Chest X-Ray Made ridiculously plain, basic, or uncomplicated in form, nature, or design; without much decoration or ornamentation

Steve Cohen, MD, PA-C Associate Professor, Dept. of Surgery & Director of PA Clinical Education Florida International University Really Simple

Step 3 

The END, Bye-Bye Thanks for Coming! Posterior Anterior (PA) Workhorse PA Films Properties

• X-ray is a “NEGATIVE” – Light is dark (ex. Air) – Less x-ray get through = shows white (eg. bone) • Beam is divergent – Posterior elements magnified – Dense posterior elements may hide anterior structures

What can you see on CXR?

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3 6 What are we looking at? Quickie Anatomy What are we looking at? Quickie Anatomy Airway

• Film “Position” – Patients left on your right • Trachea – Midline (mostly) – Open • Mostly equal from wall to wall Ribs

• Rib count – Extent quality • Bony integrity – Fracture, dislocation • Left first rib – Posterior at top • Beam hits first – Anterior at bottom Ribs

• Use 1st rib to count • Posterior ribs usually most visible – beam hits first • Seen here = 8 ribs • Clavicles – Integrity (fx, displacement) – Assessing midline • Same distance from trachea Diaphragm – Stomach Bubble

• Right higher than left diaphragm – Liver • Costophrenic angles – Fluid “haziness” • Air under diaphragm • Stomach bubble – variable Left Vessels and Heart

• Subclavian Artery • Coming off arch • Aortic Arch

• Pulmonary Artery • Returning to heart • Left Atrium • Left Ventricle Right Vessels and Heart

• Ascending Aorta • Leaving heart • Superior Vena Cava • Entering RA • Right Atrium • Right border #1 The Right Lobes

• Right Middle – touches right heart border • Right Lower – Touches right hemi-diaphragm • Overlap • Lower over other two (3D orientation) • Lower more posterior and inferior • Lower doesn’t touch heart (heart anterior)

The Left Lobes

• 2 left lobes • Upper = apex (TB) • Upper = touches heart • Lower = touches diaphragm • Significant overlap

Left Lobes – Lateral Xray Value

• On PA, could be • Left Inferior Lobe Pneumonia Hilum

• Contents – Pulmonary blood vessels – Main bronchi – Lymph nodes • Not usually seen in NL • Indentation – Hilar point – Higher left than right

• formed by descending upper lobe veins Hilar Point crossing behind lower lobe arteries

• Contents

Hilar Point • Significance  Lymph Nodes Reading Goal: Presenting the patient & supervisor ecstasy!

• This is an upright, PA chest film on Mr. Smith taken on January 1, 2016. • Exposure is adequate, there is no rotation, and there is no motion blurring. • Airway is centrally located. • There are no fractures or lesions of bones. • Cardiac silhouette is not enlarged. • Hemi-diaphragms appear normal with right slight higher than left. • Costophrenic angles are clear without blunting. • Edges of heart and major vessels are clearly visible. • Right and left lung fields are clear throughout. • Gastric bubble is visible. • There is normal hilar shadowing. • This is a normal upright, PA chest film. Steps to Reading Overview • “RIP” • Rotation • Inspiration • Penetration

“A, B, C, D, E, F, G, H, I” • Airway • Bones (& Soft Tissue) • Cardiac silhouette/size • Diaphragm • Edge of heart • Fields of lung • Gastric bubble • Hilum • Instruments (devices)

Steps to Reading

Remove accoutrements Steps in Reading CXR - ID

• Name, date and markings – Correct x-ray, person • How taken: PA, AP – Heart “magnified” on AP • Position – upright? – Fluid levels Steps in Reading CXR - Quality

• Technical Quality PIRMA –RIP •Rotation •Inspiration •Penetration Steps in Reading CXR

No rotation = Spinous process of vertebral • Technical Quality body is same distance from medial clavicle – Rotation • Look at clavicle heads • Spinous processes – Inspiration • Midclavicular line • 5th, 6th or 7th anterior rib intersects diaphragm • More: hyperinflation (COPD) • Less: inadequate inspiration – Penetration • Under: too dark • Over: too light Steps in Reading CXR

• Technical Quality – Rotation • Look at clavicle heads • Spinous processes – Inspiration • Mid-clavicular line • 5th, 6th or 7th anterior rib intersects diaphragm • More: hyperinflation (COPD) • Less: inadequate inspiration – Penetration • Under: too dark • Over: too light Inspiration Quality – Inspiration • Mid-clavicular line : 5th, 6th or 7th anterior rib intersects diaphragm Steps in Reading CXR

• Technical Quality – Rotation • Look at clavicle heads • Spinous processes If you can see the spaces between the – Inspiration vertebrae and the pulmonary vessels • Midclavicular line through heart, penetration is adequate • 5th, 6th or 7th anterior rib intersects diaphragm • More: hyperinflation (COPD) • Less: inadequate inspiration – Penetration • Under: too dark • Over: too light Under vs. Over-Penetration Magnification

• AP: heart bigger • PA preferred for “standard exams”

• Most portables are AP (warning) Angulation

• Apical lordotic view – angled toward head • Usually involves semi recumbent patient • Good for high, apical lesions – TB – Abscesses – Consolidation – Pneumothorax – Pancoast tumors Angulation features on CXR Apical Lordotic View – TB & Pancoast

• Pancoast tumor (aka pulmonary superior sulcus tumor) • ANY tumor of pulmonary apex - Lung cancer defined by location • Can spread more easily (depending on tissue type) to adjacent ribs and vertebrae • Associated neuro: brachial plexus & cervical sympathetic nerves (stellate ganglion) Steps to Reading CXR – “Big Picture”

• Take a global, all encompassing view • See any obvious abnormalities?

