How to read normal x ray

how to read normal chest x rays

1. How to read NORMAL CHEST X RAYS MODERATOR:DR.RAVINARAYAN BY:DR.PUNEET MAHAJAN PGDCC 1 ST YEAR

2. History Roentgen disocvered first example of ionizing radiation called X rays while experimenting with cathode rays in CROOKES tube. Crookes tube created free electrons by ionization of residual air in the tube by high DC voltage This voltage accelrated the electrons coming from the hot cathode to high enough velocity that they created X Rays when they struck with anode.

3. PRODUCTION OF X RAYS X rays are invisible, highly penetrating,electromagnetic radiations with very high frequency and very short wavelength of 0.1 to 1 A. When electrons released by hot cathode are accelrated by high voltage are suddenly decelrated upon collision with metal target ,the anode. Tungsten is maily used as target anode its high atomic no and melting point of 3300 F. Molybdenum is used foe mammography

4. .

5. Different tissues in body absorb X-rays at different extents: Bone- high absorption (white) Tissue- somewhere in the middle absorption (grey) Air- low absorption (black)

6. THE PLAIN FILM The PA ( postero -anterior) view: It is the most frequently required radiological examination. Comparison of current film with old films is valuable. Position: Patient facing the film, chin up with the shoulders rotated forwards to displaced the scapulae from the lungs. Exposure is made on full inspiration, centering at T5.

7. Lateral view: Comparison with PA view: Advantages : Anterior mediastinal masses Encysted pleural fluids Posterior basal consolidation Disadvantages : Lung collapse Large pleural effusion.

8. Lateral decubitus position: It is helpful to assess the volume of pleural effusion and demonstrate whether a pleural effusion is mobile or loculated. Lateral decubitus position film showing mobile pleural effusion (arrows)

9. Inspiration vs Expiration

10. This is a PA film on the left compared with a AP supine film on the right.   The AP shows magnification of the heart and widening of the mediastinum. AP film is taken mostly in very ill patients who cannot stand erect. AP VS PA VIEW

11. Poor inspiratory effort will compress and overcrowd the lung markings

12. CENTERING MEDIAL ENDS OF CLAVICLES SHOULD BE AT EQUIDISTANT FROM SPINOUS PROCESS AT T4/5 LEVEL. ROTATION CAN DISTORT MEDIASTINAL BORDERS. LUNGS NEAREST TO FILM APPEARS LESS TRANSLUCENT.

13. RT Sternal end is away from central line of spine.

14. Penetration is degree to which x rays absorbed through body. Normally the vertebral bodies should be just visible through the heart. DEPENDS UPON THE KVP kVp = Energy of x-rays = higher penetrability, it moves through tissue. The energy determines the QUALITY of x-ray produced. 1. increase in kVp = electrons gain high energy 2. higher the energy of electrons = greater quality of x-rays 3. greater quality = greater penetrability

15. TRACHEA NARROWING : Normal coronal diameter is 25mm for males nd 21 mm for females. DISPLACEMENT INTRALUMINAL LESIONS MIDLINE IN UPPER PART THEN DEVIATES TO RIGHT AROUND AORTIC KNUCKLE

16. PARATRACHEAL STRIPE RIGHT PARATRACHEAL STRIPE :RT border of trachea meeting with rt lung SEEN IN 60 % . <5MM LEFT PARATRACHEAL STRIPE NOT VISUALISED BECAUSE OF GREAT VESSELS ON LEFT BORDER OF TRACHEA

17. MEDIASTINUM AND HEART P-A view Right border: Superior vena cava Right atrium The inferior vena cava . rarely The right atrium& the superior vena cava shares more than 50%. Left border Aortic knucle Pulmonary bay LA appendage Left ventricle

18. CARDIAC MALPOSITIONS SITUS SOLITUS DEXTROCARDIA WITH SITUS INVERSUS DEXTROCARDIA WITH SITUS SOLITUS LEVOCARDIA WITH SITUS INVERSUS SITUS AMBIGIUOS

19. visceroatrial situs solitus (gastric bubble arrowed) and isolated dextrocardia . Chest radiograph of a patient with total situs inversus (gastric bubble arrowed).

20. Cardiac calcification Valvular Pericardial Myocardial Endocardial Intraluminal vascular

21. Pericardial calcification m/c cause is constrictive pericarditis . First occurs in dependent areas:Diapragm,posterior and anterior cardiac surface Better seen in lateral view. Minimally over left ventricle.

22. Aortic valve calcification

23. JUNCTION LINES ANTERIOR JUNCTION LINE FORMED BY LUNGS MEETING ANTERIOR TO THE ASCENDING AORTA. 1 MM THICK RUNS DOWNWARD BELOW THE SUPRASTERNAL NOTCH CURVING FROM LEFT TO RIGHT POSTERIOR JUNCTION LINE FORMED BY LUNGS MEETING POSTERIORLY BEHIND ESOPHAGUS 2 MM THICK STRAIGHT OR CURVED LINE,CONVEX TO LEFT EXTENDS FROM LUNG APICES TO AORTIC KNUCKLE OR BELOW

24. LUNGS 1. Upper zone : apices to lower border of 2nd rib anteriorly. 2. Middle zone :lower border of 2nd rib anteriorly to lower border of 4th rib anteriorly. • 3. Lower zone :lower border of 4th rib anteriorly to lung bases.

