COPD and Chest X-Ray Findings

Podcast

Play an AI-generated podcast conversation about this lesson

Questions and Answers

What radiographic quality is crucial for ensuring that both lungs are included in the image?

Artifact elimination

Collimation and centering (correct)

Proper contrast adjustment

Markers for anatomical identification

Which anatomical structure is assessed to determine proper trachea positioning in a chest radiograph?

Ribs

Costophrenic angles

Clavicles

Spinous processes (correct)

Which artifact is least likely to interfere with the visibility of lung markings on a chest x-ray?

Background noise from the imaging system (correct)

Medical devices inside the patient

Jewelry worn by the patient

Grid lines from equipment

What positioning error is indicated by the medial ends of the clavicles being uneven in relation to the spinous processes?

Over-rotation of the patient Signup and view all the answers

What is a crucial aspect of supine A.P. abdomen positioning to ensure optimal radiographic results?

Mid pubic symphysis must be included. Signup and view all the answers

What anatomy should be visualized clearly to adequately assess the presence of a hiatus hernia in a chest radiograph?

Diaphragm details Signup and view all the answers

Which of the following structures is NOT considered part of the small bowel?

Rectum Signup and view all the answers

Which aspect of radiographic exposure is essential for visualizing lung markings adequately?

Sufficient contrast and density Signup and view all the answers

In the context of abdominal organ anatomy, which region does the hepatic flexure belong to?

Large bowel Signup and view all the answers

Which feature suggests an inappropriate inspiratory effort in a chest x-ray?

Less than 8 posterior ribs visible Signup and view all the answers

What is the significance of demonstrating the psoas muscle clearly in a supine A.P. abdomen radiographic image?

Helps assess for possible abdominal rotation. Signup and view all the answers

What could be indicated by faint shadows of ribs and thoracic vertebrae seen through the heart shadow in a radiographic evaluation?

Presence of cardiac failure Signup and view all the answers

Which catheter is typically used for temporary access to the central venous system?

Internal jugular line Signup and view all the answers

What positioning criterion is essential for minimizing rotation in abdominal imaging?

Ensure pelvic symmetry. Signup and view all the answers

Which abdominal structure is located at the inferior costal margin in surface anatomy?

Spleen Signup and view all the answers

In discussions about hiatus hernia implications, what common symptom is often associated with this condition?

Persistent reflux Signup and view all the answers

What radiographic positioning technique is used for a patient lying flat with the midsagittal plane centered to the image receptor?

Supine position Signup and view all the answers

Which condition is characterized by abnormal permanent enlargement of the airspaces and alveolar wall destruction?

COPD - Emphysema Signup and view all the answers

What is a common radiologic appearance associated with congestive cardiac failure?

Fluid in the lungs Signup and view all the answers

Which type of hernia involves the upper portion of the stomach herniating through the esophageal hiatus?

Hiatus hernia Signup and view all the answers

Which finding on a chest X-ray indicates a significant pleural effusion?

Radiopaque meniscus at costo-phrenic angle Signup and view all the answers

What is the primary characteristic of a tension pneumothorax seen on imaging?

Deviation of the trachea Signup and view all the answers

Which of the following is NOT a symptom of COPD - emphysema?

Chest pain Signup and view all the answers

In the context of lung cancer, which type of carcinoma is mostly found in peripheral masses?

Adenocarcinoma Signup and view all the answers

What effect does a large pleural effusion typically have on the lung?

Causes lung collapse Signup and view all the answers

What does a chest radiograph taken with the patient in an erect position help to visualize regarding pleural effusion?

Air-fluid interfaces Signup and view all the answers

What is necessary to ensure that the diaphragm's sharp outlines are visible in a chest radiograph?

Sufficient inspiratory effort Signup and view all the answers

Which positioning error is indicated by the projection of the clavicles not being equidistant from the spinous processes?

Patient rotation Signup and view all the answers

What does the presence of faint shadows of the ribs and thoracic vertebrae through the heart shadow typically indicate?

