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cxr series.pdf

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baharhoseini

The document provides guidance on evaluating chest x-rays. It discusses reading chest x-rays concentrically from the periphery towards the center and outlines key areas to examine, including the airway, breathing, circulation, diaphragm, soft tissues, bones, and tubes/lines. Technical factors like positioning, inspiration, and exposure quality are also reviewed. The document emphasizes examining specific zones like the retroclavicular, hilar, retrocardiac, and subdiaphragmatic areas for abnormalities and comparing findings to normal lung anatomy.

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IN THE NAME OF GOD
Chest X-Ray In Emergency Department kavous Shahsavari Nia. MD Emergency Medicine Specialist Assistant professor of Emergency Medicine Faculty of Medicine Tabriz University of Medical Sciences Tabriz , Iran
Introduction CXR: 1) Adult 2)Childeren  Reading → Pathologic Finding → Diagnosis  Every doctor will have a different approach to reading chest X-rays CXR: 1) TRUMA → ATLS → ABCDEFG 2) Internal Medicine Chest radiographs are read « concentrically » from the periphery towards the center
A B C D E F G • OVERVIEW • A = Airway • B = Breathing • C = Circulation • D = Diaphragm • E = Emphysema (Soft Tissues) • F = Fracture (Bones) • G = Tube & Lines
OVERVIEW 1- Name & AGE & Sex 2- Date - important for comparing prior exams - Serial image 3- Position markers right(R) vs. left(L) - Gastric bubble should be on the left - Cardiac Anatomy 4- Patients position : sitting , standing , supine 1-P-A view 2-A-P 3-A-P supine 4-Lateral (Lt/Rt) 5-Lateral decubitus (Lt/Rt) 6-Lordotic 7-Oblique(Rt/Lt; post/anterior) ‫در‬ ‫انجام‬ ‫ايستاده‬ ‫حالت‬ ‫در‬ ‫سينه‬ ‫قفسه‬ ‫راديوگرافى‬ ‫بايد‬ ‫حاد‬ ‫شکم‬ ‫موارد‬ ‫تمام‬ ‫شود‬ . - 5- Technical quality
Position  Special position for special purpose - PA : Anatomy reading - AP view - AP supine : Ambulatory limit - Lateral (Lt/Rt) - Lateral decubitus : Effusion or thickening - Lordotic : Apical lesion - Oblique : helpful localize lesions and eliminate superimposed structures Right anterior oblique for left side lesion - ‫بررسی‬ ‫شامل‬ ‫استاندارد‬ : 1 ) ‫دو‬ ‫خلفی‬ ‫عکس‬ – ‫هم‬ ‫با‬ ‫تفسيرهردو‬ ‫و‬ ‫لترال‬ ‫و‬ ‫قدامی‬ & ‫مقايسه‬ ‫جديد‬ ‫با‬ ‫قديمی‬ ‫های‬ ‫عکس‬
PA ‫شود‬ ‫مي‬ ‫ها‬ ‫كناره‬ ‫به‬ ‫كتف‬ ‫هاي‬ ‫استخوان‬ ‫چرخيدن‬ ‫باعث‬ ‫لگن‬ ‫روي‬ ‫بر‬ ‫ها‬ ‫دست‬ ‫پشت‬ ‫دادن‬ ‫قرار‬ ‫اين‬ ‫كه‬ ‫هاي‬ ‫استخوان‬ ‫داخلي‬ ‫هاي‬ ‫كناره‬ ‫كه‬ ‫شود‬ ‫مي‬ ‫باعث‬ ‫كار‬ ‫كتف‬ ‫در‬ ‫يا‬ ‫نيفتد‬ ‫ها‬ ‫ريه‬ ‫روي‬ ‫كمتري‬ ‫حد‬ ‫بيف‬ ‫تد‬ .
Lat
AP AP views are less useful and should be reserved for very ill patients who cannot stand erect (trauma, LOC, …..)
cxr series.pdf
‫تفاوتهای‬ PA ‫و‬ AP • ‫بزرگی‬ ‫قدامی‬ ‫ساختارهای‬ ‫ساير‬ ‫و‬ ‫قلب‬ ‫سايه‬ ( ‫مدياستينوم‬ ) • ‫تشخيص‬ ‫افيوژن‬ ‫و‬ ‫پنوموتوراکس‬ ‫تر‬ ‫مشکل‬ ‫ريوی‬ ‫واحتقان‬ • ‫های‬ ‫سايه‬ ‫مزاحم‬ ( ‫مانيتور‬ ‫سيم‬ ، Back Board ) • ‫کمتر‬ ‫نفوذپذيری‬ ‫و‬ ‫دم‬ ،‫چرخش‬ ≈ 2 m
cxr series.pdf
cxr series.pdf
PA versus AP
Lat. decubitus ‫بررسی‬ ‫برای‬ ‫دکوپيتوس‬ ‫لترال‬ ‫وضعيت‬ : ‫پلور‬ ‫مايع‬ ‫حجم‬ ‫يا‬ ‫بودن‬ ‫متحرک‬ ‫لوکاليزه‬ ‫بودن‬ ‫افزايش‬ ‫جاذبه‬ ‫اثر‬ ‫علت‬ ‫به‬ ‫گرفته‬ ‫قرار‬ ‫پايين‬ ‫ريه‬ ‫دانسيته‬
