Normal chest Xray: Fundamentals and Basic Interpretation (By Dr Nivedita Barik)pdf.pdf
- 1. NORMAL CHEST X-RAY NORMAL CHEST X-RAY Fundamentals and Basic Interpretation Fundamentals and Basic Interpretation -Dr. Nivedita -Dr. Nivedita Barik Barik Intern,Batch 2018 Intern,Batch 2018 BJGMC,Pune BJGMC,Pune
- 2. INTRODUCTION A Chest X-ray is a common diagnostic tool used in clinical practise to evaluate lung, heart, airways and chest anatomy. It also serves as the most sensitive plain radiograph for the detection of free intraperitoneal gas or pneumoperitoneum in patients with acute abdominal pain. It is frequently used to aid in diagnosing a range of acute and chronic conditions involving all organs of the thoracic cavity. IMPORTANCE OF UNDERSTANDING THE NORMAL ANATOMY? Knowing the typical features of a normal chest X-ray is essential for distinguishing normal variations from potential abnormalities and help in quicker diagnosis Normal Chest X-ray(P-A view)
- 3. WHAT ARE THE 5 BASIC RADIOGRAPHIC DENSITIES? Least opaque Most opaque Radio-dense Radio-lucent Black White
- 4. POINTS TO NOTE BEFORE INTERPRETATION: Patient identification details Patient name, Age , Gender , Date , IPD/OPD No. , Left(L)/Right(R) Markers ASSESS TECHNICAL QUALITY Orientation Penetration Depth of Inspiration Rotation Underexposed/ Overexposed P-A View/ A-P View/ Lateral View
- 5. A) ORIENTATION/ 4 MAJOR VIEWS Postero -Anterior (P-A) View 1. Antero- Posterior (A-P) View 2. Lateral View 3. Lateral Decubitus View 4.
- 6. 1) P-A VIEW Standard view for routine Chest x-rays Xray beam projected from (P)-->(A) Parallel X-rays from a distance of 6Ft.(180cm) Cardio-thoracic ratio = 0.5 (Normal) Allows accurate and valid comparison between repeated PA CXRs. A Normal P-A Chest X-ray. NO APPARENT CARDIOMEGALY
- 7. 2) A-P VIEW Bedside (i.e. portable) radiograph, patient supine. (A)—>(P) Divergent X-rays from a distance less than 6Ft.(180cm) Sick or non- cooperative patient, patient sitting up. AP CXR. A Normal A-P Chest X-ray. Apparent Cardiomegaly due to magnification Cardio-thoracic ratio > 0.6
- 8. Clavicle OVER both the lung fields ABOVE APEX of both the lung fields Scapula Inner border AWAY FROM lung fields Inner border OVER lung fields Ribs Posterior ribs better visible Anterior ribs better visible Cardiomegaly ABSENT PRESENT P-A VIEW A-P VIEW VS
- 9. 3) LATERAL VIEW X-ray beam projected over the lateral thoracic wall with arms up and out of the way. A Normal Lateral Chest X-ray. Locate lung lesions if frontal CXR is EQUIVOCAL. Assessing pleural effusion. Evaluate heart size and contours. Identify spine lesions Differentiate lobar pathology like consolidation or collapse. Detect mediastinal masses. ADVANTAGES:
- 10. 4) LATERAL DECUBITUS VIEW Patient lies towards his lateral side(Left or Right). X-ray beam is parallel to the horizontal. Right Lateral Decubitus CXR to demonstrate Right sided Pleural Effusion
- 11. B) PENETRATION Underexposed Overexposed Adequately exposed -Too white -Misinterpreted as Pulm. Edema/fibrosis -Too Dark -Misinterpreted as Pneumothorax /Emphysema Thoracic vertebrae barely visible through heart shadow
- 12. Good inspiration C) DEPTH OF INSPIRATION Poor inspiration 6 or more anterior ribs visible Less than 6 anterior ribs visible Apparent Cardiomegaly seen Crowding of blood vessels at the base. Mimics infection
- 13. Rotation to RIGHT Rule : Spinous process of upper vertebrae should be EQUIDISTANT from medial end of clavicle D) ROTATION Rotation leads to one lung field appear darker than the other Rotation to LEFT Prominent vessels over right upper lobe mimics mass Prominent Aortic arch mimics mediastinal mass
- 14. Normal CXR: INTERPRETATION A- Airways B- Bones & soft tissue C-Cardia D- Diaphragm E- Effusion (Pleura) F- Lung Fields & Fissures G-Gastric bubble & Great vessels H- Hilum & mediastinum ABCDEFGH Approach
- 15. A) AIRWAYS Trachea and bronchi Any foreign bodies Deviation of trachea Deviation from midline indicates mediastinal mass/ pneumothorax/ pleural effusion etc Note:
- 16. Foreign body in airways Airway abnormalities Tracheal deviation to right
- 17. B) BONES & SOFT TISSUE SHADOW Look for ribs and clavicle fractures. Overinflated lungs in COPD leads to more number of ribs over lung fields Note Scapula and humerus ,if Visible. Vertebral pathologies Red arrow- right ribs Green arrow- left ribs Red arrow- clavicle Green arrow- ribs Yellow arrow-scapula BONES
- 18. Rib fracture Bone abnormalities Multiple bone metastasis -Dense sclerotic ribs, clavicle
- 19. Soft tissue shadow Supraclavicular fossa(enlarged nodes) Lateral chest wall(surgical emphysema) Under diaphragm (Pneumoperitoneum Breast tissue may obscure the costophrenic angles Thick soft tissue due to obesity may obscure some underlying structures such as lung markings Sub- cutaneous Emphysema Pneumo- peritoneum
- 20. C) CARDIA Heart silhouettes and borders should be well defined. Blurred margins indicate fluid in lungs or pneumonia Position and shape of heart. Deviations indicate structural abnormalities or disease
- 21. Cardio-thoracic Ratio : Cardiac width Thoracic width C) CARDIA Heart size : Size of the heart can be measured by CTR. Normal = <0.5 Increased CTRatio /Cardiomegaly(>0.5): A-P View or Over rotated (APPARENT) Pericardial effusion Heart failure, volume overload etc.