Proper exposure and contrast Signup and view all the answers

Which of the following is NOT a recommended quality criterion for chest radiography?

Use of a lateral view for all patients Signup and view all the answers

Which artifact is most likely to occur from the presence of jewelry on a patient during a radiographic exam?

Exposure error Signup and view all the answers

What does proper collimation in chest imaging ensure?

Avoidance of radiation exposure to other areas Signup and view all the answers

What might indicate a medical error during a radiographic exam?

Dead pixels appearing in the image Signup and view all the answers

What is indicated by a good inspiratory effort during a chest x-ray?

8-10 posterior ribs visible above the diaphragm Signup and view all the answers

Which anatomical feature must be considered when ensuring proper collimation in a chest radiograph?

Costophrenic angles Signup and view all the answers

What is a critical factor for assessing proper shoulder rotation in a chest radiograph?

Scapulae position Signup and view all the answers

What specific view is taken to evaluate the left and right lungs distinctly?

Lateral Signup and view all the answers

How does the automatic exposure control (AEC) function in radiography?

It terminates exposure based on ionization levels in a chamber. Signup and view all the answers

Which part of the airway is not typically highlighted in chest imaging?

Larynx Signup and view all the answers

What should be demonstrated to confirm proper inspiration in a chest x-ray?

Ten posterior ribs visible above the diaphragm Signup and view all the answers

What is a necessary consideration for using anti-scatter grids during imaging?

They should not be angled against grid lines. Signup and view all the answers

What imaging strategy is not effective for visualizing structures in the mediastinum?

Supine AP view Signup and view all the answers

Which grid type is specifically designed to eliminate fine grid lines in X-ray images?

Moving/oscillating grids Signup and view all the answers

Which structure is primarily responsible for visualizing pulmonary vasculature during imaging?

Great vessels Signup and view all the answers

Which of the following should NOT be present in a quality chest radiograph?

Trachea displaced to one side Signup and view all the answers

What determines the selection of AEC chambers by the radiographer?

Anatomy being examined Signup and view all the answers

What is a primary characteristic of the AP erect positioning for chest radiography?

The x-ray receptor is positioned behind the patient, aligned with the mid-sagittal plane. Signup and view all the answers

Which anatomical structures should be clearly demonstrated in a basic chest projection?

Apices, clavicles, and superior lung regions. Signup and view all the answers

What distortion of ribs is noted in a properly executed AP axial projection?

Anterior and posterior portions of the ribs are superimposed. Signup and view all the answers

What is the primary reason for choosing a left lateral decubitus position for abdominal radiography?

To visualize fluid levels effectively. Signup and view all the answers

Which positioning error is indicated if the clavicles are not horizontal in the radiograph?

Excessive rotation of the patient. Signup and view all the answers

Which of the following is NOT a criteria for proper left lateral decubitus abdomen imaging?

Only right side of the abdomen shown. Signup and view all the answers

What is the typical central ray direction for the AP erect position in chest imaging?

Caudally angled at 5-10°. Signup and view all the answers

What is the recommended breathing technique during a left lateral decubitus abdomen radiograph?

Breathe out and hold. Signup and view all the answers

What aspect of radiographic quality is essential for the visualization of lung markings?

Sufficient contrast and density. Signup and view all the answers

Which anatomical structure should be clearly shown in a left lateral decubitus position if the patient's habitus allows?

Psoas muscle. Signup and view all the answers

What is the positioning criterion for achieving optimal clarity of the apical and clavicular shadows?

Performing an AP axial projection. Signup and view all the answers

What is the consequence of failing to achieve pelvic symmetry during left lateral decubitus imaging?

Inaccurate assessment of abdominal organs. Signup and view all the answers

What occurs when ribs are visualized faintly over the heart in a chest radiograph?

Optimal exposure allowing for both bone and soft tissue visualization. Signup and view all the answers

Which setting is recommended for achieving optimal image quality in left lateral decubitus abdomen radiography?