Technical quality  Well centered: (Rotation?) - Spinous process of T4 should be between the heads of the clavicle  Exposure (penetration): - It is affected by both the duration of exposure and the power of the beam  Good expose: You will be able to see the thoracic vertebrae  Over expose film looks diffusely dark and features such as lung markings are poorly seen  Under (poorly) expose film looks diffusely light (an x-ray is a negative) and soft tissue structures are readily obscured (especially those behind the heart)  Full inspiration
cxr series.pdf
Well centered
Rotation
Good exposure(penetrate)
Under exposed/Over exposed ‫آيد‬ ‫مي‬ ‫وجود‬ ‫به‬ ‫اشعه‬ ‫كم‬ ‫نفوذ‬ ‫دليل‬ ‫به‬ ‫كه‬ ‫اشكاالتي‬ : 1 - ‫شود‬ ‫نمي‬ ‫ديده‬ ‫خوبي‬ ‫به‬ ‫چپ‬ ‫ريه‬ ‫قاعده‬ ‫و‬ ‫چپ‬ ‫ديافراگم‬ ‫همي‬ . 2 - ‫نظر‬ ‫به‬ ‫تر‬ ‫برجسته‬ ‫واقعيشان‬ ‫شكل‬ ‫به‬ ‫نسبت‬ ‫ريه‬ ‫ساختاري‬ ‫عالئم‬ ‫رسند‬ ‫مي‬ . 3- Soft tissue structures are readily obscured (especially those behind the heart)
cxr series.pdf
Good expose small pneumothorax
Over expose small pneumothorax
Full inspiration
(PA) ‫ها‬ ‫دنده‬ ‫شمارش‬
 ‫د‬ ،‫فيلم‬ ‫به‬ ‫خلفي‬ ‫هاي‬ ‫دنده‬ ‫به‬ ‫نسبت‬ ‫قدامي‬ ‫هاي‬ ‫دنده‬ ‫بودن‬ ‫نزديك‬ ‫دليل‬ ‫به‬ ‫ر‬ ‫يك‬ ‫نماي‬ PA ‫سايه‬ ‫تر‬ ‫شارپ‬ ً‫ال‬‫معمو‬ ‫و‬ ‫شده‬ ‫بزرگنمايي‬ ‫دچار‬ ‫كمتر‬ ‫ها‬ ‫آن‬ ‫هستن‬ ‫د‬ .  ‫هاي‬ ‫دنده‬ 1 ‫و‬ 2 ‫عرضي‬ ‫رائده‬ ‫امتداد‬ ‫در‬ 1 T ‫افتند‬ ‫مي‬ ‫هم‬ ‫روي‬ .
• Different tissues in our body absorb X-rays at different extents: • Bone - high absorption (White) • Air - low absorption (Black) • Tissue - somewhere in the middle absorption (Grey) - GREY- Soft tissue/water - DARK GREY- Fat
A = Airway Trachea & Bronchi  ‫نه؟‬ ‫يا‬ ‫است‬ ‫وسط‬ ‫خط‬ ‫در‬ ‫تراشه‬ ‫آيا‬
B = Breathing Pleural Space & Lung Parenchyma
Pleural  Layers: Parietal Visceral  Check the costophrenic angles Margins should be sharp ‫پلور‬ : ‫شدن‬ ‫کلسيفيه‬ ،‫شدن‬ ‫ضخيم‬ ،‫افيوژن‬  ‫پلور‬ : ‫شدن‬ ‫کلسيفيه‬ ،‫شدن‬ ‫ضخيم‬ ،‫افيوژن‬
Lungs Density Symmetry Lesions
If you see nothing abnormal on the x-ray, and yet clinical examination or history suggests otherwise, what do you do?
Before taking an x-ray off the monitor you must say: AH HA !!!
cxr series.pdf
With your eyes, you define the 4 following target zones
The first target is: the retroclavicular zone (foci of pulmonary tuberculosis, lung neoplasms, Pancoast’s tumour)
Right retro clavicular opacity
The second target is : the hilum (density, size, abnormal opacity, lymph nodes)
Dermoid cyst (hilum overlay sign)
Bilateral hilar and mediastinal enlargement
The third target is: the retrocardiac region (bronchopneumonia, atelectasis, neoplasm)
Bronchopneumonia in the posterior and lateral basal segments of the LLL
Large hiatus hernia
The fourth target is: the subdiaphragmatic zone (abdominal and abdomino-thoracic diseases)
Gastric ring
‫آناتومی‬ ‫طبيعی‬ ‫ها‬ ‫ريه‬ - ‫ريه‬ ‫راست‬ 3 ‫چپ‬ ‫ريه‬ ‫و‬ ‫لوب‬ 2 ‫لوب‬ - ‫ريه‬ ‫مايل‬ ‫فيشر‬ ‫دو‬ ‫راست‬ ( ‫اصلی‬ ) ‫افقی‬ ‫و‬ ( ‫کوچک‬ ) ‫ماي‬ ‫فيشر‬ ‫يک‬ ‫چپ‬ ‫ريه‬ ‫و‬ ‫ل‬ ( ‫اصلی‬ ) - ‫ريه‬ ‫راست‬ 10 ‫چپ‬ ‫ريه‬ ‫و‬ 9 ‫سگمان‬ ‫شوند‬ ‫مي‬ ‫جدا‬ ‫يكديگر‬ ‫از‬ ‫عرضي‬ ‫يا‬ ‫مينور‬ ‫شكاف‬ ‫توسط‬ ‫راست‬ ‫مياني‬ ‫و‬ ‫فوقاني‬ ‫لوب‬ . ‫شود‬ ‫مي‬ ‫جدا‬ ‫مياني‬ ‫و‬ ‫فوقاني‬ ‫لوب‬ ‫از‬ ‫مايل‬ ‫يا‬ ‫ماژور‬ ‫شكاف‬ ‫توسط‬ ‫راست‬ ‫ريه‬ ‫تحتاني‬ ‫لوب‬ . ‫شوند‬ ‫مي‬ ‫جدا‬ ‫يكديگر‬ ‫از‬ ‫مايل‬ ‫يا‬ ‫ماژور‬ ‫شكاف‬ ‫توسط‬ ‫چپ‬ ‫تحتاني‬ ‫و‬ ‫فوقاني‬ ‫لوب‬ . - ‫شكاف‬ ،‫شود‬ ‫مي‬ ‫گسترده‬ ‫ناف‬ ‫محل‬ ‫از‬ ً‫ا‬‫دقيق‬ ‫عرضي‬ ‫يا‬ ‫مينور‬ ‫به‬ ً‫ال‬‫اص‬ ‫يا‬ ‫شود‬ ‫مي‬ ‫ديده‬ ‫سختي‬ ‫ديده‬ ‫نمي‬ ‫شود‬ .
