X ray basics of chest radiological findings.pdf

Radiology

5. Normal X-ray

6. Underdeveloped film

7. Hard film

8. Hard film

11. Expiratory film

12. Inspiration/Expiration

14. •Lungs
Systematic Approach
upper zone
lower zone
middle zone
•Compare upper,
mid and lower
zones
•Look between
ribs for lung
detail
•Remember to
look “behind” the
heart

15. •Diaphragm
Systematic Approach
•Both diaphragms
should form a sharp
margin with the lateral
chest wall
•Both diaphragm
contours should be
clearly visible
medially to the spine
Position of stomach
gas bubble (not
present on this CXR)

16. •Soft Tissues
Systematic Approach
•Supraclavicul
ar fossae
(enlarged
nodes)
•Lateral chest
wall (surgical
emphysema)
•Under
diaphragm
(pneumoperit
oneum)

66. Despitethedecreasedsensitivityand
specificityofICUchestfilmstheyarethemost
commonlyorderedradiologicexaminationfor
inpatients.Theirusestemsfromthefactthat
studieshaveshownthatupto65%ofICUchest
filmsmayrevealasignificantorunsuspected
process.
Currently,theAmericanCollegeof
Radiologysuggeststhatdailychestradiographs
beobtainedonpatientswithacute
cardiopulmonaryproblemsandthosereceiving
mechanicalventilation.

67. Otherwise,onlyinitialchestradiographs
areneededfortheplacementorchangeof
indwellinglinesordevices.
Indications:
1.Determiningtheplacementofpatient
instrumentation-catheters,tubes,and
monitoringdevices.
2.Torecognizethecommonnormaland
pathologicalappearancesofportablechest
x-raysinthepostoperativeormedicallyill
patient.
3.Identifycomplicationsoflinesandtubes
afterinsertionandremoval.

68. TheoptimalICUchestradiograph
isobtainedintheanteroposterior(AP)
viewatatarget-to-filmdistanceof72
incheswiththepatientintheupright
positionatmaximum inspiration;
alternativelyadistanceof40inchesis
usedinthesupinepatient.Duetothe
decreasedmobilityofpatientsinthe
ICU,chestfilmsareoftentakenwhile
thepatientissupine.

69. FactorsaffectingtheappearanceoftheICU
CXR:
1.APviewresultsin:
•Themagnificationofanteriorstructures
suchastheclavicle,sternum,andheart,
oftensignificantly
•Uptoa15%differencebetweenthe
widthofthemediastinumina72-inchPA
anda40-inchAPview
•Themedialborderofthescapulais
projectedseveralcentimetresfurther
intothelung.

70. 2.Supinepositioning:
•Widensthemediastinumandheartdueto
gravitationaleffects.
•Changesthephysiologyofthepulmonary
vasculature,puttingmoreflowtothe
upperlobesandmakingdiagnosisof
cephalisationmoredifficult.
•Makesdifferentiatingbetweenpleural
effusionandparenchymalprocesses
difficult,
•Maymakedetectingapneumothorax
difficultorimpossibleduetounusual
distribution.

71. 3.Respiration:
•Incompleteinspirationcanmake
differentiatingbasilaratelectasis
andlungoedemamoredifficult.
•Maycausesignificantchangesin
theapparentsizeoftheheartand
mediastinum.
•Thediameterofapatient's
mediastinummaydifferbyupto
50%betweenanexpiratorysupine
APandaerectinspiratoryPA.

72. 1.Endotracheal Tubes:
•Theidealpositionisin
themidtrachea,5cm
fromthecarina,when
theheadisneither
flexednorextended.
Thisallowsfor
movementofthetip
withheadmovements.
•Theminimalsafe
distancefromthecarina
is2cm.
Instrumentation:

73. Thoracostomytubes-
Ideal position-all of the
fenestrations in the tube must be
within the thoracic cavity The last
side-hole in a thoracostomytube is
indicated by a gap in the
radiopaque line. If this interruption
in the radiopaque line is not within
the thoracic cavity or there is
evidence of subcutaneous air, then
the tube may not have been
completely inserted.
Tubes placed within fissures
often cease to function when the
lung surfaces become apposed.