- 22. SILHOUETTE SIGN;Obscured right heart border CTRatio > 0.5 Cardiomegaly Cardiac abnormalities -loss of normal heart border suggests intra thoracic lesions- Pneumonia/ Effusion/ Pulmonary edema
- 23. D) DIAPHRAGM Outline of the diaphragm should be clear and smooth. Right hemidiaphragm should be higher than the left Gastric bubble below left hemidiaphragm. Costophrenic and cardiophrenic angles should be sharp and acute. -More than 90 degrees indicate overinflated lungs- COPD -Blunting indicates Pleural effusion
- 24. Pneumoperitoneum -Air below diaphragm indicates hollow viscus perforation Left pleural effusion -Blunting of Costo-phrenic angle ; MENISCUS SIGN COPD/Chronic Asthma Diaphragmatic rupture -Gastric bubble ABOVE the left hemidiaphragm -Flattening of diaphragm -Hyperinflated lung fields Diaphragm abnormalities
- 25. E) EFFUSION(PLEURA) The pleura is a double layered membrane surrounding the lungs. -It is only visible when there is an abnormality present. Look for Effusion(fluid in pleural space) Pneumothorax(air in pleural space) Pleural thickening
- 26. Left pleural effusion Right sided pleural thickening Left Pneumothorax -blunting of C-P angle -fluid(WHITE) in pleural space -Air(BLACK) in pleural space -Compressed left lung -due to chronic infection/cancer
- 27. Upper zone: from the apex to 2nd costal cartilage. Middle zone: between 2nd and 4th costal cartilage. Lower zone: between 4th and 6th costal cartilage F) LUNG FIELDS & FISSURES Normally, there are visible markings throughout the lungs due to the pulmonary arteries and veins, continuing all the way to the chest wall RULE : Compare both left and right lung fields at the same level starting from apex to base Look for equal radiolucency between the two lung fields. Check for infiltrates/masses/consolidation/ air bronchograms or nodules, if any.
- 28. The HORIZONTAL FISSURE/MINOR FISSURE , is a unilateral structure in the RIGHT lung that separates the right middle lobe from the right upper lobe. The OBLIQUE / MAJOR FISSURES are bilateral structures seen in both lungs separating lung lobes. Fissures Evaluate the major and minor fissures for thickening, fluid or change in position.
- 29. G) GASTRIC BUBBLE & GREAT VESSELS The Gastric Bubble should be seen clearly BELOW LEFT HEMIDIAPHRAGM and not displaced. Check aortic size and shape and the outlines of pulmonary vessels. The aortic knob should be clearly seen. Gastric bubble Great vessels
- 30. H) HILUM & MEDIASTINUM The left hilum is normally higher than the right. Both hila should be of similar size and density Evaluate the hila for lymphadenopathy / calcifications / masses. Hilum= major bronchi + pulmonary arteries &veins. Bilateral Hilar Enlargement ; Sarcoidosis
- 31. Mediastinum Normal width of mediastinum Mediastinum is the central compartment of the thoracic cavity between the lungs . Contents: Heart, major blood vessels(aorta & pulmonary arteries),trachea,esophagus and lymph nodes Look for: Mediastinal width Contours & borders Position of trachea Aortic knob Hilar structures Right border : SVC , Right atrium Left border : Aortic arch, pulmonary artery and left ventricle Normal : 6-8cms Smooth & well-defined Gives clue about lymph node enlargement, tumors, vascular issues. Central in midline
- 32. Mediastinal widening Mediastinal width = more than 6cm on erect PA view OR. >8cm on supine AP view Thoracic aorta aneurysm -Enlarged aortic knob -Displaced trachea -Widened descending aorta Lymph node enlargment -Enlarged upper mediastinum -Ill defined aortic knob
- 33. IMPRESSION Recognise Normal Anatomical structures Follow the systematic ABCDEFGH Approach to ensure you don’t miss anything Avoid technical errors like overexposure,underexposure,rotation, and other artifacts Always correlate findings with previous X-rays and other views.
- 34. THANK YOU!