Lobes Right upper lobe:
Right middle lobe: ‫مياني‬ ‫لوب‬ ‫مجاورت‬ ‫در‬ ‫راست‬ ‫كناره‬ ‫راست‬ ‫قرار‬ ‫قلب‬ ‫دارد‬
Right lower lobe:
Left lower lobe:
Lingula:
Left upper lobe - upper division:
‫ريه‬ ‫ناف‬ ‫طبيعی؛‬ ‫آناتومی‬ • ‫ای‬ ‫مجموعه‬ ‫ريه‬ ‫ناف‬ ‫از‬ : ‫ريوی‬ ‫اصلی‬ ‫های‬ ‫شريان‬ ، ‫وريدهای‬ ‫ها‬ ‫برونکوس‬ ‫و‬ ‫ريوی‬ • ، ‫شکل‬ ،‫سايز‬ ‫کردن‬ ‫مشخص‬ ‫ريه‬ ‫ناف‬ ‫دانسيته‬ • ‫شاخه‬ ‫تا‬ ‫ريوی‬ ‫شريان‬ ‫تحتانی‬ ‫لوب‬ 2 - 4 ‫دارد‬ ‫ادامه‬ ‫سانتيمتر‬ • ‫های‬ ‫شاخه‬ ‫حاصل‬ ‫ريه‬ ‫بافت‬ ‫طبيعی‬ ‫نمای‬ ‫و‬ ‫عروقی‬ ‫تا‬ 1 ‫جداره‬ ‫سانتيمتری‬ ‫توراکس‬
Left Hilus higher (max 1-2.5 cm)
C = Circulation Heart & Medistinum
cxr series.pdf
Apical pleural cap • An apical pleural cap refers to a curved density at lung apex seen on chest radiograph • It has relatively narrow differential diagnosis:  Pleural thickening / scarring secondary to previous apical infection - typically pulmonary tuberculosis radiation fibrosis may be present in upto 10% of radiographs  Pancoast tumour  Haematoma thoracic aortic injury fractured first rib  Lymphoma : extending from neck or mediastinum  Abscess within the neck / mediastinum
cxr series.pdf
‫مدیاستینوم‬ ‫طبیعی؛‬ ‫آناتومی‬ Define: - Area between the lung - Water density Surrounded two air filled lungs and Intersected by the air filled trachea and major bronchi Anatomy dividing region: 1- SUPERIOR MEDIASTINUM Begins - root of the neck and Ends - line drawn T-4 vertebrae --- sternomanebrum junction line skims the top of the aortic arch 2- INFERIOR MEDIASTINUM Begins - this line End - diaphragm Further divided into three regions: 1- Anterior 2- Middle 3- Posterior
cxr series.pdf
Superior Mediastinum  Retrosternal: Great vessels and branches Thymus  Prevertebral: Trachea Esophagus Thoracic duct Sympathetic trunks Vagus nerves
Inferior Mediastinum  Anterior: Thymus, fat, lymph nodes  Middle: Pericardium Phrenic nerves Pericardiacophrenic artery Heart and great vessels  Posterior: Esophagus Thoracic duct Aorta and branches Vagus nerves Sympathetic trunks Azygos system of veins
1- Overall size and shape 2- Trachea: position  Mediastinum : 3- Margins (Cardiac) 4- Lines and stripes 5- Retrosternal clear space 1 - ‫توده‬ ، ‫انحراف‬ ، ‫شدن‬ ‫پهن‬ 2 - ‫نه؟‬ ‫يا‬ ‫است‬ ‫وسط‬ ‫خط‬ ‫در‬ ‫تراشه‬ ‫اگر‬ ‫كنيد‬ ‫بررسي‬ ‫را‬ ‫ها‬ ‫آبنورمالي‬ ،‫نيست‬ ‫وسط‬ ‫خط‬ ‫در‬ ً‫ا‬‫دقيق‬ ‫هوايي‬ ‫راه‬ . ،‫افيوژن‬ ‫پلورال‬ ‫مثل‬ ،‫پنوموتوراكس‬ ‫تنشن‬ ‫آتلكتازي‬ . ‫اگر‬ ‫بايد‬ ‫آن‬ ‫محل‬ ‫بايد‬ ‫دارد‬ ‫تراشه‬ ‫لوله‬ ‫بيمار‬ cm 3-4 ‫باالتر‬ ‫کارينا‬ ‫از‬ ‫باشد‬ . ‫اصلی‬ ‫برونش‬ ‫و‬ ‫تراشه‬ ‫اطراف‬ ‫در‬ ‫آزاد‬ ‫هوای‬ ‫وجود‬ ( ‫مدياستن‬ ‫پنومو‬ ) ‫كارينا‬ : ‫محاذات‬ ‫در‬ T6 - T7 ‫آن‬ ‫زاويه‬ ‫و‬ ‫گرفته‬ ‫قرار‬ 60 ‫تا‬ 70 ‫باشد‬ ‫می‬ ‫درجه‬ . ‫اگر‬ ‫از‬ ‫بيش‬ ‫زاويه‬ ‫اين‬ 90 ‫باشد‬ ‫داده‬ ‫رخ‬ ‫است‬ ‫ممكن‬ ‫علت‬ ‫سه‬ ‫به‬ ،‫باشد‬ ‫درجه‬ : 1 - ‫كارينا‬ ‫زير‬ ‫در‬ ‫چپ‬ ‫دهليز‬ ‫بزرگي‬ 2 - ‫وجود‬ Lymphadenopathy 3 - ‫وجود‬ ‫در‬ ‫توده‬ ‫مدياستن‬
cxr series.pdf
3-Margins
‫آناتومی‬ ‫و‬ ‫قلب‬ ‫طبیعی؛‬ ‫آئورت‬
Venography
cxr series.pdf
cxr series.pdf
cxr series.pdf
