technique of chest x-ray reading · technique of chest x-ray reading a. check the request form and...

Basic Technique of

Chest X-Ray Reading

馬偕醫院胸腔內科

郭許達醫師

2017/12/26

1

Technique of Chest X-Ray Reading

A. Check the request form and data on the film

B. Check the the technical quality of chest x-ray

Patient’s position --PA, sternal end

Depth of breathing -- diaphragm level

Exposure of film

C. Find abnormal picture

D. Interpretation

Hsu-Tah Kuo,MD 2

The Effect of Standing and Supine Position

3

Effects of Body Position on CXR

Standing Sitting Supine

4

同一病人在相同時間呼氣和吸氣之影像

5

Checkpoints to Evaluate Technical Quality

1.Medial tips of clavicle equidis-

tant from spinous process

2. Diaphragm at least as low as

the 10th posterior rib

3. Intervertebral spaces visible

through mediastinal shadow

4. Symmetrical radiodensity of

shoulder and soft tissues

5. Clavicles overlying 3-4th

posterior interspace

1 2 3 4 5 6

7

8

9

10

11

Hsu-Tah Kuo,MD

Mackay Memorial Hospital

6

Technique of Chest X-Ray Reading

Read the film systemically

Soft tissue and bony structure

A. Airway -- trachea

B. Blood vessels -- aorta, hilar

vessels

C. Cardiac & mediastinum

D. Diaphragm -- level, shape

E. Effusion -- CP angle

F. Field --lung fields symmetric

bilaterally.

G. Gas shadow -- stomach gas

A

B

C

D E

F

G

Soft tissue and bone

Bone

Soft

tissue

Hsu-Tah Kuo,MD


7

Anatomical Landmarks on Chest X-Ray

Trachea

Central, slightly to r’t in lower 3rd

Hilar

Level: R’t opposite 6th rib in ax,

L’t 1.5 cm higher

Size: R’t basal artery 9-16 mm

Lung Vessels

Larger in lower, roughly

symmetrical bilaterally

Horizontal Fissure

Level: 6th rib in axilla

Tr.

Hilar

Fissure Lung vessels

6th

Hsu-Tah Kuo,MD


8

Contours of the Mediastinum

L subclavian

Aortic knob

Pulm a.

Cardiac

SVC Tr.

Bi

lmb rmb

changes in the contours of mediastinal pleural at its interface with adjacent lung.

–Concave contours to straight or convex

–Loss of sharp margins about such anatomic structures

–Widening of spaces between mediastinal boundaries and mediastinal contents

As aorta

9

Cardiac silhouette and mediastinum

10

Hilar and Blood Vessels

11

Mediastinal

window on chest

CT

contrast media

12

Airway and Blood Vessels

A

B

13

Hilar and Blood Vessels

14

Anatomical Landmarks on Chest X-Ray

Heart

Size: TD < 16 cm, change < 2 cm

Shape: Classical

Position: Central, 2/3 to the left

of mid-line

Diaphragm

Level: Ant. 5-6.5 rib,

R’t 0.5-2.5 cm higher than L’t

Curve: Vertical line > 1.5 cm

Outline: shape, CP angle acute

Background Blacking

Same at equivalent level

1 2

3

4

5

6

7

Hsu-Tah Kuo,MD


15

Anatomical position -- PA & Lat view

c.Anatomical division

red= upper lobes

yellow= middle lobe

blue= lower lobe

a. division of the lungs into

1= hilar portion

2= central portion

3= peripheral portion

b.division of the lung zones

1= apex

2= upper lung field

3= middle lung field

4= lower lung field

16

Lateral View

2 Clear Spaces

Retrosternal

Retrocardiac

17

Lateral Chest X-ray Image

1. Judge the size and shape of the lungs and position and

shape of the diaphragms.

Flattening of the diaphragms (height of < 2.7cm)

2. Follow the airway from neck to the hilum

Tracheal position,

Center of hilar structures - left main bronchus

anterior – RPA; Posterior - LPA.