74. Central venous catheters:
either through the subclavian
veins or the internal jugular
veins. Ideally the catheter tip
should lie between the most
proximal venous valves of the
SVC and the right atrium as
placement beyond the superior
vena cava may be detrimental.
Malposition: the internal
jugular vein, right atrium, and
right ventricle. Pneumothorax,

75. 3. Feeding tubes-
Naso/Orogastrictubes-
the tip of the tube
should be below the
level of the diaphragm.
Malposition within the
lung have serious
consequences.
Nasojejunaltubes-
placed into the
proximal small bowel,
and confirmed by an
abdominal film.

76. Transvenouspacemakers-
Transvenouspacers are
introduced through the
internal jugular or
subclavianvein into the
apex of the right ventricle.
The pacer tip should be at
the apex with no sharp
angulations throughout its
length

77. Extra-alveolar air -manifest as
pulmonary interstitial
emphysema, pneumothorax,
pneumomediastinum,
pneumopericardiumor
subcutaneous air.

78. Pneumothorax:
Intheerectpatient,airwillrisetothe
apicolateralsurfacesofthelung.An
apicolateralpneumothoraxappearsasathin,
whitepleurallinewithnolungmarkings
beyond.Skinfoldsonapatientcanmimica
pleuraledgeandapneumothorax.
Onecansometimesdifferentiatethetwo
bynotingthattheskinfoldlinecontinues
outsideofthechest.

79. Inthesupinepatient,intrapleuralair
risesanteriorlyandmedially,often
makingthediagnosisofpneumothorax
difficult.
Anapicalpneumothoraxinasupine
patientisasignthatalargevolumeofair
ispresent.
Subpulmonicpneumothoraxoccurs
whenairaccumulatesbetweenthebaseof
thelungandthediaphragm.

81. Anterolateralairmayincreasethe
radiolucencyatthecostophrenicsulcus.Thisis
calledthedeepsulcussign.
Othersignsofsubpulmonicpneumothorax
includeahyperlucentupperquadrantwith
visualizationofthesuperiorsurfaceofthe
diaphragmandvisualizationoftheinferiorvena
cava.
Occasionally,aposteriorsubpulmonary
pneumothoraxwillresultinvisualizationofthe
moresuperioranteriordiaphragmaticsurface
andtheinferiorposteriordiaphragmaticsurface,
resultinginthedouble-diaphragmsign.

83. AtensionpneumothoraxintheICU
patientisaclinicaldiagnosisbasedon
ventilatoryandcardiaccompromise.
Radiographically,atensionpneumothorax
inanICUpatientcanbeanextremely
challengingdiagnosis.
ParenchymaldiseasesuchasARDS
mayreducelungcompliancesuchthattotal
lungcollapseinthefaceofatension
pneumothoraxmaynotoccur.

84. Mediastinalshiftisusuallyseenina
tensionpneumothorax,buttheuseof
PEEPmaypreventthisfromoccurring.
Themostreliablesignoftension
pneumothoraxisdepressionofa
hemidiaphragm.Othersignsoftension
pneumothoraxincludeshiftingofthe
heartborder,thesuperiorvenacava,and
theinferiorvenacava.Theshiftingof
thesestructurescanleadtodecreased
venousreturn.

86. Pneumomediastinum:
The radiographic
appearance of
pneumomediastinum results
fromairoutliningstructures
whicharenotnormallyvisible
onchestx-ray.Pathognomonic
signsofpneumomediastinum
includelucenciesaroundthe
greatvessels,themedialborder
ofthesuperiorvenacava,and
theazygosvein.Airmayalsobe
seenoutliningtheaorticknob,
descendingaorta,orthe
pulmonaryarteries.