And then…Systematic Review

“A, B, C, D, E, F, G, H, I” • Airway • Bones (& Soft Tissue) • Cardiac silhouette/size • Diaphragm • Edge of heart • Fields of lung • Gastric bubble • Hilum • Instruments (devices)

Systematic Review = The Details “A, B, C, D, E, F, G, H, I” • Airway • Bones • Cardiac silhouette/size • Diaphragm • Edge of heart • Fields of lung • Gastric bubble • Hilum • Instruments (devices)

Steps to Reading CXR - Airway

• Midline – No deviation or slight right (arch) slight deviation to right as it crosses • Open – width the aortic arch

Red Arrows–trachea Blue Arrows–carina Green arrows–L and R main bronchus • …pushed away from abnormal lung affected by • a large pleural effusion, • large simple, or tension pneumothorax mediastinal mass • aortic aneurysm or • mediastinal mass

pleural effusion • Trachea can be pulled towards an abnormal lung affected by • extensive collapse, • consolidation, • pulmonary fibrosis (with shrinking), • Lobectomy • Pneumonectomy (whole lung)

Pneumonectomy fibrosis Steps to Reading CXR - Bones

• Start at top • Look at all • Follow outlines – Fracture – Lesions – Soft tissue • SubQ air Steps to Reading CXR - Bones • Start at top • Look at all • Follow outlines – Fracture – Lesions like MM – Soft tissue • SubQ air How to approach CXR

? How to approach CXR

? Steps to Reading CXR – Cardiac

• Silhouette – NL: < ½ chest width • Enlarged – Cardiomegaly • Hypertrophied • CHF – Effusion • Fluid in pericardial sac

Steps to Reading CXR – Cardiac Pericardial Effusion Differential Diagnosis > 50% - ventricular dilatation (left) - cardiac failure (CHF) - right or left ventricle hypertrophy - pericardial effusion

“Water jug or bottle” sign

Pericardial Effusion Steps to Reading CXR – Cardiac • COPD – SMALL, tube heart

Steps to Reading CXR – Cardiac

Heart: 1/3 right, 2/3 left • Right border = R. atrium • Left border = L. ventricle Heart is in middle mediastinum Steps to Reading CXR – Cardiac

Poor distinction of right heart border = consolidation of right middle lobe Steps to Reading CXR – Cardiac

Poor distinction of left heart border suggests ligula consolidation Steps to Reading CXR - Cardiac

Pneumopericardium Steps to Reading CXR - Cardiac

Mediastinal emphysema (abnormal air) secondary to: Penetrating wound ± lacerated lung Perforation of esophagus or trachea Asthma and whooping cough (pneumomediastinum) Medastinum • Wide Superior mediastinum: Aortic Aneurysm widened mediastinum double aortic contour Medastinum irregular aortic contour • Wide Superior mediastinum: Aortic Dissection • Antegrade from close to aortic root (Type A) • or just beyond left subclavian artery (Type B) • Less common: retrograde extension with rupture into pericardial sac – 80% mortality w/in 2 weeks – operative mortality of 25% Steps to Reading CXR – Diaphragm

• Right higher than left • Sharp borders – R/o LL consolidation • Sharp, clear angles – Costophrenic • R/o pleural effusion – Cardiophrenic • R/o consolidation

Diaphragm

Contour: Rounded Right usually higher than the left by 1–3 cm with sharp pointed costophrenic angles Steps to Reading CXR – Diaphragm

• Right hemi-diaphragm not distinct, sharp • Right lower lobe consolidation • Costophrenic angle (right) not clear = effusion

Pleural Effusion - Exudate

• Exudative effusions – capillary permeability increased – protein, cells, serum • pneumonia, • cancer • pulmonary embolism • viral infection • TB – High protein content – High specific gravity (> 1.012) – High cell counts (>1000) • Lymphocytes, pus/PMNs Pleural Effusion = Transudate

• Transudate – low protein content – low specific gravity (< 1.012) – low nucleated cell counts (less than 500 to 1000 • primary cell types are mononuclear cells: macrophages, lymphocytes and mesothelial cells • Transudative effusions – Heart failure – Cirrhosis with ascites – Hypoalbuminemia • nephrotic syndrome Lung vs. Thoracic (effusion) Fluid Steps to Reading CXR – Diaphragm

