Normal Lateral too.. Normal PTX PTX Pl.Effusion Pl.Effusion Pneumonia Pneumonia Pneumonia Pul.Edema Pul.Edema Aspiration WOW WOW Pleural Effusions www.schreibman.info A,M 38yoF www.schreibman.info A,M 38yoF © 2013 Ken L Schreibman, PhD/MD Slide 65 of 99 © 2013 Ken L Schreibman, PhD/MD Slide 66 of 99
©Ken L Schreibman, PhD/MD 8/9/13 www.schreibman.info Intro to CXR page 12 of 17 for Non-Radiologists
Introduction to CXRs For Non-Radiologists Introduction to CXRs For Non-Radiologists Pneumothorax! PTX: Penetrating Trauma Physiology Air in the thorax… Physiology Air = Black Anatomy Anatomy PA&Lat. outside the lung PA&Lat. DualEnergy Air in the pleural space DualEnergy PortableAP (Here illustrated in orange) PortableAP Subcutaneous Looking@CXR There should be Looking@CXR Edge Air (Emphysema) Normal NOTHING pleural space Normal Left PTX PTX Lung Pl.Effusion Literally a vacuum Pl.Effusion Pneumonia The more the pleural space Pneumonia Pul.Edema fills with air outside lungs Pul.Edema Pneumo- WOW there’s less air inside lungs WOW thorax! www.schreibman.info www.schreibman.info M,M 75yoM © 2013 Ken L Schreibman, PhD/MD Slide 67 of 99 © 2013 Ken L Schreibman, PhD/MD Slide 68 of 99
Introduction to CXRs For Non-Radiologists Introduction to CXRs For Non-Radiologists PTX: Rib Fracture PTX: Spontaneous Physiology Standard view Lung view Ca++ view Physiology Standard view Lung view Anatomy Anatomy PA&Lat. 4 PA&Lat. DualEnergy DualEnergy PortableAP PTX PortableAP Looking@CXR Looking@CXR Normal Normal PTX PTX Pl.Effusion Dual Pl.Effusion Pneumonia Energy Pneumonia Pul.Edema Rocks! Pul.Edema WOW WOW www.schreibman.info A,J 66yoM www.schreibman.info S,M 18yoM © 2013 Ken L Schreibman, PhD/MD Slide 69 of 99 © 2013 Ken L Schreibman, PhD/MD Slide 70 of 99
Introduction to CXRs For Non-Radiologists Introduction to CXRs For Non-Radiologists Spontaneous Pneumothorax PTX: Tension Pneumothorax Physiology Primary Spontaneous PTX Physiology There is so much air in Anatomy Anatomy ETT PA&Lat. Absence of underlying lung disease PA&Lat. the pleural space in Tall (76”), male (3-6x), smoker (22x) one half of the chest… DualEnergy Bullae DualEnergy PortableAP Secondary Spontaneous PTX PortableAP it squishes the heart/ Looking@CXR Underlying lung disease Bleb Looking@CXR mediastinum into the Normal Normal Chronic Obstructive Heart other half of the chest. PTX Pulmonary Disease (COPD): 70% PTX Pl.Effusion Bullae rupture Pl.Effusion VentsThis pleuralcan decrease air Pneumonia 6 Pneumonia Heart/mediastinumblood flow fatally! Pul.Edema Death from PTX is uncommon (1:10 )… Pul.Edema returns to midline WOW except in TENSION PNEUMOTHORAX! WOW www.schreibman.info wikipedia.org www.schreibman.info E,K 16yoF © 2013 Ken L Schreibman, PhD/MD Slide 71 of 99 © 2013 Ken L Schreibman, PhD/MD Slide 72 of 99
©Ken L Schreibman, PhD/MD 8/9/13 www.schreibman.info Intro to CXR page 13 of 17 for Non-Radiologists
