OBJECTIVES

1. Identify normal anatomic structures of the chest and their spatial relationships to one another 2. Display familiarity with the basic principles of (e.g. radiolucency, , artifact r/t technique) CHEST X‐RAY INTERPRETATION 3. Establish a systematic approach to viewing and Dan Jacobson, MSN, RN, CPNP‐AC evaluating the pediatric AP chest X‐ray Rady Children’s Hospital San Diego October, 2013 4. Recognize common patterns of abnormality observed in the pediatric AP chest X‐ray

DISCLOSURES None

FUNDAMENTAL PRINCIPLES & CHEST ANATOMY

HISTORY CREATING A RADIOGRAPH

 1895: Wilhelm Conrad Roentgen discovered new  X‐rays composed of short wavelength form of radiation that could penetrate solid electromagnetic radiation that penetrates solid objects & cause fluorescence objects based on the material’s density

 Since this radiation was invisible with poorly  A radiograph (XR) is created when x‐rays understood properties, he named it “x‐ray” penetrate an object & produce images on a piece of photographic film  Alternate terms: radiography, roentgenology RADIOLUCENT VS. RADIOPAQUE 4 BASIC ROENTGEN RADIODENSITIES

 Higher x‐ray penetration occurs through Gas / Air structures of low density and results in (Air in , bronchi, stomach) dark/black areas on the radiograph Radiolucent (radiolucency) Fat / Soft Tissue (Lipid tissue around muscle)  Lower x‐ray penetration occurs through structures of high density & results in light/white Water areas on the radiograph (radiopaque) (Heart, blood vessels, muscle, diaphragm) Radiopaque Bone / Metal (Bones, calcium deposits, prosthesis, contrast)

SILHOUETTE SIGN

Bone  Occurs when structures of similar density are Bone adjacent to each other Air  Borders of structures become undetectable Fat Fat  Distinct structures may then appear to be a single mass

 Water Helpful in identifying chest abnormalities (e.g. disease) Air  Knowledge of normal chest anatomy is key Water

SILHOUETTE SIGN

Trachea

Carina

R & L Main Bronchi RUL LUL • Adjacent to trachea and • Adjacent to trachea and R L bronchus • Primarily anterior structure • Primarily anterior structure • Common site of Lingula RML (Inferior Portion of LUL) • Adjacent to heart • Adjacent to heart • Also anterior structure LUL RUL • L cardiac border lost with • R cardiac border lost with presence of infiltrate or presence of infiltrate or Lingula atelectasis atelectasis LLL RML RLL LLL • Adjacent to diaphragm • Adjacent to diaphragm • Primarily posterior • Primarily posterior structure RLL structure

R L Posterior ribs Trachea Clavicles 1 Articulate with 2 1 vertebral Carina 3 2 column Heart 4 SVC‐RA junction 5 3 6 Aortic knob Anterior ribs 7 4 Fade towards Hilar area 8 5 mediastinum Diaphragm 9 6 Gastric bubble Costophrenic sulci EG junction

CHEST VIEWS PA (Posterioranterior)

 XR beam passes thru chest from back to front

 Film plate placed against anterior chest & XR tube approx 6 ft. behind pt CHEST VIEWS  Best quality with regard to minimizing distortion and magnification artifact & TECHNIQUE CHEST VIEWS TECHNIQUE AP (Anteriorposterior) Under Vs Overpenetrated Film

 XR beam passes thru chest from front to back  Proper penetration = thoracic spine should be faintly visible through cardiac shadow  Film plate placed behind pt’s back & XR tube approx 36‐40 inches from chest  Underpenetration: XR appears too light d/t underexposure (soft tissues appear too white,  Most common view for hospitalized pt diaphragm borders may be lost)  Heart size magnified d/t increased distance from film plate & closer proximity of XR tube  Overpenetration: XR appears too dark d/t overexposure (edge of soft tissue skin line  Less distinct borders between structures difficult to locate, lung markings may appear absent)

TECHNIQUE TECHNIQUE Rotation Rotation

 Rotation = twisting of chest to the left or right  Tips for detecting rotation away from the XR tube which skews location/size  Clavicles: In normal unrotated CXR medial ends of of anatomic landmarks clavicles should be equidistant & appear  CXR with rotation creates abundant opportunity symmetrical (best for >3 yrs) for artifact (esp. with regard to heart, lung fields,  Anterior ribs: If one side has longer ant rib & mediastinum) segments, then pt is rotated to opposite side  Lung fields: If one lung is more radiolucent, then pt rotated towards same side  Cardiac shadow: If overtly shifted to one side, then pt rotated towards same side

