Presentation Chest X Rays

8/19/2019 Presentation Chest X Rays

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Chest X-rays

Basic to Intermediate Interpretation

Phillip Smith, BA, RRT


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Three +ain )actors Determine the Technical ualityo the Radiograph

• Inspiration

• Penetration

•

Rotation


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Inspiration

The chest radiograph should "eo"tained ith the patient in ullinspiration to help assess

intrapulmonary a"normalities#

At ull inspiration, the diaphragm

should "e o"served at a"out the levelo the .th to /0th ri" posteriorly, or the1th to 2th ri" anteriorly#


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Penetration

3n a properly e4posed chest radiograph'

• The loer thoracic verte"rae should "e visi"le through the heart

• The "ronchovascular structures "ehind

the heart $trachea, aortic arch,pulmonary arteries, etc#& should "e seen


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5ndere4posure

In an undere4posed chest radiograph,the cardiac shado is opa6ue, ithlittle or no visi"ility o the thoracic

verte"rae#

The lungs may appear much denserand hiter, much as they mightappear ith in7ltrates present#


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3vere4posure

*ith greater e4posure o the chestradiograph, the heart "ecomes moreradiolucent and the lungs "ecome

proportionately dar%er#

In an overe4posed chest radiograph, the air-7lled lung periphery "ecomes e4tremelyradiolucent, and oten gives the appearanceo lac%ing lung tissue, as ould "e seen in acondition such as emphysema#


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Rotation

Patient rotation can "e assessed "yo"serving the clavicular heads anddetermining hether they are e6ualdistance rom the spinous processes othe thoracic verte"ral "odies#


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)our ma8or positions are utili9ed orproducing a chest radiograph'

• Posterior-anterior $PA&

• :ateral

•

Anterior-posterior $AP&

• :ateral Decu"itus


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Posterioranterior $PA&Position

• The standard position or o"taining a routineadult chest radiograph

• Patient stands upright ith the anterior chestplaced against the ront o the 7lm

• The shoulders are rotated orard enough totouch the 7lm, ensuring that the scapulae do noto"scure a portion o the lung 7elds

• 5sually ta%en ith the patient in ull inspiration

• The PA 7lm is vieed as i the patient is standingin ront o you ith his;her right side on your let


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:ateral Position

• Patient stands upright ith the let sideo the chest against the 7lm and thearms raised over the head

• Allos the vieer to see "ehind theheart and diaphragmatic dome

• Is typically used in con8unction ith a PA

vie o the same chest to help determinethe three-dimensional position o organsor a"normal densities


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Anteriorposterior $AP&Position

• 5sed hen the patient is de"ilitated,immo"ili9ed, or una"le to cooperate ith thePA procedure

•

The 7lm is placed "ehind the patient


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:ateral Decu"itus Position

• The patient lies on either the right or let siderather than in the standing position as ith aregular lateral radiograph

•

The radiograph is la"eled according to the sidethat is placed don $a let lateral decu"itusradiograph ould have the patient


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Anatomical Structures inthe Chest

• +ediastinum

• =ilum

•

:ung )ields• Diaphragmatic Domes

• Pleural Suraces

•

Bones• Sot Tissue


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+ediastinum

• The trachea should "e centrally located orslightly to the right

• The aortic arch is the 7rst conve4ity on the

let side o the mediastinum• The pulmonary artery is the ne4t conve4ity

on the let, and the "ranches should "etracea"le as it ans out through the lungs

• The lateral margin o the superior venacava lies a"ove the right heart "order


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The =eart

• To-thirds o the heart should lie on the letside o the chest, ith one-third on the right

• The heart should ta%e up less that hal o

the thoracic cavity $C;T ratio > 10?&• The let atrium and the let ventricle create

the let heart "order

• The right heart "order is created entirely "y

the right atrium $the right ventricle liesanteriorly and, thereore, does not have a"order on the PA&


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=ilum

• The hila consist primarily o thema8or "ronchi and the pulmonary

veins and arteries

• The hila are not symmetrical, "utcontain the same "asic structures oneach side

• The hila may "e at the same level,"ut the let hilum is commonlyhigher than the right

• Both hila should "e o similar si9e


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:ungs

• @ormally, there are visi"le mar%ingsthroughout the lungs due to thepulmonary arteries and veins,

continuing all the ay to the chestall

• Both lungs should "e scanned,

starting at the apices and or%ingdonard, comparing the let andright lung 7elds at the same level $as

is done ith ascultation&


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:ungs

• 3n a PA radiograph, the minor7ssure can oten "e seen as a ainthori9ontal line dividing the R+:

rom the R5:#• The ma8or 7ssures are not usually

seen on a PA vie "ecause they are

"eing vieed o"li6uely#


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Diaphragm

• The let dome is normally slightly loer thanthe right due to elevation "y the liver, located

under the right hemidiaphragm#• The costophrenic recesses are ormed "y the

hemidiaphragms and the chest all#

• 3n the PA radiograph, the costophrenic recess

is seen only on each side here an angle isormed "y the lateral chest all and the domeo each hemidiaphragm $costophrenic angle