Wide window width. Signup and view all the answers

Which marker is essential to indicate in left lateral decubitus imaging?

Side and position. Signup and view all the answers

In a left lateral decubitus abdomen imaging, what should be notably included in the film capture?

As much of the diaphragm as possible. Signup and view all the answers

What is the appropriate kVp range for a prone P.A. abdomen positioning?

75 kVp, +/- 5 Signup and view all the answers

Which element is crucial to ensure nil rotation in a prone P.A. abdomen radiograph?

Symmetric pelvic alignment Signup and view all the answers

What landmark should be included in the collimation for a left lateral decubitus abdomen positioning?

Iliac crests Signup and view all the answers

In a left lateral decubitus abdomen positioning, where should the central ray (CR) be directed?

Mid-sagittal plane, half-way between the lower costal margins and the iliac crests Signup and view all the answers

What is the proper instruction to give a patient when conducting an erect A.P. abdomen imaging?

Breathe out, and hold it out Signup and view all the answers

Which anatomical structure needs to be visualized in an erect A.P. abdomen radiograph when assessing for fluid levels?

Diaphragm Signup and view all the answers

What should be properly marked to signify the correct positioning in a left lateral decubitus abdomen radiograph?

Direction of the horizontal beam Signup and view all the answers

What should be ensured regarding the exposure settings when conducting an abdomen imaging series?

Standard mAs should be roughly 30 mAs or use center-cell AEC Signup and view all the answers

Study Notes

Supine Positioning

Patient lying flat
Midsagittal plane in centre of Image Receptor (IR)
IR under back/trolley recess/bucky
Centre beam to IR under bed/in bucky
Caudal angle 5-10° (perpendicular to sternum)
Reduced Focal Film Distance (FFD)

Pathology

Chronic Obstructive Pulmonary Disease (COPD)
Emphysema
Pneumonia/infection
Cancer
Pleural effusion
Pneumothorax
Cardiomegaly
Tubes, lines & clips
Hiatus hernia

COPD - Emphysema

Chronic Obstructive Pulmonary Disease (COPD)
- Emphysema
- Chronic bronchitis
Abnormal permanent enlargement of the airspaces and alveolar wall destruction
90% of all cases caused by smoking
Symptoms: Dyspnea, coughing, wheezing

COPD - Emphysema Findings on CXR

Lung hyperinflation
Flattened hemidiaphragms
Increase in size of retrosternal air space

Pneumonia/Infection

Alveolar air replaced with fluid
Obscures lung markings
Airspace opacification - Consolidation
Patchy or extensive
+/- atelectasis (collapse)
Air bronchograms in progressive disease

Endotracheal Tube (ETT)

Endotracheal Tube (ETT)

Pneumonia - COVID 19

Pneumonia - COVID-19

Cancer

CXR is usually first investigation performed to investigate concerning symptoms
CXR cannot determine invasive features of lesions
CT used for complete staging
Masses may be central or peripheral
- Central: Mostly squamous cell carcinoma and small cell carcinoma
- Peripheral: Mostly adenocarcinoma and large cell carcinoma

Lung Cancer - Hilar Mass

Right hilum abnormal
Mediastinum widened due to lymph node enlargement
Pleural effusion also present

Right Upper Lobe Collapse

Dense opacity in right upper zone due to lobar collapse
Highly likely that a mass is obstructing the right upper lobe bronchus

Pulmonary Metastases

Secondary malignant tumours
Originate from cancer in separate organ
Single or multiple rounded nodules
Peripheral distribution and usually bilateral

Pleural Effusion

Accumulation of fluid in the pleural space
Erect position (supine and semi-erect radiographs mask findings)
On an erect radiograph:
- Small volume only seen on lateral CXR (posterior costo-phrenic recess)
- 250ml - radiopaque meniscus at costo-phrenic angle(s)
- Large volume - can create mass effect and collapse
Causes: Infection | heart failure | malignancy | cirrhosis