Cardiothoracic Ratio ‫نسبت‬ ‫داخ‬ ‫لبه‬ ‫از‬ ‫سينه‬ ‫قفسه‬ ‫عرضی‬ ‫قطر‬ ‫بيشترين‬ ‫به‬ ‫قلب‬ ‫قطر‬ ‫بيشترين‬ ‫دنده‬ ‫لی‬  Greater than 50% suggests cardiac enlargement (usually CHF or pericardial effusion)  Remember: AP views make heart appear larger than it actually is Cardiac margins should be sharp
Widened mediastinum • Widening of the mediastinum is most often due to technical factors such as patient positioning or the projection used. Rotation, incomplete inspiration, or an AP view, may all exaggerate the width of the mediastinum, as well as heart size • In the setting of trauma, patients are positioned supine while a chest x-ray is acquired, very often causing the mediastinum to appear wide spuriously • Is a mediastinum with a measured width greater than 6 cm on an upright PA chest X-ray or 8 cm on supine AP chest film(at the level of the aortic knob on the best film) • Use of cross-sections from CT and MRI will supplement this section
4- Lines and stripes: Para tracheal /Para spinal/Para esophageal(azygo esophageal)/Para aortic  Lines typically measure less than 1 mm in width and are formed by air, typically within the lung, outlining thin intervening tissue on both sides Lines present on chest radiographs include the anterior and posterior junction lines  Stripes are thicker lines formed by air outlining thicker intervening soft tissue Stripes are seen on chest radiographs including: L&R paratracheal stripes posterior tracheal stripe
5-Retrosternal clear space • ‫دارد‬ ‫وجود‬ ‫چپ‬ ‫بطن‬ ‫شدن‬ ‫بزرگ‬ ‫احتمال‬ ،‫باشد‬ ‫كم‬ ‫خيلي‬ ‫فاصله‬ ‫اگر‬ . • ‫اگر‬ ‫انسدادي‬ ‫بيماري‬ ‫احتمال‬ ،‫باشد‬ ‫زياد‬ ‫خيلي‬ ‫فاصله‬ ‫ريه‬ COPD ‫دارد‬ ‫وجود‬ .
D = Diaphragm
cxr series.pdf
‫قله‬ ‫ديافراگم‬ ‫هاي‬ : • ‫است‬ ‫متفاوتي‬ ‫هاي‬ ‫موقعيت‬ ‫داراي‬ ،‫تنفس‬ ‫مختلف‬ ‫مقادير‬ ‫با‬ ‫ديافراگم‬ . • ‫كمي‬ ً‫ال‬‫معمو‬ ‫راست‬ ‫ديافراگم‬ ‫همي‬ ‫باالتر‬ ‫ازهمي‬ ‫است‬ ‫چپ‬ ‫ديافراگم‬ (. 2 ‫تا‬ 3 ‫متر‬ ‫سانتی‬ ) ‫قلب‬ ‫آناتوميکی‬ ‫موقعيت‬ ‫و‬ ‫کبدی‬ ‫اثر‬ ‫خاطر‬ ‫به‬ • ‫شود‬ ‫می‬ ‫ديده‬ ‫راست‬ ‫ديافراگم‬ ‫تمام‬ ‫چپ‬ ‫ديافراگم‬ ‫ولی‬ ‫بدليل‬ ،‫خير‬ ‫قلب‬ ‫اينکه‬ ‫قرارمی‬ ‫ديافرگم‬ ‫روی‬ ‫گيرد‬ . • ‫زيرديافراگم‬ ‫هوای‬ ‫بررسی‬ ( ‫پريتوين‬ ‫پنومو‬ ) penetrating trauma, peritonitis, recent surgery Laparoscopy, hallow viscus perforation • ‫ديافراگم‬ ‫رويت‬ ‫عدم‬ : ‫مايعات‬ ‫نفوذ‬ ‫يا‬ ‫افيوژن‬ • ‫ديافراگم‬ ‫دوسطح‬ ‫بيشتربين‬ ‫وت‬ ‫تفا‬ : ‫ديافراگم‬ ‫فلج‬ ، ‫کالپس‬ ، ‫افيوژن‬ • ‫کوستوفرنيک‬ ‫زاويه‬ ‫شدن‬ ‫محو‬ : ‫تومور‬ ،‫اسکار‬ ،‫هموتوراکس‬ ،‫افيوژن‬ ‫پلورال‬
cxr series.pdf
E = Emphysema Soft Tissues
Soft tissue: • Look for subcutaneous emphysema (suggestive of trauma) • Soft tissue swelling • Axillary line • Calcification • Foreign body • Breasts shadow
F = Fracture Bones
cxr series.pdf
Skeletal structures Overall size, shape, contour of each bone: - Density( mineralization) - Compare cortical thickness to medullary cavity, trabecular pattern - Erosions, fractures, any lytic or blastic regions Joints: - Articular relationships - Joint spaces narrowed, widened - Calcification in the cartilages - Air in the joint space, abnormal fat pads  Note calcified anterior cartilages may obscure or mimic underlying lung lesions  Compare side to side
