Chest X ray ap and pa view , findings in various diseases

Chest xray

1. Reading of chest X-Ray Chairperson: Dr. Shashidhar Khanapure sir Presenter: Sohan C. Kotigera

2. Contents Introduction Types of chest xray – radiographic technique (chest projections) Examination of films Normal and pseudo abnormal chest x ray Identification of lung pathology and other associated conditions

3. Introduction Chest radiography employs the use of ionizing radiation of X rays to generate images of the chest. The mean radiation dose to an adult from a chest radiograph is around 0.02  mSv for PA 0.08 mSv for a lateral view. Together, this adds up to a background radiation equivalent of 10 days.

4. Chest projections PA view AP view Lateral Oblique view Inspiration/ expiration PA view Apical lordotic

5. PA view Most commonly employed View of choice (if feasible). Rays originate from and pass through the chest from posterior  anterior. Adequate delineation of the lung parenchyma and other hilar and thoracic structures.

6. AP view Done in moribund or bed ridden patients Done in those who are unable to stand and/ or unable to follow instructions.

7. PA view and lateral view

8. Features of a PA view film Medial end of the clavicle – equidistant from the vertebral column Scapulae – off the lung fields 10 posterior ribs above the diaphragm must be visible Both CP angles must be present on the film

9. PA view AP view Scapula in the periphery of the thorax Scapulae are seen over the lung fields Clavicles project over the lung fields Clavicles are present above the lung fields Posterior ribs are distinct Anterior ribs are distinct

10. 1 st step in reading a film - Identification Correct patient Correct date and time of examination Appropriate film

11. Commenting on the X-ray RIPE Rotation Inspiration Projection Exposure

12. Commenting on an xray ABCDE Airway Breathing – lungs Cardiac – heart size and borders Diaphragm – and CP angles Everything else – ribs, devices etc.

13. Rotation Medial end of each clavicle must be equidistant from the Spinous process Spinous process must be vertically oriented to the vertebral bodies

14. Inspiration 5-6 anterior ribs Lung apices CP angles Lateral rib edges should be visible

15. Exposure Well exposed film – 1. left hemi- diaphragm should be visible to the spine 2. vertebrae must be visible behind the heart

16. UNDER-PENETRATED OVER-EXPOSED Normal chest x-ray will appear to have diffuse infiltrates No adequate lung detail – can miss subtle/ early changes Left hemi diaphragm and left lung base are not visible properly Absence of peripheral vasculature No differentiation between the vertebral bodies and the intervertebral space Vertebral bodies are also seen extending into the abdominal region

17. Airway Tracheal shift/ deviation Carina and its surrounding structures/contents Hilum – the hilum is present at the centre of the film and consists of the pulmonary vasculature, thus asymmetry should raise the suspicion of a mass/ lesion/ enlarged lymph node.

18. Lungs Lungs and the concurrent pleura should be inspected for abnormalities and the best way to differentiate is to compare one side with the other which reveals a pathology. the above mentioned technique falls short if there is symmetric B/L involvement.

19. Silhouette sign Helps in identification of the presence of a pathology and its location in the chest vis-à-vis other structures. STRUCTURE CONTACT WITH LUNG Upper right heart border Anterior segment of RUL Right heart border RML – medial Upper left heart border Anterior segment of LUL Left heart border Lingula Anterior hemidiaphram Lower lobes – anterior

20. Air bronchograms Tubular outline of the bronchi/ airway which is present because of the surrounding structures being inflamed or fluid filled. Causes – interstitial disease, atelectasis, edema and most importantly – consolidation.

21. Consolidation It is the variation in the normal translucency which is seen in the lung fields due to the accumulation of substances. These substances include – Pus – pneumonia Cells – bronchiolar cell carcinoma Blood – contusion, pulmonary hemorrhage Water - aspiration

22. Collapse / atelectasis This is due to the volume loss which occurs due to the alveolar collapse or failure. Features of collapse – shift of fissures crowding of vessels increased opacity hilar shift elevation of hemidiaphram

23. ATELECTASIS PNEUMONIA Volume loss Increased total volume is generally seen in cases of pneumonia Ipsilateral shift Contralateral shift Apex at hilum Apex not centered at the hilum Air bronchograms are seen in and occur in both of the conditions.

