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Interpreting CXR Complete.Indd Interpret InterpretIng Chest X-rays Stephen Ellis Radiological imaging is now accessible to a wide range of healthcare workers, many of whom are increasingly taking on I n extended roles. This book will equip all healthcare professionals, including medical students, chest physicians, radiographers and g radiologists, with the techniques and knowledge required to interpret plain chest radiographs. Chest It is not an exhaustive text, but concentrates on interpretive skills and pattern recognition – these help the reader to understand the pitfalls and spot the clues that will allow them to correctly interpret the chest X-rays they will encounter in their daily practice. The book features over 300 high quality images, along with a X- ys range of case story images designed to enable readers to test and develop their interpretation skills. r Interpreting Chest X-Rays is a handy ready reference that will a help you to avoid making errors interpreting CXRs and decide for example: •• if a temporary pacing wire has been inserted correctly •• whether the shadows you can see are real abnormalities •• if all chest tubes and lines are located appropriately in an ITU patient •• what further imaging may assist interpretation of an apparent Ellis abnormality •• whether a post-surgical chest is significantly abnormal •• what organism might be causing an infection •• why a patient is short of breath •• whether patient positioning accounts for an abnormal appearance of a CXR •• what impact radiographic technique has had on the appearance of pathology I S B N 978-1-904842-77-4 Stephen Ellis www.scionpublishing.com 9 781904 842774 CXR COVER.indd 1 12/03/2010 12:50 Interpreting Chest X-Rays Interpreting Chest X-Rays Stephen Ellis Consultant Thoracic Radiologist St Bartholomew’s Hospital and The London Chest Hospital, London, UK © Scion Publishing Ltd, 2010 ISBN 978 1 904842 77 4 First published in 2010 All rights reserved. No part of this book may be reproduced or transmitted, in any form or by any means, without permission. A CIP catalogue record for this book is available from the British Library. Scion Publishing Limited The Old Hayloft, Vantage Business Park, Bloxham Road, Banbury, Oxfordshire OX16 9UX www.scionpublishing.com Important Note from the Publisher The information contained within this book was obtained by Scion Publishing Limited from sources believed by us to be reliable. However, while every eort has been made to ensure its accuracy, no responsibility for loss or injury whatsoever occasioned to any person acting or refraining from action as a result of information contained herein can be accepted by the authors or publishers. Although every eort has been made to ensure that all owners of copyright material have been acknowledged in this publication, we would be pleased to acknowledge in subsequent reprints or editions any omissions brought to our attention. Readers should remember that medicine is a constantly evolving science and while the authors and publishers have ensured that all dosages, applications and practices are based on current indications, there may be specic practices which dier between communities. You should always follow the guidelines laid down by the manufacturers of specic products and the relevant authorities in the country in which you are practising. Typeset by AM Design, Banbury Printed by Henry Ling Ltd, Dorchester, UK Contents Preface vii Abbreviations ix Chapter 1 Technique 1 1.1 Techniques available 1 Chapter 2 Anatomy 7 2.1 Frontal CXR 7 2.2 Lateral CXR 8 2.3 Normal variants 9 Chapter 3 In-built errors of interpretation 15 3.1 The eye–brain apparatus 15 3.2 The snapshot 16 3.3 Image misinterpretation 17 3.4 Satisfaction of search 18 3.5 Ignoring the ribs 20 Chapter 4 The fundamentals of CXR interpretation 21 4.1 The silhouette sign 21 4.2 Suggested scheme for CXR viewing 24 4.3 Review areas 29 4.4 Pitfalls 51 Chapter 5 Pattern recognition 66 5.1 Collapses 66 5.2 Ground glass opacity 79 5.3 Consolidation 79 5.4 Masses 84 5.5 Nodules 87 5.6 Lines 92 5.7 Cavities 95 Chapter 6 Abnormalities of the thoracic cage and chest wall 97 6.1 Pectus excavatum 97 6.2 Scoliosis 97 6.3 Kyphosis 99 6.4 Bone lesions 101 6.5 Chest wall / thoracic inlet 105 6.6 Thoracoplasty 108 Chapter 7 Lung tumours 110 7.1 CXR features of malignant tumours 110 7.2 CXR features of benign tumours 115 7.3 Metastases 118 7.4 Bronchial carcinoma 119 7.5 The solitary pulmonary nodule 122 v Chapter 8 Pneumonias 124 8.1 Pulmonary tuberculosis 124 8.2 Pneumococcal pneumonia 131 8.3 Staphylococcal pneumonia 132 8.4 Klebsiella pneumonia 134 8.5 Eosinophilic pneumonia 134 8.6 