Anatomy of Shoulder
cxr series.pdf
cxr series.pdf
cxr series.pdf
G = Tube & Lines
Chest Tube, NG Tube, Pulmonary artery cath
‫؟‬

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cxr series.pdf

  • 1. IN THE NAME OF GOD
  • 2. Chest X-Ray In Emergency Department kavous Shahsavari Nia. MD Emergency Medicine Specialist Assistant professor of Emergency Medicine Faculty of Medicine Tabriz University of Medical Sciences Tabriz , Iran
  • 3. Introduction CXR: 1) Adult 2)Childeren  Reading → Pathologic Finding → Diagnosis  Every doctor will have a different approach to reading chest X-rays CXR: 1) TRUMA → ATLS → ABCDEFG 2) Internal Medicine Chest radiographs are read « concentrically » from the periphery towards the center
  • 4. A B C D E F G • OVERVIEW • A = Airway • B = Breathing • C = Circulation • D = Diaphragm • E = Emphysema (Soft Tissues) • F = Fracture (Bones) • G = Tube & Lines
  • 5. OVERVIEW 1- Name & AGE & Sex 2- Date - important for comparing prior exams - Serial image 3- Position markers right(R) vs. left(L) - Gastric bubble should be on the left - Cardiac Anatomy 4- Patients position : sitting , standing , supine 1-P-A view 2-A-P 3-A-P supine 4-Lateral (Lt/Rt) 5-Lateral decubitus (Lt/Rt) 6-Lordotic 7-Oblique(Rt/Lt; post/anterior) ‫در‬ ‫انجام‬ ‫ايستاده‬ ‫حالت‬ ‫در‬ ‫سينه‬ ‫قفسه‬ ‫راديوگرافى‬ ‫بايد‬ ‫حاد‬ ‫شکم‬ ‫موارد‬ ‫تمام‬ ‫شود‬ . - 5- Technical quality
  • 6. Position  Special position for special purpose - PA : Anatomy reading - AP view - AP supine : Ambulatory limit - Lateral (Lt/Rt) - Lateral decubitus : Effusion or thickening - Lordotic : Apical lesion - Oblique : helpful localize lesions and eliminate superimposed structures Right anterior oblique for left side lesion - ‫بررسی‬ ‫شامل‬ ‫استاندارد‬ : 1 ) ‫دو‬ ‫خلفی‬ ‫عکس‬ – ‫هم‬ ‫با‬ ‫تفسيرهردو‬ ‫و‬ ‫لترال‬ ‫و‬ ‫قدامی‬ & ‫مقايسه‬ ‫جديد‬ ‫با‬ ‫قديمی‬ ‫های‬ ‫عکس‬
  • 7. PA ‫شود‬ ‫مي‬ ‫ها‬ ‫كناره‬ ‫به‬ ‫كتف‬ ‫هاي‬ ‫استخوان‬ ‫چرخيدن‬ ‫باعث‬ ‫لگن‬ ‫روي‬ ‫بر‬ ‫ها‬ ‫دست‬ ‫پشت‬ ‫دادن‬ ‫قرار‬ ‫اين‬ ‫كه‬ ‫هاي‬ ‫استخوان‬ ‫داخلي‬ ‫هاي‬ ‫كناره‬ ‫كه‬ ‫شود‬ ‫مي‬ ‫باعث‬ ‫كار‬ ‫كتف‬ ‫در‬ ‫يا‬ ‫نيفتد‬ ‫ها‬ ‫ريه‬ ‫روي‬ ‫كمتري‬ ‫حد‬ ‫بيف‬ ‫تد‬ .
  • 8. Lat
  • 9. AP AP views are less useful and should be reserved for very ill patients who cannot stand erect (trauma, LOC, …..)
  • 11. ‫تفاوتهای‬ PA ‫و‬ AP • ‫بزرگی‬ ‫قدامی‬ ‫ساختارهای‬ ‫ساير‬ ‫و‬ ‫قلب‬ ‫سايه‬ ( ‫مدياستينوم‬ ) • ‫تشخيص‬ ‫افيوژن‬ ‫و‬ ‫پنوموتوراکس‬ ‫تر‬ ‫مشکل‬ ‫ريوی‬ ‫واحتقان‬ • ‫های‬ ‫سايه‬ ‫مزاحم‬ ( ‫مانيتور‬ ‫سيم‬ ، Back Board ) • ‫کمتر‬ ‫نفوذپذيری‬ ‫و‬ ‫دم‬ ،‫چرخش‬ ≈ 2 m
  • 15. Lat. decubitus ‫بررسی‬ ‫برای‬ ‫دکوپيتوس‬ ‫لترال‬ ‫وضعيت‬ : ‫پلور‬ ‫مايع‬ ‫حجم‬ ‫يا‬ ‫بودن‬ ‫متحرک‬ ‫لوکاليزه‬ ‫بودن‬ ‫افزايش‬ ‫جاذبه‬ ‫اثر‬ ‫علت‬ ‫به‬ ‫گرفته‬ ‫قرار‬ ‫پايين‬ ‫ريه‬ ‫دانسيته‬
  • 16. Technical quality  Well centered: (Rotation?) - Spinous process of T4 should be between the heads of the clavicle  Exposure (penetration): - It is affected by both the duration of exposure and the power of the beam  Good expose: You will be able to see the thoracic vertebrae  Over expose film looks diffusely dark and features such as lung markings are poorly seen  Under (poorly) expose film looks diffusely light (an x-ray is a negative) and soft tissue structures are readily obscured (especially those behind the heart)  Full inspiration