24. Pleural diseases Pleural effusion Pneumothorax Pleural calcification or thickening Pleural mass

25. Pleural effusions Collection of fluid can be – Transudative fluid – hydrothorax Pyothorax – pus Hemothorax – blood Chylothorax – chyle Malignant – B/L pleural effusions – metastasis, lymphoma and SLE. Most common cause – cardiac in nature.

26. Pleural effusions Right sided – ascites heart failure liver abscess Left sided – pancreatitis pericarditis aortic dissection

27. Radiological signs Blunting of the CP angles – most common and best indicator of the presence of effusions. Shifting of the opacity based on change of position of the patient – best method to delineate minimal effusion with other conditions – poor exposure, diaphragmatic issues, consolidation

28. Shifting of the opacity confirms the presence of effusion, however, it is not exclusive in nature as – loculated effusions pyothorax old/ capsulated haemothorax do not have any shifting of the fluid.

29. Pnuemothorax Relatively simple to differentiate As air has the least radio opacity potential – blacking/ darkening of an area indicates the presence of air or gas The films should ideally by in PA view and efforts must be made to obtain it in this position. Care must be taken to rule out over exposure.

30. Supine film pneumothorax signs - Ipsilaterla trans – radiancy Deep finger like costo-phrenic sulcus laterally Double diaphragm sign Visualization of the undersurface of the heat and cardiac fat pads

31. Unilateral hyperlucent lung Chest wall deficiency Poland's syndrome Mastectomy Congenital pulmonary artery absence Lobar collapse Rotated film

32. Pleural calcification/ thickening Asbestosis Pancoast tumor Metastasis Old Tb Pleuritis Sarcoidosis

33. Cardia Normal – heart should not occupy more than 50% of the thoracic width i.e. the CTR <0.5 This comment must be made only in PA films.

34. Normal cardia but Elevated CTR Seen if deep inspiration cannot be taken – ascites obesity Other anatomical defects- pectus excavatum straight back syndrome

35. Cardiac contours

36. Measurement of the main pulmonary Artery The line drawn tangentially from the left heart border to the aortic knuckle bisects the point of the MPA. A value of 0 – 15mm towards the right heart border is normal with pulmonary hypertension leading to an overshooting of the line.

37. If the MPA value is elevated then the cause of the cardiac enlargement can be pinned on right heart enlargement.

38. Pulmonary vasculature Normal: Right descending pulmonary artery is less than 17mm lower lobe vessels are larger than the upper lobe vessels there is a gradual tapering of the diameter of the pulmonary vasculature from the centre to the periphery

39. Pulmonary venous hypertension Pulmonary venous hypertension: increased RDPA diameter to more than 17mm upper lobe vessels are of a similar diameter as that of the lower lobes. This is also known as cephalisation of the vasculature. Tapering of the vessels from the centre to the periphery ( normal, but its absence – other causes of the abnormal x-ray).

40. Pulmonary artery HTN Pulmonary artery HTN: the RDPA is more than 17mm in diameter the lower lobe vessels are more prominent than the ones in the upper lobe rapid decrease in the size of the pulmonary vasculature from the centre to the periphery – also known as pruning sign

41. Pericardial effusion Difficult to differentiate pericardial effusion from cardiomegaly Often aided by the presence/ absence of the concurrent clinical signs.

42. Differentiating points Distinct epicardial fat planes Normal pulmonary vasculature despite cardiomegaly Obliteration of the retro – sternal space Water bottle appearance of the enlarged cardiac silhouette

43. Diaphragm Normally the diaphragm is of the same radio opacity as that of the liver. Main points to be seen is if the diaphragm has gas under it – indicative of pneumoperitoneum, or if there’s another pathology located superiorly to the diaphragm making it undetectable.

44. Diaphragm Eventeration – due to the absence of a part of a muscle of the diaphragm which is instead replaced with a connective tissue membrane. Hemidiaphram is not visualized Multicystic mass in the chest Mediastinal shift to the opposite side.

45. Diaphragm Diaphragmatic hernia: bochdaleks and morgagnian’s Hiatal hernia: appearance is of a soft tissue lesion present just behind the heart Trauma: affects left side of the diaphragm 3 times more commonly than the right – mostly due to the buffeting action of the liver.