3. Fissure lines

4. Retrosternal, retrocardiac darkening

5. Trace around the periphery of the image.

Bowel gases , pneumoperitoneum,

18

Lordotic view

19

利用正面和側位判斷病灶位置

20

15% of the lung can be hidden by

cardiovascular structures and the diaphragm.

The lateral image can be helpful in looking

for these obscure lesions on PA films.

Identify the lesion-- PA & Lat

Hsu-Tah Kuo,MD


21

Apical lesion -Lordotic View

PA

Lordotic

CT 24

Adjust Digital Imaging

1. Adjust contrast and density to maximize

visualization of all structures

2. Measure the size of the lesion

3. Compare with the prior films

25

Terms use in chest x-ray interpretation

1. Atelectasis, collapse

2. Bulla

3. Circular, ovoid shadow

– multiple fine, nodular, coarse mottling

– small large circular shadow 2cm

4. Consolidation

5. Density- low, fairly high, very high

6. Disseminated, diffused nodular shadow

Hsu-Tah Kuo,MD 26


7. Effusion

8. Honeycomb shadow

9. Ill-defined opacity

10. Linear, band-like shadow

11. Patchy clouding

12. Reticulation

13. Cavity

14. Septal line

15. Thickened pleura

16. Tubular shadow Hsu-Tah Kuo,MD 27


28


29

Blind Area at Chest PA Film

1. Behind the inner end of the clavicle or anterior end of 1st rib

2. Apex of lower lobe on either side

3. Left lower lobe

4. Posterior costophrenic recess

5. Central part of the mediastinum

30

15% of the lung can be hidden by

cardiovascular structures and the diaphragm.

The lateral image can be helpful in looking

for these obscure lesions on PA films.

31

Silhouette

Adjacent Structures whose interfaces create a

Radiographic Silhouette PA view

1.Diaphragm & lower lobe

2.R’t cardiac border & RML

3.L’t cardiac border & Lingual segment

4.Ascending aorta & anterior segment RUL

5.Aortic knob & apical-post. Segment LUL

6.Descending aorta & superior posterior segment LLL

7.Left ventricle & LLL

Lateral view

1.Diaphragm & lower lobe

2.Inferior vena cava & medial basal segment RLL

3.Left ventrilce & LLL

Hsu-Tah Kuo,MD

1

2 3

4 5

6

7

32

Silhouette Sign

Hsu-Tah Kuo,MD 33

Silhouette Sign

34

Pattern of Chest Lesion

1. Chest wall lesion

2. Pleural lesion

3. Diaphragmatic lesion

4. Mediastinal lesion

5. Hilar enlargement

6. Atelectasis

7. Segment and lobar opacity

8. Diffuse air-space opacity

9. Multifocal ill-defined opacity

10. Diffuse fine nodular opacity

11. Fine reticular opacity

12. Coarse reticular opacity

13. Solitary nodule

14. Multiple nodules

15. Hyperlucent abnormality

35

Steps of CXR reading

This is a plain, PA chest radiograph of Mr. Clause taken on the 25

December at the North Pole General Hospital.

The most obvious abnormality is the appearance of cardiomegaly.

I will focus on this after I have first studied the radiograph

systematically. The radiograph is correctly oriented and the exposure is

satisfactory. The patient is not rotated, There are no obvious

abnormalities within the bones. The trachea is not deviated. The

mediastinum has clearly defined borders and there is no enlargement or

change in density of it or the hilar regions. There is no CXR pathology in

the lung and they are expanded normally. The diaphragms are clearly

seen although there is blunting at the right costophrenic angle with a

meniscus suggesting a small effusion. There are no abnormalities below

the diaphragm or within the soft tissues. The cardiothoracic ratio exceeds

1:2. As this is a PA film, this confirms the heart is enlarge.

With regard to the cardiomegaly, four causes are IHD, VHD, pericardial

effusion, and cardiomyopathy.