Introduction to CXRs For Non-Radiologists Introduction to CXRs For Non-Radiologists Pleural Effusion Pleural Effusion: Meniscus Physiology Just as PTX is air in pl. space Physiology Anatomy Rises to apex on upright Anatomy PA&Lat. Pleural Effusion: fluid in pl. space PA&Lat. DualEnergy Flows to bases/CPA on upright DualEnergy PortableAP PortableAP Looking@CXR Can be due to: Looking@CXR Normal Lung disease Normal Infection, PE, Malignancy PTX Heart disease PTX Pl.Effusion Congestive Heart Failure (CHF) Pl.Effusion Pneumonia Abdominal disease Pneumonia Pul.Edema Hepatic cirrhosis, Nephrotic syndrome Pul.Edema Similar to water flowing up the glass.. WOW … WOW Pleural effusions flow up chest wall. www.schreibman.info www.schreibman.info K,C 64yoF wikipedia.org © 2013 Ken L Schreibman, PhD/MD Slide 73 of 99 © 2013 Ken L Schreibman, PhD/MD Slide 74 of 99
Introduction to CXRs For Non-Radiologists Introduction to CXRs For Non-Radiologists Pleural Effusion: Silhouette Sign Pleural Effusion Fissures Physiology Basic Radiology Concept: Physiology Anatomy We see edges when adjacent Anatomy PA&Lat. structures are different density PA&Lat. DualEnergy DualEnergy Right Pl. Effusion We can see left heart border Fluid tracking into PortableAP Heart (tissue density) / Lung (air density) PortableAP Minor fissure Looking@CXR We can see left hemidiaphragm Looking@CXR Major fissures Normal Diaphr. (tissue density) / Lung (air density) Normal PTX We can’t see RIGHT heart border PTX Pl.Effusion Heart / Pleural Effusion (both tissue den.) Pl.Effusion Pneumonia “The pleural effusion is silhouetting Pneumonia Left Pl. Effusion Silhouettes out: Pul.Edema out the right heart border and Pul.Edema Heart/Diaphragm WOW hemidiaphragm” WOW CP angle www.schreibman.info K,C 64yoF www.schreibman.info M,J 70yoM © 2013 Ken L Schreibman, PhD/MD Slide 75 of 99 © 2013 Ken L Schreibman, PhD/MD Slide 76 of 99
Introduction to CXRs For Non-Radiologists Introduction to CXRs For Non-Radiologists Pleural Effusion: Free Flowing Pleural Effusion: Loculated Physiology Upright PA UprightDecubitus Lateral view Physiology Upright PA Upright Lateral Anatomy “Laying down” Anatomy Left-side-down decubitus view PA&Lat. … on one side PA&Lat. DualEnergy DualEnergy PortableAP PortableAP Looking@CXR Looking@CXR Normal Normal Pleural Effusion NOT Free Flowing Pleural Effusion Layering out PTX Layering out PTX Pl.Effusion Pl.Effusion Pneumonia Pneumonia Pul.Edema Pul.Edema WOW Left-side-down decubitus view WOW www.schreibman.info H,R 44yoM www.schreibman.info F,C 88yoF © 2013 Ken L Schreibman, PhD/MD Slide 77 of 99 © 2013 Ken L Schreibman, PhD/MD Slide 78 of 99
©Ken L Schreibman, PhD/MD 8/9/13 www.schreibman.info Intro to CXR page 14 of 17 for Non-Radiologists
Introduction to CXRs For Non-Radiologists Introduction to CXRs For Non-Radiologists Pneumonia Air Space Disease: Right Lower Lobe Physiology Pleural Effusion: Fluid outside lung Physiology Upright PA Upright Lateral Anatomy CXR: Tissue density (Silhouettes heart/diaphragm) Anatomy PA&Lat. PA&Lat. DualEnergy Dependent on upright & decubitus views DualEnergy PortableAP Sharp meniscus border PortableAP Looking@CXR Pneumonia: Fluid inside lung (Alveoli) Looking@CXR Normal Normal PTX “Air Space Disease” PTX Pl.Effusion CXR: Tissue density (Silhouettes heart/diaphragm) Pl.Effusion Pneumonia Lobar (segmental) distribution Pneumonia Pul.Edema Fuzzy border Pul.Edema WOW WOW www.schreibman.info Fourth only text slide www.schreibman.info T,A 39yoF © 2013 Ken L Schreibman, PhD/MD Slide 79 of 99 © 2013 Ken L Schreibman, PhD/MD Slide 80 of 99
