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Chest X-ray Chest X-ray Interpretation Interpretation Bucky Boaz, ARNP-C

Chest X-ray Interpretation Bucky Boaz, ARNP-C. Introduction Routinely obtained Pulmonary specialist consultation Inherent physical exam limitations Chest

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Page 1: Chest X-ray Interpretation Bucky Boaz, ARNP-C. Introduction Routinely obtained Pulmonary specialist consultation Inherent physical exam limitations Chest

Chest X-rayChest X-rayInterpretationInterpretation

Bucky Boaz, ARNP-C

Page 2: Chest X-ray Interpretation Bucky Boaz, ARNP-C. Introduction Routinely obtained Pulmonary specialist consultation Inherent physical exam limitations Chest

IntroductionIntroduction

Routinely obtainedPulmonary specialist consultationInherent physical exam limitationsChest x-ray limitationsPhysical exam and chest x-ray provide

compliment

Page 3: Chest X-ray Interpretation Bucky Boaz, ARNP-C. Introduction Routinely obtained Pulmonary specialist consultation Inherent physical exam limitations Chest

Essentials Before Getting Essentials Before Getting StartedStarted

Exposure– Overexposure– Underexposure

Sex of Patient– Male– Female

Page 4: Chest X-ray Interpretation Bucky Boaz, ARNP-C. Introduction Routinely obtained Pulmonary specialist consultation Inherent physical exam limitations Chest

Essentials Before Getting Essentials Before Getting StartedStarted

Path of x-ray beam– PA– AP

Patient Position– Upright– Supine

Page 5: Chest X-ray Interpretation Bucky Boaz, ARNP-C. Introduction Routinely obtained Pulmonary specialist consultation Inherent physical exam limitations Chest

Essentials Before Getting Essentials Before Getting StartedStarted

Breath– Inspiration– Expiration

Page 6: Chest X-ray Interpretation Bucky Boaz, ARNP-C. Introduction Routinely obtained Pulmonary specialist consultation Inherent physical exam limitations Chest

Systematic ApproachSystematic Approach

Bony FrameworkSoft TissuesLung Fields and HilaDiaphragm and Pleural SpacesMediastinum and HeartAbdomen and Neck

Page 7: Chest X-ray Interpretation Bucky Boaz, ARNP-C. Introduction Routinely obtained Pulmonary specialist consultation Inherent physical exam limitations Chest

Systematic ApproachSystematic Approach

Bony Fragments– Ribs– Sternum– Spine– Shoulder girdle– Clavicles

Page 8: Chest X-ray Interpretation Bucky Boaz, ARNP-C. Introduction Routinely obtained Pulmonary specialist consultation Inherent physical exam limitations Chest

Systematic ApproachSystematic Approach

Soft Tissues– Breast shadows– Supraclavicular areas– Axillae– Tissues along side of

breasts

Page 9: Chest X-ray Interpretation Bucky Boaz, ARNP-C. Introduction Routinely obtained Pulmonary specialist consultation Inherent physical exam limitations Chest

Systematic ApproachSystematic Approach

Lung Fields and Hila– Hilum

Pulmonary arteries Pulmonary veins

– Lungs Linear and fine nodular

shadows of pulmonary vessels

– Blood vessels– 40% obscured by other

tissue

Page 10: Chest X-ray Interpretation Bucky Boaz, ARNP-C. Introduction Routinely obtained Pulmonary specialist consultation Inherent physical exam limitations Chest

Systematic ApproachSystematic Approach

Diaphragm and Pleural Surfaces– Diaphragm

Dome-shaped Costophrenic angles

– Normal pleural is not visible

– Interlobar fissures

Page 11: Chest X-ray Interpretation Bucky Boaz, ARNP-C. Introduction Routinely obtained Pulmonary specialist consultation Inherent physical exam limitations Chest

Systematic ApproachSystematic Approach

Mediastinum and Heart– Heart size on PA– Right side

Inferior vena cava Right atrium Ascending aorta Superior vena cava

Page 12: Chest X-ray Interpretation Bucky Boaz, ARNP-C. Introduction Routinely obtained Pulmonary specialist consultation Inherent physical exam limitations Chest

Systematic ApproachSystematic Approach

Mediastinum and Heart– Left side

Left ventricle Left atrium Pulmonary artery Aortic arch Subclavian artery and

vein

Page 13: Chest X-ray Interpretation Bucky Boaz, ARNP-C. Introduction Routinely obtained Pulmonary specialist consultation Inherent physical exam limitations Chest