這是王大川先生今年12月5日在本院拍攝PA view 的胸部X光片

最明顯異常的地方是在左肺上肺野可以看到一個腫塊。先全部系統性讀完整個片子以後再來討論這個腫塊部分。

拍攝時病人的位置正常，沒有歪斜，且在吸飽氣下拍攝，肺組織的影像清晰。

骨骼部份在鎖骨，肋骨部分沒有看見異常。

氣管在中央沒有偏移。

Aortic arch, ascending aorta, SVC, 和肺門血管正常大小。

心臟影像正常， mediastinum 沒有變寬。

兩邊橫膈高度正常。

肋膜腳尖銳，沒有看見鈍化積水現象。

肺野沒有異常病灶出現。

橫膈下肺部沒有異常陰影。

Chest X-Ray Reading

1. Give a Factual Report

– What you sees or think

– Position, size, shape, character, effect on surrounding

2. Diagrammatic Drawing

3. Interpretation

– Anatomical site, underlying pathological process

– Correlate any tentative conclusions with clinical

picture

Hsu-Tah Kuo,MD 39

Interpretation of Chest Lung Abnormality James C. Reed Chest Radiology

40

1. Find a true abnormality

2. Localize the abnormality soft tissue, chest wall, pleural, diaphragm, mediastinum,

hilum, peripheral vessels, or the lung parenchyma

3. Classified or describe the pattern patterns of parenchymal lung: nodule, mass,

diffuse opacity, cavity, calcification, atelectasis

4. Assess the distribution localized or diffuse, peripheral or central,

in the upper vs. lower lobe, or alveolar vs. interstitial

Algorithmic Application of Chest Patterns

James C. Reed Chest Radiology

41

1. Pattern identification

2. Differential diagnosis (all the categories of disease that might lead to the identified pattern)

3.Narrow the differential diagnosis by 1.Analysis of the film for additional radiologic findings

2.Evolving patterns of the disease by review of serial examinations

3.Correlation of the patterns with clinical and laboratory data

Hsu-Tah Kuo,MD


Large Air way Obstruction

42

Pneumothorax Inspiration, Expiration

Inspiration Expiration


氣胸呈現在胸腔的上方及外緣，看到如髮絲，不透亮的臟膜

少量的氣胸時，吐氣胸部攝影

Mackay Memorial Hospital. HT Kuo,MD


43

Thoracic Cage & Soft Tissue

Mammoplasty Kyphosis

44

Breast Shadow

45


Hepatoma and rib metastasis


Multiple myeloma

46


Mackay Memorial Hospital. HT Kuo,MD 48

Lung

Collapse


Lung Collapse


Lung Consolidation after Epistaxis


Mycoplasmal

pneumonia

52

Klebsiella

Pneumonia

訾 x 玲

2003/3/14 2003/3/18

2003/3/26 2003/3/30 53

54

Pulmonary TB

病史:

危險因素: DM, Alcoholism, immune abn., Aborigines, Family TB

好發部位: Apico-posterior seg., Superior segment of lower lobe

55

男 , 51, DM, Persistent cough for 3 months; BW loss 7

kg in 4 months; poor intake(+), Fever (-)

Pulmonary Tuberculosis

肺結核 – 兩側上肺葉浸潤肺結核 – 兩側上肺葉浸潤

粟粒性結核重度肺結核 56

57

Productive Fibrotic

Cavity Pleural Effusion Milinary

Calcified

Severity of Pulmonary TB

58

Far advanced degree

0 (正常), 1(輕度), 2(中度無空洞), 3(中度有空洞), 4(重度無空洞),

5(重度有空洞), 6(肋膜積水), 7(陳舊性肺結核)

59

TB treat 朱哲X

2002-12-30 2003-2-27

2003-4-18 2003-7-11

60

Follow up Chest x-Ray

Severe Acute Respiratory Syndrome (SARS)