46. Diaphragm There is often associated eventeration of abdominal contents into the thorax seen in the X-ray There is also seen – collar sign where there is a constriction at the site of the tear from where the organ has protruded into the thoracic cavity. NG tube above the diaphragmatic level on the left side is also another indicator of the same.

47. Costo phrenic angels Normal – clearly visible CP angels Loss – fluid or blunting

48. Aortic knuckle Arching back over the left main bronchus Reduced definition of the knuckle is seen in case of aneurysm,

49. Aorto pulmonary window Space between the arch of the aorta and the pulmonary arteries. Space can be lost in case of mediastinal Lymphadenopathy/ malignancy.

50. Other important things to note in a chest x ray Bones Soft tissue – hematoma etc. Medical devices – pacemakers, NG tube, artificial valves.

51. Mediastinum The mediastinum is conventionally divided into superior and inferior sections. Inferior – anterior, middle and posterior segments. 2/3 of the heart lies in the left side of the chest and 1/3 lies on the right. Left border – left atrium and left ventricle Right border – right atrium alone

52. Devices Central line ET tube Thoracostomy tube Pacemaker Nasogastric tube

53. Normal looking abnormal x-rays Mediastinal mass Breast tissue vs. lung opacities Cervical ribs Small pneumothorax

54. Normal x rays in the presence of underlying pathology Pulmonary thrombo-embolism Asthma Croup Viral pneumonia

55. Differentials

56. Coin lesion Carcinoma Hamartoma Metastasis Granuloma TB Rare: hydatid cyst, abscess, hematoma, adenoma

57. Multiple coin lesions Metastasis Septic emboli Abscesses Multiple emboli Rare: wegeners granulomatosis, rheumatoid lung

58. Cavitatory lesions TB Hydatid Carcinoma Septic infarct Uncommon: lymphoma, hematoma, bullae, pneumatocoele

59. Apical involvement in chest x-ray TB Pancoasts tumor Metastases Pleural thickening Extra pleural disease

60. Peribronchial thickening Chronic bronchitis Asthma Edema Bronchiectasis Cystic fibrosis

61. Diffuse pulmonary infiltrates Acute: ARDS Aspiration hemorrhage cardiogenic edema

62. Diffuse pulmonary infiltrates Chronic: TB aspergillosis sarcoidosis silicosis

63. Diffuse pulmonary infiltrates Upper lobe Lower lobe S – silicosis C – coal workers pneumoconisois H – histiocytosis A - AS R – radiation T - TB R - RA A - Asbestosis S – Scleroderma I – iodiopathic O – other – bleomycin , amiodarone etc.

64. Miliary opacities Miliary pattern: sarcoidosis, metastasis, Tb, silicosis, pneumoconiosis Dense nodules: silicosis, hemosiderosis, metal, microlithiasis

65. CP angle mass Fat pad – post pregnancy, obesity, steroids Pericardial cyst Pericardial tumor

66. Hyper inflated lungs Bilateral Unilateral Apparent unilateral COPD Foreign body Rotated film Asthma Pneumothorax Increased density on opposite side Alpha 1 AT deficiency Pulmonary embolus (large) Absent breast – mastectomy Aspergillosis Lung cyst Absent pectoral muscle Bronchiolistis Unilateral emphysema Scoliosis Cystic fibrosis Post lobectomy

67. Specific x ray features

68. CCF Cardiomegaly Pulmonary congestion UL>/= LL Prominent lymphatics – blurring of hilar vessels Visible lymphatics – kerly A and B lines Diffuse patchy opacities

69. Pulmonary edema Kerley’s lines Diffuse reticular pattern Sub pleural thickening and edema

70. Mind Map 1. Types of CXR 2. Choice of CXR based on patient Identification of the CXR Differentiating points for different views and significance RIPE ABCDE Commenting on the normal and abnormal parts of the X-RAY in a sequential fashion Characteristic CXR DD for commonly seen lesions Use of CXR for device related matters Importance of and the advantages of an old and cheap investigation

71. Source Chest X-ray made easy – D karthikeyan Deepa Chegu

72. Thank You