  • 21. Under exposed/Over exposed ‫آيد‬ ‫مي‬ ‫وجود‬ ‫به‬ ‫اشعه‬ ‫كم‬ ‫نفوذ‬ ‫دليل‬ ‫به‬ ‫كه‬ ‫اشكاالتي‬ : 1 - ‫شود‬ ‫نمي‬ ‫ديده‬ ‫خوبي‬ ‫به‬ ‫چپ‬ ‫ريه‬ ‫قاعده‬ ‫و‬ ‫چپ‬ ‫ديافراگم‬ ‫همي‬ . 2 - ‫نظر‬ ‫به‬ ‫تر‬ ‫برجسته‬ ‫واقعيشان‬ ‫شكل‬ ‫به‬ ‫نسبت‬ ‫ريه‬ ‫ساختاري‬ ‫عالئم‬ ‫رسند‬ ‫مي‬ . 3- Soft tissue structures are readily obscured (especially those behind the heart)
  • 26. (PA) ‫ها‬ ‫دنده‬ ‫شمارش‬
  • 27.  ‫د‬ ،‫فيلم‬ ‫به‬ ‫خلفي‬ ‫هاي‬ ‫دنده‬ ‫به‬ ‫نسبت‬ ‫قدامي‬ ‫هاي‬ ‫دنده‬ ‫بودن‬ ‫نزديك‬ ‫دليل‬ ‫به‬ ‫ر‬ ‫يك‬ ‫نماي‬ PA ‫سايه‬ ‫تر‬ ‫شارپ‬ ً‫ال‬‫معمو‬ ‫و‬ ‫شده‬ ‫بزرگنمايي‬ ‫دچار‬ ‫كمتر‬ ‫ها‬ ‫آن‬ ‫هستن‬ ‫د‬ .  ‫هاي‬ ‫دنده‬ 1 ‫و‬ 2 ‫عرضي‬ ‫رائده‬ ‫امتداد‬ ‫در‬ 1 T ‫افتند‬ ‫مي‬ ‫هم‬ ‫روي‬ .
  • 28. • Different tissues in our body absorb X-rays at different extents: • Bone - high absorption (White) • Air - low absorption (Black) • Tissue - somewhere in the middle absorption (Grey) - GREY- Soft tissue/water - DARK GREY- Fat
  • 29. A = Airway Trachea & Bronchi  ‫نه؟‬ ‫يا‬ ‫است‬ ‫وسط‬ ‫خط‬ ‫در‬ ‫تراشه‬ ‫آيا‬
  • 30. B = Breathing Pleural Space & Lung Parenchyma
  • 31. Pleural  Layers: Parietal Visceral  Check the costophrenic angles Margins should be sharp ‫پلور‬ : ‫شدن‬ ‫کلسيفيه‬ ،‫شدن‬ ‫ضخيم‬ ،‫افيوژن‬  ‫پلور‬ : ‫شدن‬ ‫کلسيفيه‬ ،‫شدن‬ ‫ضخيم‬ ،‫افيوژن‬
  • 33. If you see nothing abnormal on the x-ray, and yet clinical examination or history suggests otherwise, what do you do?
  • 34. Before taking an x-ray off the monitor you must say: AH HA !!!
  • 36. With your eyes, you define the 4 following target zones
  • 37. The first target is: the retroclavicular zone (foci of pulmonary tuberculosis, lung neoplasms, Pancoast’s tumour)
  • 39. The second target is : the hilum (density, size, abnormal opacity, lymph nodes)
  • 40. Dermoid cyst (hilum overlay sign)
  • 41. Bilateral hilar and mediastinal enlargement
  • 42. The third target is: the retrocardiac region (bronchopneumonia, atelectasis, neoplasm)
  • 43. Bronchopneumonia in the posterior and lateral basal segments of the LLL
  • 45. The fourth target is: the subdiaphragmatic zone (abdominal and abdomino-thoracic diseases)
  • 47. ‫آناتومی‬ ‫طبيعی‬ ‫ها‬ ‫ريه‬ - ‫ريه‬ ‫راست‬ 3 ‫چپ‬ ‫ريه‬ ‫و‬ ‫لوب‬ 2 ‫لوب‬ - ‫ريه‬ ‫مايل‬ ‫فيشر‬ ‫دو‬ ‫راست‬ ( ‫اصلی‬ ) ‫افقی‬ ‫و‬ ( ‫کوچک‬ ) ‫ماي‬ ‫فيشر‬ ‫يک‬ ‫چپ‬ ‫ريه‬ ‫و‬ ‫ل‬ ( ‫اصلی‬ ) - ‫ريه‬ ‫راست‬ 10 ‫چپ‬ ‫ريه‬ ‫و‬ 9 ‫سگمان‬ ‫شوند‬ ‫مي‬ ‫جدا‬ ‫يكديگر‬ ‫از‬ ‫عرضي‬ ‫يا‬ ‫مينور‬ ‫شكاف‬ ‫توسط‬ ‫راست‬ ‫مياني‬ ‫و‬ ‫فوقاني‬ ‫لوب‬ . ‫شود‬ ‫مي‬ ‫جدا‬ ‫مياني‬ ‫و‬ ‫فوقاني‬ ‫لوب‬ ‫از‬ ‫مايل‬ ‫يا‬ ‫ماژور‬ ‫شكاف‬ ‫توسط‬ ‫راست‬ ‫ريه‬ ‫تحتاني‬ ‫لوب‬ . ‫شوند‬ ‫مي‬ ‫جدا‬ ‫يكديگر‬ ‫از‬ ‫مايل‬ ‫يا‬ ‫ماژور‬ ‫شكاف‬ ‫توسط‬ ‫چپ‬ ‫تحتاني‬ ‫و‬ ‫فوقاني‬ ‫لوب‬ . - ‫شكاف‬ ،‫شود‬ ‫مي‬ ‫گسترده‬ ‫ناف‬ ‫محل‬ ‫از‬ ً‫ا‬‫دقيق‬ ‫عرضي‬ ‫يا‬ ‫مينور‬ ‫به‬ ً‫ال‬‫اص‬ ‫يا‬ ‫شود‬ ‫مي‬ ‫ديده‬ ‫سختي‬ ‫ديده‬ ‫نمي‬ ‫شود‬ .