Small Pleural Effusion

Pneumothorax/PTX

Spontaneous | Traumatic | Tension
Sudden, often severe onset chest pain and SOB
Air in pleural space (Commonly apical on erect radiograph)
- Lung edge visible with no lung markings peripheral
- Collapse of lung (towards hilum)
Closed or penetrating
- Penetrating: rib # +/- subcutaneous emphysema
Intercostal catheter (ICC) used to drain large volume

Spontaneous Pneumothorax

Young
Fit
Male
Tall and thin build

Tension Pneumothorax

Air collection constantly enlarging
Deviation of the trachea
Compression of the contralateral side
Mediastinal shift
ICC inserted to drain air from pleural space

Inspiration/Expiration

Inspiration/Expiration with Sharp filter applied

Cardiac Failure

Congestive cardiac failure (CCF) | congestive heart failure (CHF) | heart failure (HF)
Cardio-ventricular dysfunction - unable to pump blood sufficiently for body’s needs
Right/Left ventricular failure
Radiologic appearance- fluid in the lungs, cardiomegaly, pleural effusion

Cardiomegaly

Cardiothoracic Ratio (CTR)

Hiatus Hernia

Upper portion of the stomach herniates through the oesophageal hiatus
At least one less rib visible on expiration
Sharp outlines of heart and diaphragm
Faint shadows of the ribs and superior thoracic vertebrae visible through the heart shadow
Lung markings visible from the hilum to the periphery of the lung
Pain | reflux | medication

Tubes, lines & clips/wires

Tubes
- Endotracheal tube (ETT)
- Naso-gastric tube (NGT)
- Intercostal catheter (ICC) - chest drain
Central venous catheters (CVC)
- Peripherally inserted central catheter (PICC)
- Internal jugular line
- Implantable ports
Clips/wires
- Sternal sutures/wires
- ECG clips and wires
- Pacemaker

Pacemaker

Radiographic Critique - Chest

Quality Criteria:
- Markers
- Artefact
- Anatomy
- Collimation and Centring
- Positioning
- Exposure

The Abdomen

Anatomy and Surface Anatomy

Gastrointestinal Anatomy (Lower)

- Stomach
- Small Bowel
    - Duodenum
    - Jejunum
    - Ileum
- Large Bowel
    - Caecum
    - Ascending Colon
    - Transverse Colon
    - Descending Colon
    - Sigmoid / Rectum
     - Appendix

Abdominal Surface Anatomy

Xiphoid
Inferior Costal Margin
Iliac Crest
ASIS
Greater Trochanter
Symphysis Pubis
Ischial Tuberosity

Divisions of the Abdomen

Abdominal Organs

Thoracic Organs

Abdominal / Thoracic Interface: The Diaphragm

Abdominal Organs: Gastrointestinal

Abdominal Organs: Spleen

Abdominal Organs: Liver

Abdominal Organs: Genitourinary

Abdominal Organs: Psoas Muscle

The A.P.Supine Abdomen.

Supine A.P.Abdomen Positioning

The Supine A.P.Abdomen Critique.

As much diaphragm shown as possible.
Mid pubic symphysis included.
Psoas muscle seen, if habitus allows.
Nil rotation (pelvic symmetry).
Wide window width.
Markers to indicate side and position

The P.A.Prone Abdomen.

Bony Anatomy

The chest is made up of two parts: the anterior and the posterior
Anterior chest is made up of the clavicle, sternum, and sternocostal articulations
Posterior chest is made up of 12 thoracic vertebrae, 12 paired ribs, and 2 scapulae

Visceral Anatomy

The chest contains the airway, lungs, and mediastinum, including the heart and great vessels
The diaphragm separates the chest from the abdomen

Airway

Airway is made up of the trachea, bronchi, and bronchioles
The trachea bifurcates at the carina into the right and left main bronchi
The right main bronchus is wider, shorter and straighter than the left main bronchus
The right lung has 3 lobes: superior, middle, and inferior
The left lung has 2 lobes: superior and inferior

