BASICCHESTXRAYmodAdam

Basic Chest X-Ray Interpretation,Adam Guttentag, M.D.,All photos retain the copyrights of their original authors, 2005 Adam Guttentag, MD,How do you look at a chest x-ray?,Avoid tunnel vision!,or,Have a system,The Lateral Chest Film,Find abnormalities hidden on the frontal filmConfirm abnormalities suspected from frontal filmDont be afraid to look at it!,Our best friend!,Looking at the lateral CXR,Hilar structures on the lateral film,“Ring around the bronchus”,Technical Factors,Positioningstraight vs oblique,(How well try to fool you),Effect of obliquity on heart size,Technical Factors,Positioningstraight vs obliquePA vs AP,Technical Factors,Positioningstraight vs obliquePA vs APerect vs supine,erect,supine,Technical Factors,Positioningstraight vs obliquePA vs APerect vs supinelordotic vs kyphotic,lordotic,kyphotic,Technical Factors,Positioningstraight vs obliquePA vs APerect vs supinelordotic vs kyphotic,Effect on mediastinal contour,Technical Factors,Depth of inspirationVisualization of pathology depends on contrast provided by air in the lungsCount ribs!,10,8,Short of breath,One minute later,8,Technical Factors,Body habitus,Radiographic technique:Is it really different?Changing technique can make disease look better or worse.,Is the heart large? Is the mediastinum wide?,Same patient, 4 films within one month,Recognizing air space disease,Alveolar spaces filled withsomething.Radiologists report:“consolidation”“air space opacity”“fluffy density”“infiltrate”Nonspecific:Atelectasis, pneumonia, bleeding, edema, tumor,The Silhouette Sign,Indicates air space disease.Obscuration of a normally seen border, e.g. diaphragm or heart.Opacity with sharp edge along a fissure.,Localizing disease from the silhouette sign,Localizing disease from the silhouette sign,RUL,RML,UL,LL,RML or lingula,16 hours later,What happened here?,Lobar Atelectasis,Best sign shift of a fissureRapid development and clearanceAir bronchograms if non-obstructiveSecondary signs:Mediastinal shiftElevated diaphragmRibs closer togetherVague increased density,LLL Atx,Next day,RUL Atx,RML Atx,LUL Atx,Pneumonia,Signs:Air bronchogramSilhouette - “positive” or “negative”Dense hilum“Spine” signAll are signs of any air space processDx of pneumonia depends on appropriate clinical scenario.,Air bronchogram sign,Pseudomonas pneumonia,Lung cancer,Air bronchograms CT,Right middle lobe,Right upper lobe,Right lower lobe,Dense hilum, spine sign,Dense hilum, spine sign again,Four days later,Final Exam,21 y.o. with fever and cough,Hyperlucent hemithorax: why?,Did you notice the mass?,Lymphoma,Take home message #1,Its a chest x-ray, not a lung x-ray.,6 cm lung mass missed. How?,Take home message #2,Old films are your friend!,Elderly man with hypotension,Suddenly septic,Pneumatosis of small bowel,Take home message #3,The patient pays forthe whole film!,Review Questions,All are kinds of air space disease except:,HemorrhagePneumoniaTumorSarcoidosis Atelectasis,The most specific sign of atelectasis is:,Obscuration of a diaphragmShift of a fissureAir bronchogramsDensity over the spineMediastinal shift,This can make the heart look larger than it is:,Lordotic positioningAP positioningExpiratory filmSupine positioningAll of the above,Additional Reading,Chest Roentgenology Felson, B W.B. Saunders Co, Philadelphia 1973 Chapter 2: Localization of Intrathoracic Disease. pp 22-70.Pare JAP and Fraser RG Synopsis of Diseases of the Ches