  • 49. Right middle lobe: ‫مياني‬ ‫لوب‬ ‫مجاورت‬ ‫در‬ ‫راست‬ ‫كناره‬ ‫راست‬ ‫قرار‬ ‫قلب‬ ‫دارد‬
  • 53. Left upper lobe - upper division:
  • 54. ‫ريه‬ ‫ناف‬ ‫طبيعی؛‬ ‫آناتومی‬ • ‫ای‬ ‫مجموعه‬ ‫ريه‬ ‫ناف‬ ‫از‬ : ‫ريوی‬ ‫اصلی‬ ‫های‬ ‫شريان‬ ، ‫وريدهای‬ ‫ها‬ ‫برونکوس‬ ‫و‬ ‫ريوی‬ • ، ‫شکل‬ ،‫سايز‬ ‫کردن‬ ‫مشخص‬ ‫ريه‬ ‫ناف‬ ‫دانسيته‬ • ‫شاخه‬ ‫تا‬ ‫ريوی‬ ‫شريان‬ ‫تحتانی‬ ‫لوب‬ 2 - 4 ‫دارد‬ ‫ادامه‬ ‫سانتيمتر‬ • ‫های‬ ‫شاخه‬ ‫حاصل‬ ‫ريه‬ ‫بافت‬ ‫طبيعی‬ ‫نمای‬ ‫و‬ ‫عروقی‬ ‫تا‬ 1 ‫جداره‬ ‫سانتيمتری‬ ‫توراکس‬
  • 55. Left Hilus higher (max 1-2.5 cm)
  • 56. C = Circulation Heart & Medistinum
  • 58. Apical pleural cap • An apical pleural cap refers to a curved density at lung apex seen on chest radiograph • It has relatively narrow differential diagnosis:  Pleural thickening / scarring secondary to previous apical infection - typically pulmonary tuberculosis radiation fibrosis may be present in upto 10% of radiographs  Pancoast tumour  Haematoma thoracic aortic injury fractured first rib  Lymphoma : extending from neck or mediastinum  Abscess within the neck / mediastinum
  • 60. ‫مدیاستینوم‬ ‫طبیعی؛‬ ‫آناتومی‬ Define: - Area between the lung - Water density Surrounded two air filled lungs and Intersected by the air filled trachea and major bronchi Anatomy dividing region: 1- SUPERIOR MEDIASTINUM Begins - root of the neck and Ends - line drawn T-4 vertebrae --- sternomanebrum junction line skims the top of the aortic arch 2- INFERIOR MEDIASTINUM Begins - this line End - diaphragm Further divided into three regions: 1- Anterior 2- Middle 3- Posterior
  • 62. Superior Mediastinum  Retrosternal: Great vessels and branches Thymus  Prevertebral: Trachea Esophagus Thoracic duct Sympathetic trunks Vagus nerves
  • 63. Inferior Mediastinum  Anterior: Thymus, fat, lymph nodes  Middle: Pericardium Phrenic nerves Pericardiacophrenic artery Heart and great vessels  Posterior: Esophagus Thoracic duct Aorta and branches Vagus nerves Sympathetic trunks Azygos system of veins
  • 64. 1- Overall size and shape 2- Trachea: position  Mediastinum : 3- Margins (Cardiac) 4- Lines and stripes 5- Retrosternal clear space 1 - ‫توده‬ ، ‫انحراف‬ ، ‫شدن‬ ‫پهن‬ 2 - ‫نه؟‬ ‫يا‬ ‫است‬ ‫وسط‬ ‫خط‬ ‫در‬ ‫تراشه‬ ‫اگر‬ ‫كنيد‬ ‫بررسي‬ ‫را‬ ‫ها‬ ‫آبنورمالي‬ ،‫نيست‬ ‫وسط‬ ‫خط‬ ‫در‬ ً‫ا‬‫دقيق‬ ‫هوايي‬ ‫راه‬ . ،‫افيوژن‬ ‫پلورال‬ ‫مثل‬ ،‫پنوموتوراكس‬ ‫تنشن‬ ‫آتلكتازي‬ . ‫اگر‬ ‫بايد‬ ‫آن‬ ‫محل‬ ‫بايد‬ ‫دارد‬ ‫تراشه‬ ‫لوله‬ ‫بيمار‬ cm 3-4 ‫باالتر‬ ‫کارينا‬ ‫از‬ ‫باشد‬ . ‫اصلی‬ ‫برونش‬ ‫و‬ ‫تراشه‬ ‫اطراف‬ ‫در‬ ‫آزاد‬ ‫هوای‬ ‫وجود‬ ( ‫مدياستن‬ ‫پنومو‬ ) ‫كارينا‬ : ‫محاذات‬ ‫در‬ T6 - T7 ‫آن‬ ‫زاويه‬ ‫و‬ ‫گرفته‬ ‫قرار‬ 60 ‫تا‬ 70 ‫باشد‬ ‫می‬ ‫درجه‬ . ‫اگر‬ ‫از‬ ‫بيش‬ ‫زاويه‬ ‫اين‬ 90 ‫باشد‬ ‫داده‬ ‫رخ‬ ‫است‬ ‫ممكن‬ ‫علت‬ ‫سه‬ ‫به‬ ،‫باشد‬ ‫درجه‬ : 1 - ‫كارينا‬ ‫زير‬ ‫در‬ ‫چپ‬ ‫دهليز‬ ‫بزرگي‬ 2 - ‫وجود‬ Lymphadenopathy 3 - ‫وجود‬ ‫در‬ ‫توده‬ ‫مدياستن‬
  • 72. Cardiothoracic Ratio ‫نسبت‬ ‫داخ‬ ‫لبه‬ ‫از‬ ‫سينه‬ ‫قفسه‬ ‫عرضی‬ ‫قطر‬ ‫بيشترين‬ ‫به‬ ‫قلب‬ ‫قطر‬ ‫بيشترين‬ ‫دنده‬ ‫لی‬  Greater than 50% suggests cardiac enlargement (usually CHF or pericardial effusion)  Remember: AP views make heart appear larger than it actually is Cardiac margins should be sharp