Systematic ApproachSystematic Approach

Abdomen and Neck– Abdomen

Gastric bubble Air under diaphragm

– Neck Soft tissue mass Air bronchogram

Page 14: Chest X-ray Interpretation Bucky Boaz, ARNP-C. Introduction Routinely obtained Pulmonary specialist consultation Inherent physical exam limitations Chest

Summary of Density Summary of Density

Air Water Bone Tissue

Tissue

Page 15: Chest X-ray Interpretation Bucky Boaz, ARNP-C. Introduction Routinely obtained Pulmonary specialist consultation Inherent physical exam limitations Chest

Pitfalls to Chest X-ray Pitfalls to Chest X-ray InterpretationInterpretation

Poor inspirationOver or under penetrationRotationForgetting the path of the x-ray beam

Page 16: Chest X-ray Interpretation Bucky Boaz, ARNP-C. Introduction Routinely obtained Pulmonary specialist consultation Inherent physical exam limitations Chest

Lung AnatomyLung Anatomy

Trachea Carina Right and Left Pulmonary

Bronchi Secondary Bronchi Tertiary Bronchi Bronchioles Alveolar Duct Alveoli

Page 17: Chest X-ray Interpretation Bucky Boaz, ARNP-C. Introduction Routinely obtained Pulmonary specialist consultation Inherent physical exam limitations Chest

Lung AnatomyLung Anatomy

Right Lung– Superior lobe– Middle lobe– Inferior lobe

Left Lung– Superior lobe– Inferior lobe

Page 18: Chest X-ray Interpretation Bucky Boaz, ARNP-C. Introduction Routinely obtained Pulmonary specialist consultation Inherent physical exam limitations Chest

Lung Anatomy on Chest X-rayLung Anatomy on Chest X-ray

PA View:– Extensive overlap– Lower lobes extend

high

Lateral View:– Extent of lower lobes

Page 19: Chest X-ray Interpretation Bucky Boaz, ARNP-C. Introduction Routinely obtained Pulmonary specialist consultation Inherent physical exam limitations Chest

Lung Anatomy on Chest X-rayLung Anatomy on Chest X-ray

The right upper lobe (RUL) occupies the upper 1/3 of the right lung.

Posteriorly, the RUL is adjacent to the first three to five ribs.

Anteriorly, the RUL extends inferiorly as far as the 4th right anterior rib

Page 20: Chest X-ray Interpretation Bucky Boaz, ARNP-C. Introduction Routinely obtained Pulmonary specialist consultation Inherent physical exam limitations Chest

Lung Anatomy on Chest X-rayLung Anatomy on Chest X-ray

The right middle lobe is typically the smallest of the three, and appears triangular in shape, being narrowest near the hilum

Page 21: Chest X-ray Interpretation Bucky Boaz, ARNP-C. Introduction Routinely obtained Pulmonary specialist consultation Inherent physical exam limitations Chest

Lung Anatomy on Chest X-rayLung Anatomy on Chest X-ray

The right lower lobe is the largest of all three lobes, separated from the others by the major fissure.

Posteriorly, the RLL extend as far superiorly as the 6th thoracic vertebral body, and extends inferiorly to the diaphragm.

Review of the lateral plain film surprisingly shows the superior extent of the RLL.

Page 22: Chest X-ray Interpretation Bucky Boaz, ARNP-C. Introduction Routinely obtained Pulmonary specialist consultation Inherent physical exam limitations Chest

Lung Anatomy on Chest X-rayLung Anatomy on Chest X-ray

These lobes can be separated from one another by two fissures.

The minor fissure separates the RUL from the RML, and thus represents the visceral pleural surfaces of both of these lobes.

Oriented obliquely, the major fissure extends posteriorly and superiorly approximately to the level of the fourth vertebral body.

Page 23: Chest X-ray Interpretation Bucky Boaz, ARNP-C. Introduction Routinely obtained Pulmonary specialist consultation Inherent physical exam limitations Chest

Lung Anatomy on Chest X-rayLung Anatomy on Chest X-ray

The lobar architecture of the left lung is slightly different than the right.

Because there is no defined left minor fissure, there are only two lobes on the left; the left upper

Page 24: Chest X-ray Interpretation Bucky Boaz, ARNP-C. Introduction Routinely obtained Pulmonary specialist consultation Inherent physical exam limitations Chest

Lung Anatomy on Chest X-rayLung Anatomy on Chest X-ray

Left lower lobes

Page 25: Chest X-ray Interpretation Bucky Boaz, ARNP-C. Introduction Routinely obtained Pulmonary specialist consultation Inherent physical exam limitations Chest

Lung Anatomy on Chest X-rayLung Anatomy on Chest X-ray

These two lobes are separated by a major fissure, identical to that seen on the right side, although often slightly more inferior in location.