Introduction to CXRs For Non-Radiologists Introduction to CXRs For Non-Radiologists Air Space Disease: Left Lower Lobe Air Space Disease: Left Lower Lobe Physiology Upright PA Upright Lateral Physiology Upright PA Upright Lateral Anatomy Anatomy PA&Lat. PA&Lat. Importance of DualEnergy DualEnergy Lateral view! PortableAP PortableAP Looking@CXR Looking@CXR Density behind heart (Can’t see lung Density over spine Normal Normal markings thru heart) “Spine Sign” PTX PTX = LL ASD Pl.Effusion Pl.Effusion Pneumonia Pneumonia Pul.Edema Pul.Edema WOW WOW www.schreibman.info S,M 8yoM www.schreibman.info S,R 74yoM © 2013 Ken L Schreibman, PhD/MD Slide 81 of 99 © 2013 Ken L Schreibman, PhD/MD Slide 82 of 99
Introduction to CXRs For Non-Radiologists Introduction to CXRs For Non-Radiologists Air Space Disease: Right Middle Lobe Air SpacePost Disease:-Obstructive Right Pneumonia Upper Lobe Physiology Upright PA Upright Lateral Physiology Mass obstructing RMSB Anatomy Anatomy Peristent Airspace Disease PA&Lat. PA&Lat. Severe Atelectasis R Lung DualEnergy DualEnergy Right-shift heart/mediastinum PortableAP PortableAP Looking@CXR Looking@CXR Normal Normal PTX PTX Pl.Effusion Pl.Effusion PNEUMONIA NEEDS TO Pneumonia Pneumonia BE FOLLOWED UNTIL Pul.Edema Pul.Edema RESOLUTION! WOW WOW 3 months later… 6 weeks after that… www.schreibman.info B,D 49yoM www.schreibman.info G,M 62yoF © 2013 Ken L Schreibman, PhD/MD Slide 83 of 99 © 2013 Ken L Schreibman, PhD/MD Slide 84 of 99
©Ken L Schreibman, PhD/MD 8/9/13 www.schreibman.info Intro to CXR page 15 of 17 for Non-Radiologists
Introduction to CXRs For Non-Radiologists Introduction to CXRs For Non-Radiologists Pulmonary Edema: Spaces Pulmonary Edema: Fluid Overload Physiology Pleural Effusion: Fluid outside lung Physiology ER: Portable semi-upright AP ER: Portable semi-upright AP Anatomy Pleural Space Anatomy PA&Lat. PA&Lat. DualEnergy Pneumonia: Fluid in lung DualEnergy PortableAP Air Space (Alveoli) PortableAP Looking@CXR Pulmonary Edema: Looking@CXR Normal Normal C Fluid in lung C PTX C PTX C Pl.Effusion Interstitial Space C C Pl.Effusion Fluid leaks from capillaries C C Pneumonia C C Pneumonia C Pul.Edema Interstitial Space C Pul.Edema C WOW Alveoli Pleural Space C C WOW www.schreibman.info www.schreibman.info O,L 73yoF © 2013 Ken L Schreibman, PhD/MD Slide 85 of 99 © 2013 Ken L Schreibman, PhD/MD Slide 86 of 99
Introduction to CXRs For Non-Radiologists Introduction to CXRs For Non-Radiologists Pulmonary Edema: Fluid Overload Pulmonary Edema: Cardiogenic Physiology ER: Portable semi-upright AP ER: Portable semi-upright AP Physiology With Congestive Heart Failure (CHF) Anatomy Anatomy LV doesn’t pump well (doesn’t empty well) PA&Lat. PA&Lat. Blood gets backed up in LV DualEnergy DualEnergy PortableAP PortableAP LV dilates (chamber enlarges, wall thins) Looking@CXR Looking@CXR Blood backs up in LA (enlarges) Normal Normal Blood backs up in PV Lungs PTX PTX Engorgement of LA Pl.Effusion Pl.Effusion pul. vessels RA Pneumonia Pneumonia Upper lobes RV LV Pul.Edema Pul.Edema Fluid leaks from WOW Baseline (post-dialysis) 6 days later… (missed dialysis) WOW capillaries Interstitial Space www.schreibman.info T,P 81yoF www.schreibman.info © 2013 Ken L Schreibman, PhD/MD Slide 87 of 99 © 2013 Ken L Schreibman, PhD/MD Slide 88 of 99
