chest x ray intepretation in pulmonology thomas handoyo - chest x ray... · workshop thomas handoyo...

WORKSHOP

THOMAS HANDOYO

CHEST X RAY INTEPRETATION IN PULMONOLOGY

DIVISION OF RESPIROLOGY AND CRITICAL CAREDEPARTEMENT OF INTERNAL MEDICINE

DR KARIADI HOSPITAL / FK UNDIP SEMARANG

Curriculum vitae

Dr. Thomas Handoyo, SpPD-KP

Pendidikan

S1 : FK Universitas Diponegoro Semarang lulus tahun 2001

Spesialis : Ilmu Penyakit Dalam FK Universitas Diponegoro Semarang tahun 2010

Konsultan : Konsultan Pulmonologi Kolegium IPD bulan Maret tahun 2019

Pekerjaan

Staf Medis Fungsional Ilmu Penyakit Dalam RSUP Dr. Kariadi/ FK UNDIP Semarang.

Ketua TB MDR RSUP Dr. Kariadi Semarang (2013 – sekarang)

Ketua Koalisi Organisasi Profesi TB Jawa Tengah ( 2019 – sekarang)

Pokja (TWG) TB MDR Kementerian Kesehatan)

INTRODUCTION

• X-rays are a type of electromagnetic radiation with wavelengthsbetween 0.01 and 10 nm.

• On the electromagnetic spectrum, the wavelength of X-rays is shorter than that of ultraviolet radiation and longer than that of gamma radiation.

• Shorter wavelength X-rays (0.10–0.01 nm) are referred to as ‘hard’ because they can penetrate solid objects. It is these that are used in medical imaging.

• Since their discovery in 1895 by the German physicist Wilhelm Roentgen, X-rays have been used widely for medical imaging and remain key to diagnosing and treating patients.

Figure 1. An X-ray tube. Electrons are emitted by a cathode into the vacuum, emitting X-rays when hitting the anode at the right (i.e. current) speed.

INTRODUCTION

Thus, the radiographic appearance of thoracic structures depends mainly on their density. While areas with a high density per unit volume (e.g., cortical bone) appear light or white, areas with a lower density that are more transparent to roentgen rays (e.g., air in the alveoli) appear dark.

INTRODUCTION

FUNDAMENTAL OF CXR INTEPRETATION

• When interpreting a CXR it is important to make an assessment of whether the x-ray is of diagnostic quality.

• In order to facilitate this, first pay attention to two radiographic parameters prior to checking for pathology; namely the quality of the film and patient-dependent factors.

• A suboptimal x-ray can mask or even mimic underlying disease.

Quality assessmentIs the film correctly labelled?

What to check for?

• Does the x-ray belong to the correct patient?

Check the patient’s name on the film.

• Have the left and right side markers been labelled correctly, or does the patient really have dextrocardia?

• Lastly has the projection of the radiograph (PA vs. AP) been documented?

Assessment of exposure qualityIs the film penetrated enough?

• On a high quality radiograph, the vertebral bodies should just be visible through the heart.

• If the they are not visible, then an insufficient number of x-ray photons have passed through the patient to reach the x-ray film.

• As a result the film will look ‘whiter’ leading to potential ‘overcalling’ of pathology.

• Similarly, if the film appears too ‘black’, then too many photons have resulted in overexposure of the x-ray film.

• This ‘blackness’ results in pathology being less conspicuous and may lead to ‘undercalling’.

The effect of varied exposure on the quality of the final image

Is the film PA or AP ?

11

Why are PA Views Preferred over AP Views?

• PA view diminishes magnification, especially the heart

• PA view has better quality

AP views are indicated for:

• Patients too ill to stand1) In younger children 2) When there is doubt on a PA view about abnormalities in

hidden areas like retro-clavicular regions

PA View: Correct Standing or Sitting Position for CXR

If the patient is in

supine position, the

cardiac outline and

mediastinum is enlarged.

The scapula may be on

the lung field.

X-ray tube

X-ray cassette

AP View

ANTERIOR

POSTERIOR

14

AP: leads to false

cardiomegaly

PA: same patient heart no

longer magnified

AP VIEW vs PA VIEW

The technician should always specify if the view is not PA view;

this should be marked on the film, either at the bottom of the film or on the side

PA VIEW IS THE PREFERRED VIEW

15

PA View left-anterior oblique right-anterior oblique

D1 D2 D3

D3> D1>D2

The Diameter of the Cardiac Shadow Changes

with the Incidence of the X-Ray Beam

The cardiomediastinal contour is

significantly magnified on this AP

film. This needs to be appreciated and

not overcalled.