87. Abnormal fluid collection:
Pleural effusions:
Blood,chyme,pus,transudatesor
exudates.Theappearanceofapleural
effusiononachestfilmislargelydependent
onthepositionofthepatient.
Fluidinthechestcavitywill
accumulateinthedependentareasofthe
chest.Thismakesidentifyingsmall
collectionsextremelydifficult,especiallyin
thesupinepatient.

88. Fluidintheposteriorbasilarspaceappears
asanhomogenousgradedincreaseinthe
densityofthelungbase,maximalinferiorly.
Thenormalbronchovascularmarkingsare
notlost.Astheamountoffluidincreases,the
diaphragmaticcontourandlateralcostophrenic
sulcusmaybeobliterated.
Fluidintheapex,inasupinepatient,is
moreeasilyidentified.Alargepleuraleffusion
mayappearasapleuralcapwithfluid
occasionallycollectingonthemedialside,
appearingasawidenedmediastinum.

90. Subpulmoniceffusions:
Uptoalitreoffluidmaycollect
betweenthediaphragmandthelungwithout
bluntingofthecostophrenicangle.
Radiographically, subpulmonic
effusionsappearasaraiseddiaphragmwith
flatteningandlateraldisplacementofthe
dome.Thegastricbubbleandsplenicflexure
ofthecolonshowdisplacementinferiorly.
Thedistancebetweenthelungandthe
stomachbubblewillexceed2cmin
subpulmonaryeffusions.

92. Pericardial effusions:
Accumulations of fluid between
the visceral (epicardium) and
parietal pericardium. Blood in the
pericardium (hemopericardium)
may be an important clue to post
operative bleeding.
Radiographically, pericardial
effusions appear as changes in
the size and shape of the cardiac
silhouette resulting a featureless,
globular or "water bottle" shape

93. Pulmonaryoedema:
Theinitialphaseofcardiogenic
pulmonaryoedemaismanifestedas
redistributionofthepulmonaryveins.This
isknowascephalizationbecausethe
pulmonaryveinsofthesuperiorzonedilate
duetoincreasedpressure.Thisdiagnosisis
madewhentheupperlobevesselsareequal
toorlargerindiameterthanthelowerlobe
vessels.Thediagnosisofcephalizationis
moredifficultinthesupinepatientdueto
gravitationaleffects.

94. Classically,alveolaroedemaappearsas
bilateralopacitiesthatextendinafanshape
outwardfromthehilumina"batwing"
pattern.Astheoedemaworsens,theopacities
becomeincreasinglyhomogenous.
Typically,theradiographicappearanceof
pulmonaryoedemaincludesoneormoreofthe
following:cephalizationofpulmonaryvessels,
Kerley'sBlinesperibronchialcuffing,bat
wingpattern,patchyshadowingwithair
bronchograms,andincreasedcardiacsize.
Generally,pulmonaryoedemaisbilateraland
maychangerapidly.

95. Onemethodofdifferentiatingpulmonary
oedemafromothercausesoflungopacitiesis
thegravitationalshifttest.Thepatientiskeptin
thesupinepositionfortwohoursbeforeachest
filmistaken.Thenthepatientisleftinthe
decubitispositionwiththesuspicious
hemithoraxintheindependentpositionfor2to
3hoursbeforeasecondfilmistaken.In85%of
patientswithpulmonaryoedemathereisashift
intheopacityasopposedto80%ofpatient
withoutpulmonaryoedemawhohadnoshift.

97. Atelectasis:
Itisthemostfrequentabnormality
detectedintheICUchestfilm.Atelectasis
inICUpatientsoccursmostfrequentlyin
theleftlowerlobe,presumablydueto
compressionofthelowerlobebronchus
bytheheart,inthesupinepatient.
Crowdingofvessels,shiftingofstructures
suchasinterlobarfissurestowardsareas
oflungvolumelossandelevationofthe
hemidiaphragmsuggestsatelectasis.

98. Plate like atelectasis