61

MR

ML

HCVD

Radiographic Appearance of Cardiac

Pulmonary Edema LA Myxoma

62

大量胸水會把氣管、縱膈、心臟推到他側沒有出現推移 (1)endobronchial obstruction (Foreign body,neoplasm)

(2)Pleural adhesion, (3)Fixed mediastinum

Mackay Memorial Hospital Mackay Memorial Hospital


63

MR

ML

Radiographic Finding of Pleural Effusion Upright film Supine film

64

Empyema

Streptokinase inj 65

Intrathoracic Goiter Well-defined mass 把氣管推到另一側

ＣＴ可見甲狀腺自頸部延伸到縱膈甲狀腺影像密度不均勻，會有局部鈣化注射顯影劑後，甲狀腺的ＣＴ密度會增加; 放射碘核醫掃瞄



陳 X 招 88 F 66

Lymphoma 游 X 婷 18 yrs. F




67

Lung Cancer with Mediastinal Metastasis

Mediastinal mass contiguous with a lung

tumor; Tumor conduct > 1/4 circum of

the aortic wall ; tumor conduct > 3cm

mediastinum

LN > 1 cm Dx metastasis, Accuracy 70%.

Lung Ca 30% mediastinoscopy (-) have

LN metastasis at surgery.

T 4 diagnosis




68

Sarcoidosis

兩側對稱性淋巴結腫大. 最常發生在支氣管肺部淋巴結、右側氣管旁淋巴結, aorticopulmonary window



69

Aortic Aneurysm

Atherosclerosis

Hypertension

age>40

Mass at aortic contour

contiguous with the aorta.

Aortic dissection identify an

intimal flap



70

Achalasia 27 yrs F. Freq. choking



Bird beak appearance 71

Hiatal Hernia, Para-esophageal 陳 X 娥




72

Emphysema

Hyperinflation

1. Increase lung height

2. Flattened diaphragm

3. Retrosternal space >2.5cm

Hyperlucency of the lungs

Rapid tapering of the vascular

markings

73

74

Portable Chest X-ray

Endotracheal tube

Malpositioned CVP catheter

75

Pulmonary Artery Catheter

Tip in the interlobar pul

artery: <2 cm lateral to hilum

Complications:

– Malposition: too proximal or too distal (24%)

– Arrhythmia, cardiac damage

– Pulmonary hemorrhage, infarction

76

Malpositioned PA catheter

77

Pneumomediastinum and subcutaneous

emphysema - The early sign of barotrauma

78

Cardiomegaly , pulmonary vessel cephalization

79

Try to read this film

• Thorax

• A

• B

• C

• D

• E

• F

• G

Thorax A

B

C

D

E

F

G

80


• Thorax

• A

• B

• C

• D

• E

• F

• G

Thorax

A

B

C

D E

F

G 81


• Thorax

• A

• B

• C

• D

• E

• F

• G

A

B

C

D E

F

G

Thorax

82

Try to Read this film

• Thorax

• A

• B

• C

• D

• E

• F

• G

A

B

C

D

E

F

G

Thorax

83


• Thorax

• A

• B

• C

• D

• E

• F

• G

A

B

C

D E

F

G

Thorax

84


• Thorax

• A

• B

• C

• D

• E

• F

• G

A

B

C

D E

F

G

Thorax

85

86

Try to read

this film

• Thorax

• A

• B

• C

• D

• E

• F

• G

87

Try to read

this film

• Thorax

• A

• B

• C

• D

• E

• F

• G


• Thorax

• A

• B

• C

• D

• E

• F

• G

A

B

C

D E

F

G

Thorax

88


• Thorax

• A

• B

• C

• D

• E

• F

• G

89

判讀胸部X 光片

1.說出攝影為PA, AP,Lat. 如果照得不好指出缺失

2.估計大約年齡或性別

3.再按ABCDEFG 讀出正常或異常點

4.按照異常 pattern說出可能的疾病診斷

5. 可能再進一步的檢查或方法會幫忙診斷

91

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