• Flattened in COPD – Blunted costophrenic angles • Other – Small heart – Hyperinflated lungs • 8th rib at MCL – Hilum calcifications • Heavy smoker

Steps to Reading CXR – Diaphragm

• Abdominal air • Rupture / Herniation

Unusual CXR Reading – Diaphragm

• c/c: SOB • PMH/PSH: Smoker 1ppd/25 years – GSW left thorax & abdomen with involved spleen 30 years PTA • CXR: – Hyperinflation (COPD) & mild thoracic scoliosis – Cloudy left hemidiaphragm and costophrenic angle/gutter • Splenosis: heterotropic spelenic tissue implantation due to splenic trauma/spillage

Steps to Reading CXR – Edge (Heart) Silhouette Sign • 2 structures, different densities abutting – Interface between them is clear – Left heart / Lung • 2 structures, same densities – Interface between them is Unclear – pneumonia / right heart border = silhouette sign • Example: heart/blood – both fluid/soft tissue density • Example: Liver dome/diaphragm Steps to Reading CXR – Edge (Heart)

• What to look for?  Silhouette sign (= pathology) – Loss of NL borders between intrathoracic mass & heart border – RMLobe  right heart border

NORMAL Steps to Reading CXR – Edge (Heart)

• What to look for?  Silhouette sign – loss of NL borders between intrathoracic mass & heart border – RMLobe  right heart border = indistinct = RML Pneumonia Steps to Reading CXR – Edge (Heart)

• What to look for?  Silhouette sign – loss of NL borders between intrathoracic mass & heart border – LULobe  left heart border NORMAL Steps to Reading CXR – Edge (Heart)

• What to look for?  Silhouette sign – loss of NL borders between intrathoracic mass & heart border – LULobe  left heart border = indistinct = Left Upper Lobe Pneumonia Steps to Reading CXR – Fields of Lungs

• Roughly symmetrical • “Fuzzy” marking throughout – Vascular – Lung soft tissue/parenchyma • Terminology variable – Patchy shadowing – Widespread opacities – Multifocal densities

Steps to Reading CXR – Fields of Lungs

• Missing markings – Collapse (bad word) • Deflated OR • Compacted (air loss) – Pneumothorax • With flat diaphragm

Steps to Reading CXR – Fields of Lungs 4 Primary Patterns

1. Consolidation - alveoli filling with fluid, pus, blood, cells (including tumor) or other = opacities • Lobar • Diffuse • Multifocal (often, Ill-defined) 2. Interstitial - involvement of supporting tissue of lung parenchyma resulting in fine or coarse reticular opacities or small nodules • Course reticular opacifications • Fine reticular opacifications • Small “fine” nodules 3. Nodule or mass - space occupying lesion • Solitary • Multiple 4. Atelectasis - collapse of a part of lung • decrease or loss of air in alveoli = volume loss increases density Steps to Reading CXR – Fields of Lungs

• Looking at Lung Fields

Pulmonary nodule • Small, “spot”, “coin lesion” • < 3 cm (~ 1.2 inches)

• 3 cm = mass • More likely cancer

Steps to Reading CXR – Fields of Lungs

• Look for abnormal shadowing, opacities white shadows on chest X-ray represent more dense or solid • (Pancoast) tumor, TB

Steps to Reading CXR – Fields of Lungs

• Opacities – tumors (malignant or benign) • Cannon ball opacities - usually due to extra-thoracic malignancy

Steps to Reading CXR – Fields of Lungs

• Fluid levels: pleural effusion, abscess • Fluid levels in UPRIGHT patients only! Lung Abscess Lung Fields – Tram Tracks

• Bronchiectasis – Abnormal dilatation of bronchus – Irreversible? • CT most accurate in dx • CXR: Tram-track sign – thickened non-tapering (parallel) walls Steps to Reading CXR – Gastric Bubble

• Normal: small dark, under diaphragm, w/fluid level • Bubble above diaphragm = hiatal hernia into chest or rupture Steps to Reading CXR – Hilum

• Normal: pulmonary blood vessels, no lymph nodes “seen” • Any cloudiness = nodes or mass; Need further study, and/or biopsy Steps to Reading CXR – Hilum

• Abnormal: Seeing lymph nodes… Steps to Reading CXR – Hilum

• Wide Superior mediastinum: Mediastinal lymphadenopathy

Sarcoidosis

Chronic dz, Unk cause Enlarged lymph nodes all over body Hodgkin's Lymphoma Granulomas from reticuloendothelial system Steps to Reading CXR – Instruments & Intubation

• Pads, wires, tubes, pacers, etc.

Right main stem intubation Summary and Review • “RIP” • Rotation • Inspiration • Penetration

“PIRMA” “A, B, C, D, E, F, G, H, I” • Airway • Bones (& Soft Tissue) • Cardiac silhouette/size • Diaphragm • Edge of heart • Fields of lung • Gastric bubble • Hilum • Instruments (devices)

Thank you! Go out and conquer CXR

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