On the PA film, taken only an hour

later, the mediastinum appears

normal.

Patient-dependent factorsAsessment of patient rotation

• Identifying patient rotation is important.

• Patient rotation may result in the normal thoracic anatomy becoming distorted; cardiomediastinalstructures, lung parenchyma and the bones and soft tissues may all appear more, or less, conspicuous.

• To the uninitiated, failure to appreciate this could easily lead to ‘overcalling’ pathology.

A well centred x-ray. Medial ends of clavicles are equidistant from

the spinous process

This patient is rotated to the left. Note the spinous process is

close to the right clavicle and the left lung is ‘blacker’ than

the right, due to the rotation.

Assessment of adequacy of inspiratory effort

• Ensuring the patient has made an adequate inspiratory effort is important in the initial assessment of the CXR.

• It is ascertained by counting either the number of visible anterior or posterior ribs.

• If six complete anterior or ten posterior ribs are visible then the patient has taken an adequate inspiratory effort.

• Conversely, fewer than six anterior ribs implies a poor inspiratory effort and more than six anterior ribs implies hyper-expanded lungs.

Six complete anterior ribs (and ten posterior ribs) are clearly visible.

An example of poor inspiratory effort.

Only four complete anterior

ribs are visible. This results in several

spurious findings: cardiomegaly,

a mass at the aortic arch and patchy

opacification in both lower zones

Same patient following an adequate

inspiratory effort. The CXR now

appears normal

NotesIf a poor inspiratory effort is made or if the CXR is taken in expiration, then several potentially spurious findings can result:

• apparent cardiomegaly

• apparent hilar abnormalities

• apparent mediastinal contour abnormalities

• the lung parenchyma tends to appear of increased density, i.e. ‘white lung’.

• Needless to say any of these factors can lead to CXR misinterpretation.

REVIEW OF IMPORTANT ANATOMY

Heart and mediastinum

• The cardiothoracic ratio should be less than 0.5 i.e. A/B<0.5.

• A cardiothoracic ratio of greater than 0.5 (in a good quality film)suggests cardiomegaly.

Assessment of cardiomediastinal contour

Assessment of hylar regions

Both hilar should be concave. This results from the superior pulmonary

vein crossing the lower lobe pulmonary artery. The point of intersectionis known as the hilar point (HP)

Assessment of trachea• The trachea is placed usually just to the

right of the midline, but can bepathologically pushed or pulled to either side, providing indirect supportfor an underlying abnormality.

• The right wall of the trachea should be clearly seen as the so-called right para-tracheal stripe.

• The para-tracheal stripe is visible by virtue of the silhouette sign: air within the tracheal lumen and adjacent right lung apex outline the soft tissue-density tracheal wall.

• Loss or thickening of the para-tracheal stripe intimates adjacent pathology.

Evaluation of mediastinal compartments

It is useful to consider the

contents of the mediastinum as belonging to three compartments:

• Anterior mediastinum: anterior to the pericardium and trachea.

• Middle mediastinum: between the anterior and posterior mediastinum.

• Posterior mediastinum: posterior to the pericardial surface

Lung and Pleura

• There are two layers of pleura: the parietal pleura and the visceral pleura.

• The parietal pleura lines the thoracic cage and the visceral pleura surrounds the lung.

• Both of these layers come together to form reflections which separate the individual lobes. These pleural reflections are known as fissures.

Right lung

• Upper lobe

• Middle lobe

• Lower lobe.

Left lung

• Upper lobe; this contains the lingula

• Lower lobe.

Lobar and pleural anatomy –

frontal view

Lobar and pleural anatomy –

left lateral view.Lobar and pleural anatomy –

Right lateral view.