The portion of the left lung that corresponds anatomically to the right middle lobe is incorporated into the left upper lobe.

Page 26: Chest X-ray Interpretation Bucky Boaz, ARNP-C. Introduction Routinely obtained Pulmonary specialist consultation Inherent physical exam limitations Chest

The Normal Chest X-rayThe Normal Chest X-ray

PA View:1. Aortic arch2. Pulmonary trunk3. Left atrial appendage4. Left ventricle5. Right ventricle6. Superior vena cava7. Right hemidiaphragm8. Left hemidiaphragm9. Horizontal fissure

Page 27: Chest X-ray Interpretation Bucky Boaz, ARNP-C. Introduction Routinely obtained Pulmonary specialist consultation Inherent physical exam limitations Chest

The Normal Chest X-rayThe Normal Chest X-ray

Lateral View:1. Oblique fissure

2. Horizontal fissure

3. Thoracic spine and retrocardiac space

4. Retrosternal space

Page 28: Chest X-ray Interpretation Bucky Boaz, ARNP-C. Introduction Routinely obtained Pulmonary specialist consultation Inherent physical exam limitations Chest

The Silhouette SignThe Silhouette Sign

An intra-thoracic radio-opacity, if in anatomic contact with a border of heart or aorta, will obscure that border. An intra-thoracic lesion not anatomically contiguous with a border or a normal structure will not obliterate that border.

Page 29: Chest X-ray Interpretation Bucky Boaz, ARNP-C. Introduction Routinely obtained Pulmonary specialist consultation Inherent physical exam limitations Chest

Putting It All TogetherPutting It All Together

Page 30: Chest X-ray Interpretation Bucky Boaz, ARNP-C. Introduction Routinely obtained Pulmonary specialist consultation Inherent physical exam limitations Chest
Page 31: Chest X-ray Interpretation Bucky Boaz, ARNP-C. Introduction Routinely obtained Pulmonary specialist consultation Inherent physical exam limitations Chest

Understanding Pathological Understanding Pathological ChangesChanges

Most disease states replace air with a pathological process

Each tissue reacts to injury in a predictable fashion

Lung injury or pathological states can be either a generalized or localized process

Page 32: Chest X-ray Interpretation Bucky Boaz, ARNP-C. Introduction Routinely obtained Pulmonary specialist consultation Inherent physical exam limitations Chest

Liquid DensityLiquid Density

Liquid density Increased air density

Generalized Localized

Diffuse alveolarDiffuse interstitialMixedVascular

InfiltrateConsolidationCavitationMassCongestionAtelectasis

Localized airway obstructionDiffuse airway obstructionEmphysemaBulla

Page 33: Chest X-ray Interpretation Bucky Boaz, ARNP-C. Introduction Routinely obtained Pulmonary specialist consultation Inherent physical exam limitations Chest

ConsolidationConsolidation

Lobar consolidation:– Alveolar space filled with

inflammatory exudate– Interstitium and

architecture remain intact– The airway is patent– Radiologically:

A density corresponding to a segment or lobe

Airbronchogram, and No significant loss of lung

volume

Page 34: Chest X-ray Interpretation Bucky Boaz, ARNP-C. Introduction Routinely obtained Pulmonary specialist consultation Inherent physical exam limitations Chest

AtelectasisAtelectasis

Loss of air Obstructive atelectasis:

– No ventilation to the lobe beyond obstruction

– Radiologically: Density corresponding to a

segment or lobe Significant loss of volume Compensatory

hyperinflation of normal lungs

Page 35: Chest X-ray Interpretation Bucky Boaz, ARNP-C. Introduction Routinely obtained Pulmonary specialist consultation Inherent physical exam limitations Chest

Stages of Evaluating an Stages of Evaluating an AbnormalityAbnormality

1. Identification of abnormal shadows

2. Localization of lesion

3. Identification of pathological process

4. Identification of etiology

5. Confirmation of clinical suspension Complex problems

Introduction of contrast medium CT chest MRI scan

Page 36: Chest X-ray Interpretation Bucky Boaz, ARNP-C. Introduction Routinely obtained Pulmonary specialist consultation Inherent physical exam limitations Chest