Introduction to CXRs For Non-Radiologists Introduction to CXRs For Non-Radiologists Multi Chamber Cardiomegaly Evolution of CHF Physiology Upright PA Upright Lateral Physiology Upright PA PortableUpright PASemi -upright AP Anatomy Anatomy PA&Lat. PA&Lat. DualEnergy DualEnergy PortableAP PortableAP Looking@CXR Looking@CXR Normal Normal PTX PTX Pl.Effusion Pl.Effusion Pneumonia Pneumonia Pul.Edema Pul.Edema WOW WOW 2009: Baseline 2012:2011:2010: PulmonaryNeeds Needs Pacemaker Edema O2 www.schreibman.info B,L 77yoF www.schreibman.info B,L 77yoF © 2013 Ken L Schreibman, PhD/MD Slide 89 of 99 © 2013 Ken L Schreibman, PhD/MD Slide 90 of 99
©Ken L Schreibman, PhD/MD 8/9/13 www.schreibman.info Intro to CXR page 16 of 17 for Non-Radiologists
Introduction to CXRs For Non-Radiologists Introduction to CXRs For Non-Radiologists What to Order When (WOW) What to Order When (WOW) Physiology Chest: PA & Lateral Upright views Physiology Chest: Portable Supine AP view Anatomy This is the standard exam for the lungs Anatomy NOT equivalent to PA & Lateral PA&Lat. Lungs maximally inflated PA&Lat. Much harder to see DualEnergy Heart magnification minimized DualEnergy Pneumothorax PortableAP Importance of multiple views PortableAP Pleural Effusions Looking@CXR Useful to see: Looking@CXR Cardiomegaly Normal Normal Pneumonia (air space disease) Used ONLY when patient can’t be upright PTX Pneumothorax (+/- “tension”) PTX Pl.Effusion Pl.Effusion Used in ER/ICU Congestive Heart Failure (CHF) To evaluate tube positions (ET, NG, central lines) Pneumonia Pleural Effusion Pneumonia Pul.Edema Cardiomegaly Pul.Edema Any findings on Portable CXR should be WOW Increased interstitial markings WOW further imaged with another study www.schreibman.info Now just text slides… www.schreibman.info Now just text slides… © 2013 Ken L Schreibman, PhD/MD Slide 91 of 99 © 2013 Ken L Schreibman, PhD/MD Slide 92 of 99
Introduction to CXRs For Non-Radiologists Introduction to CXRs For Non-Radiologists CXR: Charges What to Order When (WOW) Physiology UWHC 2013 Charges Physiology Chest CT (Computed Tomography) Anatomy Anatomy PA&Lat. PA & Lateral views: $227 PA&Lat. Best way to see inside lungs Following up suspicious things seen on CXR DualEnergy Dual Energy PA & Lat: $227 DualEnergy Working up pulmonary nodules, tumors PortableAP Portable AP view: $203 PortableAP Looking@CXR Looking@CXR Can see tiny PTX, Effusions missed on CXR Normal Normal But are these tiny things really a problem??? PTX PTX Workup chronic interstitial lung disease Pl.Effusion Pl.Effusion Ordered by Pulmonologist Pneumonia Pneumonia Chest CT = 3 years background radiation Pul.Edema Pul.Edema Don’t want to order too many serial Chest CTs WOW WOW too close together www.schreibman.info Now just text slides… www.schreibman.info Now just text slides… © 2013 Ken L Schreibman, PhD/MD Slide 93 of 99 © 2013 Ken L Schreibman, PhD/MD Slide 94 of 99