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Pleura

• The pleura and pleural spaces illonly "e visi"le hen there is ana"normality present

• Common a"normalities seen iththe pleura include pleuralthic%ening, or uid or air in thepleural space#


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Sot Tissue

Thic% sot tissue may o"scure underlyingstructures'

• Thic% sot tissue due to o"esity may

o"scure some underlying structures suchas lung mar%ings

• Breast tissue may o"scure thecostophrenic angles

:ucencies ithin sot tissue may representgas $as o"served ith su"cutaneous air&


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Bones

The "ones visi"le in the chest radiograph include'

• Ri"s

• Clavicles

•

Scapulae• erte"rae

• Pro4imal humeri

The "ones are useul as mar%ers to assess patientrotation, ade6uacy o inspiration, and 4-raypenetration#


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Descri"ing A"normal )indings on aChest Radiograph

• *hen addressing an a"normal 7nding ona chest radiograph, only a description ohat is seen, rather than a diagnosis,

should "e presented $a chest radiographalone is not diagnostic, "ut is only onepiece o descriptive inormation used toormulate a diagnosis&

• Descriptive ords such as shados,density, or patchiness, should "e used todiscuss the 7ndings


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Common A"normal )indings on Chest Radiographs


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Silhouette Sign

• The loss o the lung;sot tissueinterace due to the presence o uidin the normally air-7lled lung

• I an intrathoracic opacity is inanatomic contact ith a "order, thenthe opacity ill o"scure that "order

• Commonly seen ith the "orders othe heart, aorta, chest all, anddiaphragm


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Air Bronchogram

A tu"ular outline o an airay made visi"le due tothe 7lling o the surrounding alveoli "y uid orinammatory e4udates

Conditions in hich air "ronchograms are seen'

• :ung consolidation

• Pulmonary edema

• @on-o"structive pulmonary atelectasis

• Interstitial disease

• @eoplasm

• @ormal e4piration


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Consolidation

The lung is said to "e consolidated henthe alveoli and small airays are 7lledith dense material#

This dense material may consist o'

• Pus $pneumonia&

•

)luid $pulmonary edema&• Blood $pulmonary hemorrhage&

• Cells $cancer&


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Atelectasis

• Almost alays associated ith alinear increased density due to

volume loss

• Indirect indications o volume lossinclude vascular croding ormediastinal shit toard the collapse

• Possi"le o"servance o hilarelevation ith an upper lo"ecollapse, or a hilar depression ith a

loer lo"e collapse


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Pneumonia

Typical 7ndings on the chestradiograph include'

• Airspace opacity

• :o"ar consolidation

• Interstitial opacities


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Pleural !usion

3n an upright 7lm, an e!usion ill cause "lunting onthe lateral costophrenic sulcus and, i large enough, onthe posterior costophrenic sulcus#

• Appro4imately 00 ml o uid are needed to detect an

e!usion in a PA 7lm, hile appro4imately E1 ml ouid ould "e visi"le in the lateral vie

In the AP 7lm, an e!usion ill appear as a graded ha9ethat is denser at the "ase

A lateral decu"itus 7lm is helpul in con7rming ane!usion as the uid ill collect on the dependent side


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Pneumothora4

• Appears in the chest radiograph asair ithout lung mar%ings

• In a PA 7lm it is usually seen in the

apices since the air rises to the leastdependent part o the chest

• The air is typically ound peripheral

to the hite line o the visceralpleura

• Best demonstrated "y an e4piration

7lm


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Pulmonary dema

There are to "asic types o pulmonaryedema'

• Cardiogenic pulmonary edema caused

"y increased hydrostatic pulmonarycapillary pressure

• @oncardiogenic pulmonary edema

caused "y either altered capillarymem"rane permea"ility or decreasedplasma oncotic pressure


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Congestive =eart )ailure

Common eatures o"served on thechest radiograph o a C=) patientinclude'

• Cardiomegaly $cardiothoracic ratioF 10?&

• Cephali9ation o the pulmonary veins

• Appearance o Gerley B lines

• Alveolar edema oten present in aclassis perihilar "at ing pattern o

density


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mphysema

Common eatures seen on the chestradiograph include'

• =yperination ith attening o the

diaphragms

• Increased retrosternal space

• Bullae

• nlargement o PA;R $corpulmonale&


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:ung +ass

A lung mass ill typically present as alesion ith sharp margins and ahomogenous appearance, in contrastto the di!use appearance o an

in7ltrate#


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Presentation Chest X Rays