Putting It Into PracticePutting It Into Practice

Page 37: Chest X-ray Interpretation Bucky Boaz, ARNP-C. Introduction Routinely obtained Pulmonary specialist consultation Inherent physical exam limitations Chest

Case 1Case 1

Page 38: Chest X-ray Interpretation Bucky Boaz, ARNP-C. Introduction Routinely obtained Pulmonary specialist consultation Inherent physical exam limitations Chest
Page 39: Chest X-ray Interpretation Bucky Boaz, ARNP-C. Introduction Routinely obtained Pulmonary specialist consultation Inherent physical exam limitations Chest

A single, 3cm relatively thin-walled cavity is noted in the left midlung. This finding is most typical of squamous cell carcinoma (SCC). One-third of SCC masses show cavitation

Page 40: Chest X-ray Interpretation Bucky Boaz, ARNP-C. Introduction Routinely obtained Pulmonary specialist consultation Inherent physical exam limitations Chest

Case 2Case 2

Page 41: Chest X-ray Interpretation Bucky Boaz, ARNP-C. Introduction Routinely obtained Pulmonary specialist consultation Inherent physical exam limitations Chest
Page 42: Chest X-ray Interpretation Bucky Boaz, ARNP-C. Introduction Routinely obtained Pulmonary specialist consultation Inherent physical exam limitations Chest

LUL Atelectasis: Loss of heart borders/silhouetting. Notice over inflation on unaffected lung

Page 43: Chest X-ray Interpretation Bucky Boaz, ARNP-C. Introduction Routinely obtained Pulmonary specialist consultation Inherent physical exam limitations Chest

Case 3Case 3

Page 44: Chest X-ray Interpretation Bucky Boaz, ARNP-C. Introduction Routinely obtained Pulmonary specialist consultation Inherent physical exam limitations Chest
Page 45: Chest X-ray Interpretation Bucky Boaz, ARNP-C. Introduction Routinely obtained Pulmonary specialist consultation Inherent physical exam limitations Chest

Right Middle and Left Upper Lobe Pneumonia

Page 46: Chest X-ray Interpretation Bucky Boaz, ARNP-C. Introduction Routinely obtained Pulmonary specialist consultation Inherent physical exam limitations Chest

Case 4Case 4

Page 47: Chest X-ray Interpretation Bucky Boaz, ARNP-C. Introduction Routinely obtained Pulmonary specialist consultation Inherent physical exam limitations Chest
Page 48: Chest X-ray Interpretation Bucky Boaz, ARNP-C. Introduction Routinely obtained Pulmonary specialist consultation Inherent physical exam limitations Chest

Cavitation:cystic changes in the area of consolidation due to the bacterial destruction of lung tissue. Notice air fluid level.

Page 49: Chest X-ray Interpretation Bucky Boaz, ARNP-C. Introduction Routinely obtained Pulmonary specialist consultation Inherent physical exam limitations Chest

Cavitation

Page 50: Chest X-ray Interpretation Bucky Boaz, ARNP-C. Introduction Routinely obtained Pulmonary specialist consultation Inherent physical exam limitations Chest

Case 5Case 5

Page 51: Chest X-ray Interpretation Bucky Boaz, ARNP-C. Introduction Routinely obtained Pulmonary specialist consultation Inherent physical exam limitations Chest
Page 52: Chest X-ray Interpretation Bucky Boaz, ARNP-C. Introduction Routinely obtained Pulmonary specialist consultation Inherent physical exam limitations Chest

Tuberculosis

Page 53: Chest X-ray Interpretation Bucky Boaz, ARNP-C. Introduction Routinely obtained Pulmonary specialist consultation Inherent physical exam limitations Chest

Case 6Case 6

Page 54: Chest X-ray Interpretation Bucky Boaz, ARNP-C. Introduction Routinely obtained Pulmonary specialist consultation Inherent physical exam limitations Chest
Page 55: Chest X-ray Interpretation Bucky Boaz, ARNP-C. Introduction Routinely obtained Pulmonary specialist consultation Inherent physical exam limitations Chest

COPD: increase in heart diameter, flattening of the diaphragm, and increase in the size of the retrosternal air space. In addition the upper lobes will become hyperlucent due to destruction of the lung tissue.

