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 I have very little CO Air sacs C C 2 2 DualEnergy C C DualEnergy Room Air is 21% O C 2 Room Air is 0.04% CO2 C O PortableAP PortableAP O2 O O2 2 Bronchioles C 2 O C 2 Looking@CXR C Looking@CXR O O2 O2 2 O2 Looks like C O2 C O2 Normal Normal bunch of grapes. O2 O2 O2 PTX PTX O2 Lungs O Pl.Effusion Interstitial spaces Pl.Effusion 2 Diffusion! O2 CO2 Pneumonia Outside alveoli Pneumonia 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 Lungs Normal Normal CO2 RBC CO2 PTX 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.