MARKED ROTATION SAME PATIENT: MINIMIZED ROTATION SYSTEMATIC APPROACH & COMMON FINDINGS

A SYSTEMATIC APPROACH 1. AIRWAY ‐ TRACHEA

Airway (trachea)  Column of radiolucent gas density midway Bones (thorax / ribs / IC spaces) between the clavicles and over the spine th Cardiac (heart / mediastinum / hilum)  Carina near the level of 6 posterior rib Diaphragm  Abnormal findings:  Tracheal deviation or narrowing Soft tissues  Malpositioned ETT Pleural surfaces  FBO Lung fields Tubes (tubes, catheters, lines, wires, etc.)

ANATOMIC TRACHEAL ABNORMALITY TRACHEAL NARROWING / TRACHEAL DEVIATION AFTER INSERTION

2. BONES ‐ THORAX / RIBS / IC SPACES 2. BONES ‐ THORAX / RIBS / IC SPACES

 Visualized bone densities: clavicles, ribs, spine, &  Intercostal spaces numbered according to humeri superior rib (thus 1st ICS is below 1st rib)

 Posterior ribs articulate with vertebral column  Abnormal findings:  Asymmetry (rotation vs. actual?)  Anterior ribs fade towards mediastinum (d/t low  Fx density cartiliginous connective tissue)  Scoliosis  Clavicles are landmark for thoracic inlet  Widening / narrowing of IC spaces

CLAVICULAR FX BILATERAL RIB FRACTURES R RIB FRACTURES WITH CALLUS RIB ANOMALIES & SCOLIOSIS

3. CARDIAC –HEART / MEDIASTINUM 3. CARDIAC –HEART / MEDIASTINUM

 Mediastinum comprised of trachea, heart, major  Presence of thymus in superior mediastium blood vessels, R & L bronchi (combination of common in infants (usually undetectable by 5 yrs water & air densities) of age)

 R heart border formed by RA (RA is approx two  Abnormal findings: vertebral bodies beneath the carina)  Mediastinal deviation (atelectasis, mass, PTX)  L heart border formed by LA & LV  Widened mediastinum (hemorrhage, mass, thymus)  Cardiomegaly (myocarditis, CHF, CHD, fluid overload)  2/3 of heart normally lies to the left of the midline  Narrowed cardiac shadow (hypovolemia, hyperinflation)

 Normal cardiothoracic ratio < 50% (horizontal width of the heart divided by the widest interval of the thorax)

CARDIOMEGALY THYMUS

70% WIDENED MEDIASTINUM 3. CARDIAC –HILUM

 Consists of pulmonary arteries & veins in the central chest  Blotchy appearance r/t various areas of radiopacity associated with sizes & densities of vasculature  L hilar area obscured by heart shadow so appears smaller & more elevated than R hilum

 Abnormal findings:  Prominence/thickening of upper lobe vessels  Dilation of hilar trunks

PROMINENT PERIHILAR MARKINGS 4. DIAPHRAGM

 Appears as water density with each hemidiaphragm being dome‐shaped

 R hemidiaphragm usually higher than L hemidiaphragm d/t presence of liver

 EG (esophogeal gastric) junction located where L hemidiaphragm meets L side of thoracic spine

 Abnormal findings:  Elevation (atelectasis, phrenic nerve injury)  Flattening (hyperinflation, PTX)

HYPERINFLATION HYPERINFLATION BI‐BASILAR ATELECTASIS 5. SOFT TISSUES

 Primarily consist of fat & water densities within the chest

 Should be symmetrical

 Abnormal findings:  Subcutaneous emphysema  Anasarca

ANASARCA SQ EMPHYSEMA &

6. PLEURAL SURFACES

 Pleurae normally appear as thin lines along lateral edges of the chest and diaphragm

 Costophrenic sulci should be distinct sharp points at the lateral lung bases (resemble V’s)

 Abnormal findings:  Pleural line medial deviation (effusion, PTX)  Blunted costophrenic sulci (effusion)  (PTX) PTX: AFTER CT INSERTION

7. LUNG FIELDS 7. LUNG FIELDS

 Predominantly air density with minimal tissue or  Hypoventilation or expiratory film blood (high radiolucency)  Lung markings appear crowded/compressed with  Both should have similar lucency hazy bases bilaterally  Enlarged heart shadow ( cardiothoracic ratio)  Adequate inspiration  Abnormal findings:  6‐7 anterior ribs or 8‐9 posterior ribs visible above diaphragm  Airspace disease – consolidation or atelectasis  Less than 1/3 of heart projected below  Interstitial disease hemidiaphragms  Asymmetry  Both hemidiaphragms rounded  Hypoventilation