Page 56: Chest X-ray Interpretation Bucky Boaz, ARNP-C. Introduction Routinely obtained Pulmonary specialist consultation Inherent physical exam limitations Chest

Chronic emphysema effect on the lungs

Page 57: Chest X-ray Interpretation Bucky Boaz, ARNP-C. Introduction Routinely obtained Pulmonary specialist consultation Inherent physical exam limitations Chest

Case 7Case 7

Page 58: Chest X-ray Interpretation Bucky Boaz, ARNP-C. Introduction Routinely obtained Pulmonary specialist consultation Inherent physical exam limitations Chest
Page 59: Chest X-ray Interpretation Bucky Boaz, ARNP-C. Introduction Routinely obtained Pulmonary specialist consultation Inherent physical exam limitations Chest

Pseudotumor: fluid has filled the minor fissure creating a density that resembles a tumor (arrow). Recall that fluid and soft tissue are indistinguishable on plain film. Further analysis, however, reveals a classic pleural effusion in the right pleura. Note the right lateral gutter is blunted and the right diaphram is obscurred.

Page 60: Chest X-ray Interpretation Bucky Boaz, ARNP-C. Introduction Routinely obtained Pulmonary specialist consultation Inherent physical exam limitations Chest

Case 8Case 8

Page 61: Chest X-ray Interpretation Bucky Boaz, ARNP-C. Introduction Routinely obtained Pulmonary specialist consultation Inherent physical exam limitations Chest
Page 62: Chest X-ray Interpretation Bucky Boaz, ARNP-C. Introduction Routinely obtained Pulmonary specialist consultation Inherent physical exam limitations Chest

Pneumonia:a large pneumonia consolidation in the right lower lobe. Knowledge of lobar and segmental anatomy is important in identifying the location of the infection

Page 63: Chest X-ray Interpretation Bucky Boaz, ARNP-C. Introduction Routinely obtained Pulmonary specialist consultation Inherent physical exam limitations Chest

Case 9Case 9

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Page 65: Chest X-ray Interpretation Bucky Boaz, ARNP-C. Introduction Routinely obtained Pulmonary specialist consultation Inherent physical exam limitations Chest

CHF:a great deal of accentuated interstitial markings, Curly lines, and an enlarged heart. Normally indistinct upper lobe vessels are prominent but are also masked by interstitial edema.

Page 66: Chest X-ray Interpretation Bucky Boaz, ARNP-C. Introduction Routinely obtained Pulmonary specialist consultation Inherent physical exam limitations Chest

24 hours after diuretic therapy

Page 67: Chest X-ray Interpretation Bucky Boaz, ARNP-C. Introduction Routinely obtained Pulmonary specialist consultation Inherent physical exam limitations Chest

Case 10Case 10

Page 68: Chest X-ray Interpretation Bucky Boaz, ARNP-C. Introduction Routinely obtained Pulmonary specialist consultation Inherent physical exam limitations Chest
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Chest wall lesion: arising off the chest wall and not the lung

Page 70: Chest X-ray Interpretation Bucky Boaz, ARNP-C. Introduction Routinely obtained Pulmonary specialist consultation Inherent physical exam limitations Chest

Case 11Case 11

Page 71: Chest X-ray Interpretation Bucky Boaz, ARNP-C. Introduction Routinely obtained Pulmonary specialist consultation Inherent physical exam limitations Chest
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Pleural effusion: Note loss of left hemidiaphragm. Fluid drained via thoracentesis

Page 73: Chest X-ray Interpretation Bucky Boaz, ARNP-C. Introduction Routinely obtained Pulmonary specialist consultation Inherent physical exam limitations Chest

Case 12Case 12

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Lung Mass

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Case 13Case 13

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Small Pneumothorax: LUL

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Case 15Case 15

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Right Middle Lobe Pneumothorax: complete lobar collapse

Page 82: Chest X-ray Interpretation Bucky Boaz, ARNP-C. Introduction Routinely obtained Pulmonary specialist consultation Inherent physical exam limitations Chest

Post chest tube insertion and re-expansion

Page 83: Chest X-ray Interpretation Bucky Boaz, ARNP-C. Introduction Routinely obtained Pulmonary specialist consultation Inherent physical exam limitations Chest

Case 16Case 16

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Metastatic Lung Cancer: multiple nodules seen

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Case 17Case 17

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Right upper lower lobe pulmonary nodule

Page 89: Chest X-ray Interpretation Bucky Boaz, ARNP-C. Introduction Routinely obtained Pulmonary specialist consultation Inherent physical exam limitations Chest

Case 18Case 18

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Tuberculosis

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Case 19Case 19

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Perihilar mass: Hodgkin’s disease

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Case 20Case 20

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Widened Mediastinum: Aortic Dissection

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Case 21Case 21

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Pulmonary artery stenosis with cardiomegally likely secondary to stenosis.

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Questions?Questions?