How read chest xr 2
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1) The document provides guidance on how to read a chest x-ray, including assessing technical quality, determining if it is a PA or AP view, and evaluating penetration and inspiration. 2) It describes how to analyze the lungs by comparing vascular markings in different regions, identifying fissures and localizing lesions. 3) Three case studies are presented and summarized, showing examples of right upper lobe atelectasis, left upper lobe atelectasis, and left lower lobe atelectasis. Key findings are described for each case.
How read chest xr 2
- 1. HOW READ CHEST XR -2 ANAS SAHLE ,MD
- 3. RPPI Is the film centered? Rotation Is it PA or AP film ? Positioning Is it exposed properly ? Penetration Is it a good inspiration film? Inspiration
- 4. observing the clavicular heads determining whether they are equal distance from the spinous process of the thoracic vertebral bodies
- 5. RPPI Is the film centered? Rotation Is it PA or AP film ? Positioning Is it exposed properly ? Penetration Is it a good inspiration film? Inspiration
- 6. If the scapulae no longer overlie the lung fields then the film is PA If the scapulae overlie the lung fields then the film is AP
- 9. RPPI Is the film centered? Rotation Is it PA or AP film ? Positioning Is it exposed properly ? Penetration Is it a good inspiration film? Inspiration
- 10. Normal Penetrated An overpenetrated PA film PA film
- 11. Normal Penetrated underpenetrated PA PA film film
- 12. RPPI Is the film centered? Rotation Is it PA or AP film ? Positioning Is it exposed properly ? Penetration Is it a good inspiration film? Inspiration
- 13. The diaphragm should be found at about the level of the 8th - 10th posterior rib or 5th - 6th anterior rib on good inspiration
- 14. look at the lungs
- 15. Scan both lungs starting at the apices and working down comparing left with right at the same level
- 16. Compare and contrast vascular markings in upper vs. lower lung fields in PA view
- 17. List conditions, where vascular markings are prominent in upper lung fields • Mitral stenosis • Congestive heart failure • Alpha one antitrypsin deficiency
- 18. Compare and contrast vascular markings in outer third vs. inner two thirds of lungs
- 19. increased markings in outer third of lung fields? increased pulmonary flow • In: 1. Left to right shunts (ASD, VSD, PDA)
- 20. increased markings in outer third of lung fields? • In : 2. Interstitial disease 3. Lymphangitic malignant spread 4. CHF with increased lymphatic flow
- 21. Fissures
- 23. The position of lesion can be described in terms of zones
- 24. To accurately localize a lesion on chest X ray you need to look at both the PA and lateral films
- 25. First look at the PA film
- 26. The upper zone lies above the anterior border of the 2nd rib
- 27. The middle zone lies between the right anterior borders of the 2nd and 4th ribs
- 28. The lower zone lies between the right anterior border of the 4th rib and the diaphragm
- 29. It does not give any information about the lobes of the lung
- 30. Look at the borders of the lesion • If the lesion is next to a dense (white) structure then the border between the lesion and that structure will be lost This is called the silhouette sign
- 31. Now look at the lateral film
- 33. A brief look at the lateral CXR Key points • There should be a decrease in density from superior to inferior in the posterior mediastinum. • The retrosternal airspace should be of the same density as the retrocardiac airspace.
- 34. Identify the oblique fissure • (pass obliquely downwards from the T4/T5 vertebrae through the hilum ending at the anterior third of the diaphragm)
- 35. Identify the horizontal fissure • (pass horizontally from the midpoint of the hilum to the anterior chest wall)
- 36. If the lesion lies posterior to the oblique fissure it must lie within the lower lobe
- 37. If the lesion lies anterior to the oblique fissure it may be in the upper or middle lobe
- 38. If the lesion is below the horizontal fissure it is in the middle lobe
- 39. If the lesion is above the horizontal fissure it is in the upper lobe
- 40. There is no middle lobe on the left
- 41. POSITION PA AP QUALITY ROTATION PENETRATION INSPIRATION LESION Homo Heterogenous Densityinfiltration necrotic Zone Centralperipheral Silhouet sign MEDIASTINAL Central deviasionwided COSTO-PHRENIC ANGEL Freeoblitern OTHER Bone soft tissuediaphragm
- 42. CASE-1 This elderly male had recent onset of streaky hemoptysis.?
- 43. POSITION •AP CXR QUALITY •Poor Technical Quality •homogeneous density in the right upper zone LESION , elevation of the transverse fissure •Central trachea and mediasteinal MEDIASTINAL •Free costo-phrenic angels ANGELS •NO OTHER
- 44. S sign • homogeneous density in the right upper zone • elevation of the transverse fissure ( Instead of the transverse fissure being straight) • there is a bulge at the medial end giving it an inverted S shape. • Golden described this sign and the explanation for it is that the upper lobe collapse is due to a right hilar mass which accounts for the medial bulge
- 46. Homogenous Atelectasis Right Upper Lobe density right upper lung field. Mediastinal shift to right. Loss of silhouette of ascending aorta. Movement of oblique and transverse fissures.
- 47. Case-2 This middle-aged female complained of: •Hemoptysis •loss of weight two months’ duration.
- 48. POSITION •PA CXR QUALITY •Poor Technical Quality •(poor penetration). •hazy, veil-like opacification LESION •in the left upper zone,obscured aortic arc,from hilar to peripheral •Central trachea and mediasteinal MEDIASTINAL •Obscured left costo-phrenic angels ANGELS •Elevate left hemidiaphragm •NO OTHER
- 49. Illustration • The CXR shows evidence of left upper lobe collapse. • There is a hazy, veil-like opacification in the left upper lobe, which does not have a sharp inferior margin unlike right upper lobe collapse. • This is because there is usually no left transverse fissure and the lobe collapses anteriorly.. • There is also volume loss in the left hemithorax as evidenced by an elevated left hemidiaphragm and crowding of the left upper ribs. • Sometimes the trachea may also be deviated to the same side and the aortic knuckle may be obscured by the collapse
- 50. Mediastinal shift to left. Density left upper lung field. Loss of aortic knob and left hilar silhouettes. Atelectasis Left Upper Lobe
- 51. A: Forward movement of oblique fissure C: Atelectatic LUL B: Herniated right lung Atelectasis Left Upper Lobe
- 52. Bowing sign •LUL atelectasis or following resection •The oblique fissure bows forwards
- 53. Bowing sign
- 54. CASE-3 • 50-year-old female with a past history of tuberculosis had • chronic cough over the past year.
- 55. POSITION •PA CXR QUALITY •GOOD Technical Quality •No LESION •Left lung smaller than right •Left deviation trachea and MEDIASTINAL mediasteinal •Obscured left costo-phrenic angels ANGELS •Elevate left hemidiaphragm •NO OTHER
- 56. Inhomogeneous cardiac density. Triangular retrocardiac density. Left hilum pulled down. Atelectasis Left Lower Lobe
- 57. •Lateral left diaphragm not visible •Increased density over lower spine Left Lower Lobe Atelectasis