25. 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

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

27. RIGHT LOWER LOBE 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.

28. Lung 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.

29. No defined left minor fissure, there are only two lobes on the left; the left upper lobe and left lower lobe.

30. Left lower lobes LEFT LOWER LOBES

31. Lung 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.

32. Pulmonary artery MPA Forms convexity on left mediastinal border b/w arch of aorta and straight left heart border. RPA runs horizontally to the right and is not seen on frontal view divides in mediastinum forming descending br.of RPA wich is visible on x ray LPA continues as branch of MPA and gives upper lobe branch as it passes left main bronchus forming upper part of left hilum.

33. 0 mm Main Pulmonary Artery Ao 15 mm Main Pulmonary Artery Ao LV LV Main pulmonary artery ranges from 0 mm–15mm from tangent line

34. Pulmonary veins Right and left upper lobe neins In the outer two thirds of the lungs, arteries cannot be distinguished from veins on chest radiography VEINS CAN BE DISTINGUISHED FROM ARTERIES AS VEINS FOLLOW HORIZONTAL COURSE TO LEFT ATRIUM

35. Venous Hypertension RDPA usually > 17 mm Upper lobe vessels equal to or larger than size of lower lobe vessels = Cephalization

36. KERLEY LINES Kerley A lines Kerley B lines 1-2 mm ,non brnaching lines originating from hilum 2-6 cm long Thickened Interlobular septa Transverse non branching 1-2 mm lines at lung base perpendicular to pleura 1-3 cm long Thickened Interlobular septa

37. The 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.

38. Diaphragm Right is normally higher than left by 1.5-3cm On inspiration the domes of the diaphragms are at the level of the 6 th rib anteriorly and 10 th rib posteriorly . ????CHECK ????? Costophrenic angles crisp? Air under diaphragms? Flattened diaphrags Loss of diaphragm definition Elevated hemidiaphragm Tenting

39. Pleural effusion

40. Soft Tissues Breast shadows Supraclavicular areas Axillae Tissues along side of breasts Abdomen Gastric bubble Air under diaphragm Neck Soft tissue mass

41. Bones : Check the bones for any fracture , lesions, density or mineralization. Bony Fragments Ribs Sternum Spine Shoulder girdle Clavicles

42. Superior rib notching Polio Restrictive lung disease Neurofibromatosis Connective tissue disease Osteogenesis imperfecta Hyperparathyroidism

43. Causes of inferior rib notching Unitateral Blalock-Taussig operation Subclavian artery occlusion Aortic coarctation involving left subclavian artery or anomalous right subclavian artery Bitateral Aorta-coarcation, occlusion, aortitis Subclavian-Takayasu's disease, atheroma Pulmonary oligaemia-FaIlot's tetralogy; pulmonary atresia, stenosis; Venous-SVC, IVC obstruction Shunts-intercostal-pulmonary fistula; pulmonary-intercostal arteriovenous fistula Others-hyperparathyroidism; neurogenic; idiopathic

44. . Cardiac anomaly with hypoplastic clavicle ????? HOLT ORAM SYNDROME

45. STERNUM PECTUS EXCAVATUM PECTUS CARINATUM STRAIGHT BACK SYNDROME ALL THESE CONDITIONS ARE ASSESSED BY PA AND LATERAL VIEWS

46. Turner syndrome Marfan syndrome Ehlers Danlos Syndrome Noonan syndrome Trisomy 18 Trisomy 21 H omocystinuria Osteogenesis imperfecta PECTUS EXCARINATUM Best viewed in lateral film Increased anterioposterio diameter. Increased pulmonary vascular resistance due to L>R shunt

47. Pectus excavatum Congenital or acquired Rickets Pseudocardiomegaly False prominence of pulmonary artery

48. Viewing lateral film Clear spaces :Retrosternal AND retrocardiac Obliteraion of retrosternal space:thymoma,aneurysms of aorta and nodal masses. Vertebral translucency :posterior basal consolidation Diaphragm outline :Both diaphragms are visible throughout their length except left anteriorly Acute posterior costophrenic angles

49. Trachea Right pulmoanry artery anterior to caring. LPA is posterior and superior and veins are inferior. CARDIAC CONTOURS ANTERIOR BORDER Ascending aorta Pulmonary artery Right ventricle POSTERIOR BORDER Pulmonary artery Left atrium Left ventricle from above downwards

50. The Normal Chest X-ray Lateral View: Oblique fissure Horizontal fissure Thoracic spine and retrocardiac space Retrosternal space