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 & . 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  Pl.Effusion Pneumonia Looking at CXR something Pul.Edema  Pneumonia Pul.Edema ALL health care providers WOW  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 , sternum, spine PTX  …pass thru patient… Pl.Effusion Heart & 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 > 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 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- 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 (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 PosteriorAnterior, “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 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  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 () 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 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 : 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) , Stomach Pneumonia laparoscopy Colon Pul.Edema Bowel Perforation! Pul.Edema WOW () 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) “” 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: 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 (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: 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 ) 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 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 (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  Looking@CXR very good at seeing inside blood vessels Normal Traumatic Aortic Laceration Normal Can be used to see Pulmonary Emboli! PTX  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