CLEAR LUNG FIELDS HYPOVENTILATION AIR SPACE DISEASE (ALVEOLI) CONSOLIDATION / INFILTRATE

 Reduction in alveolar air volume d/t  Characterized by opacities in lung fields that may consolidation (infiltrates) and/or atelectasis appear as silhouette sign or include air bronchograms  Consolidation / infiltrate = replacement of air in alveoli with fluid or tissue  Commonly caused by respiratory infection or edema  Atelectasis = alveolar collapse  Less common cause: malignancy/mass

RLL CONSOLIDATION BILATERAL INFILTRATES

INFILTRATES WITH AIR BRONCHOGRAMS BILATERAL MASSES ATELECTASIS ATELECTASIS

 Characterized by lung opacities that may shift  Primary contributing factor is often position of chest structures towards atelectatic hypoventilation region (e.g. mediastinum, diaphragm)  Distinguished from consolidation by:  Common Causes / Types  Shifting position on CXR over serial exams  Resorptive: air absorbed from alveoli d/t  Homogeneous density (infiltrates more likely to compromised ventilation from obstruction above level of alveolus (e.g. mucus plug, FBO, mass) be patchy or varied in composition)  Passive: compression of alveoli d/t increased intrathoracic pressure (e.g. tension PTX)  Adhesive: loss of surfactant (e.g. ARDS)

LLL & LINGULAR ATELECTASIS INTERSTITIAL DISEASE

 Increase in volume of alveolar interstitium (not alveolar air space)

 Typical causes: inflammation, fluid accumulation (edema), fibrosis

 If normal aeration of alveoli, then characterized by increased vascular markings

PULMONARY EDEMA 8. TUBES, CATHETERS, WIRES, LINES

 Usually equivalent of tissue‐to‐bone density  Sometimes challenging to discern external vs. internal  Examples:  ETT  NGT/NJT  CVC/PICC line  Pacer wires or internal pacer  ECG electrodes

 O2 mask tubing  Tracheostomy tube  Chest tube  Esophogeal temp probe  VP shunt 8. TUBES, CATHETERS, WIRES, LINES 8. TUBES, CATHETERS, WIRES, LINES Placement Considerations Placement Considerations

 ETT  SC CVC  Should be below thoracic inlet and 2‐3 cm above  Tip should be located in region of SVC RA junction carina  Common areas of malposition: internal jugular  Ascends with extension & descends with flexion vein & RA  Appears artificially high when pt in prone position  Small risk of PTX during insertion

 NGT  PICC  Most commonly malpositioned tube  Difficult to visualize (very slim line)  All lumens should be within stomach beyond EG  CXR should be taken with arm at 45o angle junction to minimize aspiration risk  Optimal location similar to that of CVC  Risk of catheter migration over time

PICC LINE TRACHEOSTOMY TUBE

ETT, NGT, CVP LINE MALPOSITIONED ETT & NGT VP SHUNT & PORTACATH

CASE STUDIES

Case 1 Case 2

Case 3 Case 4 Case 5 Case 6

Case 7 Case 8

Case 9 Case 10 Case 11 Case 12

Case 13 Case 14

Case 15 Case 16 Case 17 Case 18

Case 19 Case 20

Case 21 Case 22 Case 23 Case 24

REFERENCES REFERENCES

Arthur R (2000). Interpretation of the paediatric chest X‐ray. Hill JR, Horner PE, Primack SL (2008). ICU imaging. Clinics in Paediatric Respiratory Reviews, 1, 41‐50. Chest Medicine, 29, 59‐76. Beckstrand RL (2001). Understanding the chest radiographs of Siela D (2002). Using chest radiography in the intensive care unit. infants and children: The AIR systematic approach. Critical Care Nurse, 22 (4), 18‐27. Critical Care Nurse, 21 (3), 54‐65. Siela D (2008). evaluation and interpretation. Bramson RT, Griscom NT, Cleveland RH (2005). Interpretation of AACN Advanced Critical Care, 19, 444‐473. chest radiographs in infants with cough and fever. Squire LF, Novelline RA (1988). Fundamentals of Radiology, 236, 22‐29. (4th ed.). Cambridge: Harvard University Press. Goodman LR (1999). Felson’s Principles of Chest Roentgenology: A Programmed Text. Philadelphia: Saunders.