  • 73. Widened mediastinum • Widening of the mediastinum is most often due to technical factors such as patient positioning or the projection used. Rotation, incomplete inspiration, or an AP view, may all exaggerate the width of the mediastinum, as well as heart size • In the setting of trauma, patients are positioned supine while a chest x-ray is acquired, very often causing the mediastinum to appear wide spuriously • Is a mediastinum with a measured width greater than 6 cm on an upright PA chest X-ray or 8 cm on supine AP chest film(at the level of the aortic knob on the best film) • Use of cross-sections from CT and MRI will supplement this section
  • 74. 4- Lines and stripes: Para tracheal /Para spinal/Para esophageal(azygo esophageal)/Para aortic  Lines typically measure less than 1 mm in width and are formed by air, typically within the lung, outlining thin intervening tissue on both sides Lines present on chest radiographs include the anterior and posterior junction lines  Stripes are thicker lines formed by air outlining thicker intervening soft tissue Stripes are seen on chest radiographs including: L&R paratracheal stripes posterior tracheal stripe
  • 75. 5-Retrosternal clear space • ‫دارد‬ ‫وجود‬ ‫چپ‬ ‫بطن‬ ‫شدن‬ ‫بزرگ‬ ‫احتمال‬ ،‫باشد‬ ‫كم‬ ‫خيلي‬ ‫فاصله‬ ‫اگر‬ . • ‫اگر‬ ‫انسدادي‬ ‫بيماري‬ ‫احتمال‬ ،‫باشد‬ ‫زياد‬ ‫خيلي‬ ‫فاصله‬ ‫ريه‬ COPD ‫دارد‬ ‫وجود‬ .
  • 78. ‫قله‬ ‫ديافراگم‬ ‫هاي‬ : • ‫است‬ ‫متفاوتي‬ ‫هاي‬ ‫موقعيت‬ ‫داراي‬ ،‫تنفس‬ ‫مختلف‬ ‫مقادير‬ ‫با‬ ‫ديافراگم‬ . • ‫كمي‬ ً‫ال‬‫معمو‬ ‫راست‬ ‫ديافراگم‬ ‫همي‬ ‫باالتر‬ ‫ازهمي‬ ‫است‬ ‫چپ‬ ‫ديافراگم‬ (. 2 ‫تا‬ 3 ‫متر‬ ‫سانتی‬ ) ‫قلب‬ ‫آناتوميکی‬ ‫موقعيت‬ ‫و‬ ‫کبدی‬ ‫اثر‬ ‫خاطر‬ ‫به‬ • ‫شود‬ ‫می‬ ‫ديده‬ ‫راست‬ ‫ديافراگم‬ ‫تمام‬ ‫چپ‬ ‫ديافراگم‬ ‫ولی‬ ‫بدليل‬ ،‫خير‬ ‫قلب‬ ‫اينکه‬ ‫قرارمی‬ ‫ديافرگم‬ ‫روی‬ ‫گيرد‬ . • ‫زيرديافراگم‬ ‫هوای‬ ‫بررسی‬ ( ‫پريتوين‬ ‫پنومو‬ ) penetrating trauma, peritonitis, recent surgery Laparoscopy, hallow viscus perforation • ‫ديافراگم‬ ‫رويت‬ ‫عدم‬ : ‫مايعات‬ ‫نفوذ‬ ‫يا‬ ‫افيوژن‬ • ‫ديافراگم‬ ‫دوسطح‬ ‫بيشتربين‬ ‫وت‬ ‫تفا‬ : ‫ديافراگم‬ ‫فلج‬ ، ‫کالپس‬ ، ‫افيوژن‬ • ‫کوستوفرنيک‬ ‫زاويه‬ ‫شدن‬ ‫محو‬ : ‫تومور‬ ،‫اسکار‬ ،‫هموتوراکس‬ ،‫افيوژن‬ ‫پلورال‬
  • 81. Soft tissue: • Look for subcutaneous emphysema (suggestive of trauma) • Soft tissue swelling • Axillary line • Calcification • Foreign body • Breasts shadow
  • 84. Skeletal structures Overall size, shape, contour of each bone: - Density( mineralization) - Compare cortical thickness to medullary cavity, trabecular pattern - Erosions, fractures, any lytic or blastic regions Joints: - Articular relationships - Joint spaces narrowed, widened - Calcification in the cartilages - Air in the joint space, abnormal fat pads  Note calcified anterior cartilages may obscure or mimic underlying lung lesions  Compare side to side
  • 89. G = Tube & Lines
  • 90. Chest Tube, NG Tube, Pulmonary artery cath