Introduction to CXRs For Non-Radiologists Introduction to CXRs For Non-Radiologists Pulmonary Emboli Pulmonary Emboli: WOW Physiology Life Threatening Condition Physiology Can’t Diagnosis with CXR! Anatomy Blood clots in legs veins are common Anatomy PA&Lat. PA&Lat. CXR may show non-specific findings Deep Venous Thrombosis (DVT) CXR may be normal! DualEnergy If a clot breaks loose, it travels up the veins, DualEnergy PortableAP PortableAP Nuclear Medicine (VQ Scan) Looking@CXR entering larger veins (won’t get stuck), Looking@CXR Normal entering the vena cava right heart, Normal Angiograms (Aorta, Pul.Art.) PTX travels through main pulmonary artery, PTX We don’t do these anymore Pl.Effusion finally getting trapped in smaller arteriole. Pl.Effusion Been replaced by CT-A (MR-A) Pneumonia No gas exchange occurs off that arteriole Pneumonia Pul.Edema If embolus is large enough, it will prevent gas Pul.Edema WOW exchange in a large percentage of the lung. WOW www.schreibman.info Now just text slides… www.schreibman.info Now just text slides… © 2013 Ken L Schreibman, PhD/MD Slide 95 of 99 © 2013 Ken L Schreibman, PhD/MD Slide 96 of 99
©Ken L Schreibman, PhD/MD 8/9/13 www.schreibman.info Intro to CXR page 17 of 17 for Non-Radiologists
Introduction to CXRs For Non-Radiologists Introduction to CXRs For Non-Radiologists What to Order When (WOW) What to Order When (WOW) Physiology Chest: CT-A (CT-Angiography) Physiology Chest MRI / MR-A Anatomy Rapid IV contrast bolus to see blood vessels Anatomy Ordered much less frequently than CT PA&Lat. PA&Lat. More issues with MR, longer scan time DualEnergy Increasingly frequently being ordered in ER DualEnergy PortableAP to rule out life threatening conditions: PortableAP At progressive imaging centers, like UW, Looking@CXR Pulmonary Embolism Looking@CXR very good at seeing inside blood vessels Normal Traumatic Aortic Laceration Normal Can be used to see Pulmonary Emboli! PTX Aortic Dissection PTX Without Radiation! Pl.Effusion Also gives very nice look a lungs Pl.Effusion Used in young women to avoid rad. to developing breasts Pneumonia Don’t need to order a Chest CT if you are Pneumonia (Birth Control Pills are a risk for forming Pulmonary Emboli) Pul.Edema already getting a Chest CT-A Pul.Edema Without Iodine-Based Contrast! WOW 3 years radiation + large IV contrast bolus WOW Used in patients with allergies or renal issues www.schreibman.info Now just text slides… www.schreibman.info Now just text slides… © 2013 Ken L Schreibman, PhD/MD Slide 97 of 99 © 2013 Ken L Schreibman, PhD/MD Slide 98 of 99
Introduction to CXRs For Non-Radiologists Any Questions? Physiology Anatomy PA&Lat. DualEnergy PortableAP Looking@CXR Normal PTX Pl.Effusion Pneumonia Pul.Edema WOW www.schreibman.info © 2013 Ken L Schreibman, PhD/MD Slide 99 of 99
©Ken L Schreibman, PhD/MD 8/9/13 www.schreibman.info