Standard Chest Series

The standard chest series includes a PA projection and a lateral projection

PA Chest

The PA chest projection should show:
- Evidence of proper collimation
- Entire lung fields from the apices to the costophrenic angles
- No rotation
- Sternal ends of the clavicles equidistant from the vertebral column
- Trachea visible in the midline
- Equal distance from the vertebral column to the lateral border of the ribs on each side
- Proper shoulder rotation demonstrated by scapulae projected outside the lung fields
- Proper inspiration demonstrated by ten posterior ribs visible above the diaphragm
- Sharp outlines of heart and diaphragm
- Faint shadows of the ribs and superior thoracic vertebrae visible through the heart shadow
- Lung markings visible from the hilum to the periphery of the lung

Lateral Chest

The lateral chest projection should show:
- The entire lung fields from the apices to the costophrenic angles
- The posterior costophrenic recesses
- The right and left hilum and their positions
- The heart and its borders

Automatic Exposure Control (AEC)

AEC uses ionization chambers to terminate the radiation exposure
The radiographer selects the chambers based on the anatomy being imaged
AEC helps keep exposure as low as possible while still delivering adequate detail

Scatter Removal Grids

Scatter removal grids are used to reduce scatter radiation and improve image contrast
Grids are placed between the patient and the detector
Focused grids are the most common type of grid
Moving/oscillating grids eliminate grid lines and are used within the bucky system
Virtual grids use digital reconstruction to reduce scatter without using a physical grid

Anti-Scatter Grids

Use of a grid requires an increase in mAs to compensate for the higher absorption of radiation
Grid lines should not be angled against the beam
The detector should not be placed back to front in the holder
Grids should be used at a specific FFD

Bucky System

The bucky system holds the grid and the detector,
It allows for a moving grid that eliminates grid lines from the image
The bucky system allows for automated exposure control (AEC)

Erect Bucky

Erect bucky refers to the positioning of the patient and grid for an upright PA chest x-ray done with the patient standing.
The detector can be DR or CR.
It can have either a fixed or oscillating grid.
AEC helps with controlling the exposure.

Positioning

Patient preparation for a chest x-ray includes:
- Identifying the patient and obtaining consent
- Explaining the procedure
- Ensuring the patient isn't pregnant
- Removing clothing, jewelry, and any potential artifacts
- Dressing the patient in a gown

PA Chest Quality Criteria

The PA chest image should be assessed for the following:
- Markers: on the correct side and clear of anatomy
- Artefacts: these can be from patient, system errors, or exposure errors
- Anatomy: ensuring both lungs are included from the apices to the costophrenic angles
- Collimation: superior collimation includes the apex of the lung, inferior collimation distal to the costophrenic angles, and lateral collimation close to the skin edge
- Centering: mid-sagittal plane aligned with the middle of the image receptor
- Positioning: apical lung visible above the clavicles, scapulae projected clear of the lung fields, no rotation, good inspiratory effort
- Exposure: proper density and contrast to visualize bone and soft tissue, with fain visualization of bony skeleton through the mediastinum, clear outline of the diaphragm, and appropriate lung markings

Additional Chest Projections

Additional projections of the chest can be performed:
- AP erect: patient sits upright with caudad angle of 5-10 degrees
- Supine: patient lying on their back
- Expiration: patient instructed to exhale and hold their breath

Lordotic Projection

Lordotic projection is used to separate the clavicles and apices
It presents with clavicles above the lung apices and ribs projected horizontally

AP Erect

AP erect offers a different view of the chest compared to a simple PA
The patient must be positioned upright with the IR behind their back
The caudad angle should be 5-10 degrees

References & Resources

The text mentions multiple websites and resources for further information on chest radiology.

Studying That Suits You

Use AI to generate personalized quizzes and flashcards to suit your learning preferences.

Description

This quiz covers the Supine Positioning techniques for imaging patients with various lung pathologies, particularly focusing on Chronic Obstructive Pulmonary Disease (COPD) and its complications, such as emphysema and pneumonia. It includes critical findings observed on chest X-rays and their implications for diagnosis.