Opportunistic infections 135 Chapter 9 Chronic airways disease 137 9.1 Asthma 137 9.2 Chronic bronchitis 138 9.3 Emphysema 139 9.4 Bronchiectasis 141 Chapter 10 Diuse lung disease 145 10.1 Interstitial disease – the reticular pattern 145 10.2 LAM 147 10.3 Langerhans cell histiocytosis 148 10.4 Pulmonary sarcoid 149 10.5 Hypersensitivity pneumonitis 152 Chapter 11 Pleural disease 155 11.1 Eusion 155 11.2 Pneumothorax 168 11.3 Pleural thickening 178 11.4 Pleural malignancy 181 11.5 Benign pleural tumours 184 Chapter 12 Left heart failure 185 Chapter 13 The heart and great vessels 190 13.1 Valve replacements 191 13.2 Cardiac enlargement 192 13.3 Ventricular aneurysm 193 13.4 Pericardial disease 195 13.5 Coarctation of the aorta 197 13.6 Aortic aneurysm 199 13.7 Atrial septal defect 203 13.8 Pacemakers 205 Chapter 14 Pulmonary embolic disease 209 Chapter 15 The mediastinum 212 15.1 The ‘hidden’ areas of the mediastinum 213 15.2 The hila 219 15.3 Stents 221 Chapter 16 The ITU chest X-ray 224 16.1 Adult respiratory distress syndrome 229 16.2 The CXR following thoracic surgery 229 Chapter 17 The story lms 233 Further reading 239 Appendix 240 Index 241 vi 04 The fundamentals of CXR interpretation 4.1 The silhouette sign A silhouette is the outline of an object defined by the hardly any X-rays, generates excellent silhouettes (Fig. shadow it casts. In terms of a CXR, the silhouette sign 4.1). Unfortunately, the contrast resolution of plain is based on the same concept except that X-rays, to radiography is such that silhouettes are only formed which soft tissues are translucent rather than opaque, by bone, soft tissue, fat and aerated lung. Note that replace light. The formation of a silhouette on a vessels, lymph nodes, muscle, fluid, and connective CXR depends on two tissues of sufficiently different tissue are all of soft tissue density and are therefore of density lying against each other in such a way that two the same density on plain X-rays (Fig. 4.2). adjacent X-rays will pass through one, or the other, The loss of the normal silhouettes on a CXR but not both tissues. In this way, when the adjacent results from an increase in density of the adjacent X-rays reach the film / detector they will generate lower density tissue; on a CXR this is usually aerated different shades of grey, which, if sufficiently different lung adjacent to a soft tissue structure, indicating will be discernable (see Fig. 4.1). This is the principle a pathological process. Knowing the anatomy of that underlies all plain X-rays, but in the chest it is the silhouettes not only allows the recognition of particularly important as aerated lung, which absorbs pathology but also aids localisation of that pathology. Figure 4.1. Silhouette CXR. The axial CT image at the level of the aortic arch is projected in perspective over a CXR and the shaded lines match the air–soft tissue interfaces to the silhouettes they form. 21 22 | INTERPRETING CHEST X-RAYS Figure 4.2. Interfaces. This is a normal CXR with a few areas highlighted and magnified to demonstrate examples of the various soft tissue interfaces visible on a CXR: • soft tissue / aerated lung – solid black arrows • soft tissue / air – solid white arrow (contour of the breast) • soft tissue / bone – open black arrow • soft tissue / fat – open white arrow Another reason for not seeing an interface between two tissues of sufficiently different density on CXR is because the orientation of the interface is not in line with the incident X-rays (Fig. 4.3). Perhaps the most important silhouettes on the CXR tend not to be described as such. The density of blood-filled vessels is not great, but is sufficiently different to aerated lung to render all but the very peripheral vessels visible. Indeed, when the bronchi become too small to be seen and the normal lung interstitium is too fine to be seen, the vessels are the only indication of the presence of lung for the majority of the CXR. As a result, it is the appearance of the vessels that gives the most immediate indication of lung pathology. 4.1 THE SILHOUETTE SIGN | 23 Figure 4.3. Pleural based lesions on CXR and CT. These are the (a) CXR and (b) CT images of two pleural based lesions. Due to the curvature of the chest wall only the medial margins of the lesions cast a silhouette (arrows); the remainder of the margins are in the wrong orientation to form a silhouette. (a) (b) 24 | INTERPRETING CHEST X-RAYS 4.2 Suggested scheme for CXR viewing The following scheme suggests a systematic way of viewing a CXR that is not determined by anatomical boundaries. If you develop your own scheme bear in mind the potential pitfalls detailed here.
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