VII CXR.pdf

Taibah University College of Medical Rehabilitation Sciences Respiratory Therapy Department Patient Assessment Course (RT 244) Radiology of the chest Taibah University  Overview Technical aspects of chest radiography Systematic approach to...

Taibah University College of Medical Rehabilitation Sciences Respiratory Therapy Department Patient Assessment Course (RT 244) Radiology of the chest Taibah University  Overview Technical aspects of chest radiography Systematic approach to reading CXR Basic CXR anatomy 3  Thoracic Imaging X-ray (CXR) Computed Tomography (CT) Magnetic Resonance (MR) Ultrasonography (US) Nuclear Medicine PET/CT Radionuclide ventilation perfusion imaging  Indications of chest x-ray Evaluation of symptoms Screening for lung Evaluation of signs cancer Pre-employment and prior to surgery Evaluation of placement of devices and tubes Screening after procedures (central line, lung biopsy, chest tube, thoracentesis) Density of tissue and radio opacity  A systematic approach to reading a CXR ChestX-ray Image Credit: Lung Health Image Library/Gary Hampton 13  Put it in right order Patient’s right side Patient’s left side Aortic knob Gastric bubble should be on the left Mark on film Heart: two thirds to the left  Chest x-ray viewing guide Quality Be Systematic Correct CXR Name Orientation Date of Penetration/ birth/Age Exposure Date Inspiration Left and Rotation right, mark Angulation Abnormality What (pathology) Where (site) Extent (size) Diagnosis  Patient Position PA, AP, lateral or decubitus view Rotation – Sternal end clavicles equal from vertebral body If AP what position  AP All x-rays in the ICU are portable and are AP view Portable AP  Views Lateral View Oblique view  Decubitus View Lateral Decubitus View PA on side Small pleural effusions Pneumothorax  Assess CXR Technical Quality Inspiratory effort – 9-10 posterior ribs (5 -6 anterior) Penetration – thoracic intervertebral disc space just visible Positioning / rotation – medial clavicle heads equidistant from spinous process 7  Penetration/Exposure Proper Exposure How dark or light a film is Is the film over or under penetrated if under penetrated you will not be able to see the thoracic vertebrae.  Inspiratory or expiratory Good inspiratory effort: – If anterior end of 6th or 7th rib reaches mid-clavicular line of diaphragm, it is Inspiratory Xray. Poor inspiraory effort Inspiratory film CXR – 9 posterior ribs are visible. – 5 anterior ribs are visible. Expiratory – Less than 9 posterior ribs are visible. – Less than 5 anterior ribs are visible. Poor Inspiration  Inspiratory effort If more ribs are apparent above the hemi- diaphragm, the inspiratory volume is large or the patient is hyper inflated. If fewer ribs are apparent above the hemi diaphragm, the inspiratory volume is small or the patient has restricted lung volumes. Image credit: Curry International Tuberculosis Center, University of California, San Francisco 8  2 1 3 4 5 6 7 8 9 10 Image credit: Curry International Tuberculosis Center, University of California, San Francisco 8  2 1 3 4 5 6 7 8 9 10 Image credit: Curry International Tuberculosis Center, University of California, San Francisco 8  2 1 3 4 5 6 7 8 9 10 Image credit: Curry International Tuberculosis Center, University of California, San Francisco 8  Rotation Check for rotation – Does the thoracic spine align in the center of the sternum and between the clavicles? – Are the clavicles level?  Centering and symmetry of thorax The sternoclavicular joints should be an equal distance from the spines of the thoracic vertebrae.  Heart The mediastinal shadow should be slightly to the left of center and in contact with the diaphragm. The cardiothoracic index should be about one-third to one-half. Look for the aortic arch (aortic knob), to the left A cardiophrenic angle is the intersection of the vertical curvature of the heart shadow and the horizontal curvature of the hemi diaphragm. Look for sharp cardiophrenic angles on the right and left side of the heart.  Mediastinum - Heart Size No larger than half width of chest Position Two thirds on the left Borders Clear Systematic approach Airway  Airway Trachea Deviated Carina Artificial airway  Bone Ribs Scapulae Clavicles Vertebrae  Check the Heart Size Shape Silhouette-margins should be sharp Diameter (>1/2 thoracic diameter is enlarged heart) Remember: AP views make heart appear larger than it actually is.  Hilar region The hila (lung roots) are complicated structures mainly consisting of the major bronchi and the pulmonary veins and arteries. These structures pass through the narrow hila on each side and then branch as they widen out into the lungs. The hila are not symmetrical but contain the same basic structures on each side. Hilum—Normally, the hilum is 1 to 2 cm higher on the left than on the right side of the mediastinum. D.D of enlarged hilum Enlarged pulmonary artery Enlarged lymph nodes Mass  Diaphragm Shape Height: right –6rib ant, left – 7 ant The right hemidiaphragm is higher than the left Margins should Cardiophrenic angle be sharp Costophrenic angle Clear Pin point  Diaphragm Look at the diaphram: for tenting free air abnormal elevation Margins should be sharp (the right hemidiaphram is usually slightly higher than the left)  Lung Fields Black with lung markings Other opacity indicated pathology Fissures Zones Air bronchograms Consolidation  Radiologic lung zones The Chest Xray is usually divided into three zones  Lung Zones Dividing the lungs into zones allows more careful attention to be paid to each smaller area. If this is not done it is easy to ignore important abnormalities. Note that the lower zones reach below the diaphragm. This is because the lungs pass behind the dome of the diaphragm into the posterior sulcus of each hemithorax. Normal lung markings can be seen below the well defined edges of the diaphragm.  Pleural spaces Normal pleura and pleural spaces Trace round the entire edge of the lung where pleural abnormalities are more readily seen Start and end at the hila Is there pleural thickening? Is there a pneumothorax? The lung markings should be visible to the chest wall Is there an effusion? The costophrenic angles and hemidiaphragms should be well defined.  Check the Lung Fields Infiltrates Increased interstitial markings Nodules/Masses Patchy opacity Air bronchograms Increased vascularity Cyst Cavity  Lung findings Darker areas Lighter areas Radiolucent – Opacities – Pneumothorax – Atelectasis – Cysts/bulla – “infiltrates” – Air bronchograms Blood Pus Water – Nodules or mass Bronchitis  Pneumothorax Black jet opacity Visceral pleural line Collapsed lung With or without mediastinal shift Pneumothorax in ICU Deep sulcus Deep sulcus  Consolidation/pneumonia Caused by filling of alveoli with fluid, pus, blood, cells (tumor), etc. May be diffuse, or isolated to segments or lobes of the lung May be associated with air bronchograms (air-filled bronchus surrounded by opacified lung) Mass Pleural effusion White homogeneous opacity Obliterating costophrenic angle Rising to axilla