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? 4 3 2 5 5 1 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