DiaphragmsAssessment of diaphragms

The right hemidiaphragm is ‘higher’ than the left. Both

costophrenic angles are sharply outlined


The outlines of both hemidiaphragms should be clearly

visible


Assess for diaphragmatic flattening. The distance

between A and B should be at least 1.5 cm

Bones and soft tissuesAssessment of bones and soft tisssues

Remember to scrutinise every rib, (from the anterior to posterior),

the clavicles vetebrae and the shoulders

Bones and soft tissuesAssessment of bones and soft tisssues

The ‘hidden’ areas Lateral View is important

38

Lateral View

39

AO

PA

RV

LA

LV

40

Heart and

Mediastinum

Vessels

Ascending

Aorta

Superior

Vena Cava

Right Pulmonary

Artery

Right

Ventricle

Descending

Aorta

Courtesy of Dr Jeanbourquin France

A brief look at the lateral CXRImportant anatomy relating to the lateral CXR

Key points

There should be a

decrease in density from

superior to inferior in the

posterior mediastinum.

The retrosternal airspace

should be of the same

density as the retrocardiac

airspace

42

Retro sternal clear space

Retro cardiac clear space

The “Clear Spaces”

43


Retro tracheal

space

Courtesy of Dr Jeanbourquin France

44

The retro sternal space

is filled with a massNormal lateral view

45

Anterior opacity in the mediastinum

(red arrow on the PA view)

Filling of the retrosternal space on the lateral view

46

Retro cardiac clear

space


47Normal CXR Retro-cardiac opacity

Diaphragms

The right hemidiaphragm is usually ‘higher’ than the left. The outline of

the right can be seen extending from the posterior to anterior chest

wall. The outline of the left hemidiaphragm stops at the posterior heart

border. Air in the gastric fundus is seen below the left hemidiaphragm.

Step Details• Identification, time

1. the X-ray

2. the clinical information

• Check technical factors – quality of film, patient dependent

factors, AP/PA

• Examination

1. trachea and root of the neck

2. lung fields

3. silhouette sign

4. mediastinum and heart

5. fissures

6. hila

7. diaphragm and below the diaphragm

8. bones and soft tissues

9. artefacts

10. abnormal densities

• Diagnosis –

REMEMBER

• DIAGNOSIS

DIA : MELALUI / THROUGH

GNOSIS : PROSES BERPIKIR / LOGIC THINKING

Trachea and Bronchus

Trachea

Main right

bronchus

Main left

bronchus

Trachea

Right upper

lobe bronchus

Left upper

Lobe bronchus

Right Bronchography

(this examination, with opacification of bronchi by iodine contrast fluid, is no longer performed)

Left Bronchography

Minor Fissure

Right View

Large Oblique

Fissure

Left View

Left

Fissure

The fissure are

sometimes

visible on the

lateral view

On the PA view

only minor

fissure is

sometimes

visible

Sections of

the Lungs

Bronchial Syndromes

Different Radiological Syndromes

• Atelectasis

• Bronchiectasis

Atelectasis

• Atelectasis is the consequence of an obstruction of

the bronchus by an intrinsic or extrinsic element.

• The air in the alveolar system progressively

disappears and the lung retracts.

This retraction can involve a segment, a lobe or the

entire lung.

Main Etiology of Atelectasis

• Bronchial Cancer:

• TB (bronchial TB or extrinsic compression by TB adenopathy)

• Extrinsic compression by adenopathy or malignant tumor

• Foreign body (in children, remember peas or small toys which are not radio-opaque)

Less frequent:

• Asthma

• Chronic bronchitis

• Viral or bacterial pneumonia

• Atelectasis after thoracic or abdominal surgery or trauma

The X-ray image mimics

consolidation but it is characterized by:

• Systematised (close to a fissure)

• Loss of volume

• Homogeneity

• Absence of air bronchogram

• Variable size: segment, lobe or entire lung

•ATELECTASIS

Right

Superior

Lobe

Atelectasis

by Cancer

• Right scapula pain

• Worsening condition

• Smoker (40 pack/year)

• AFB sputum negative

Bronchiectasis

Bronchiectasis is a disease characterised by dilatation

and irreversible destruction of the bronchial tree

Barker A. N Engl J Med 2002;346:1383-1393

Etiology of Bronchiectasis

Localised• TB, bacterial or viral infection, especially in children

(measles, whooping cough)

• Foreign body

• Bronchus stenosis, extrinsic compression (adenopathy)

Diffuse• TB, bacterial or viral infection, especially in children

(measles, whooping cough)

• Cystic Fibrosis• Other congenital diseases: Situs inversus, immotile

cilia syndrome• Disglobulinemy, chronic immune deficit, chronic auto-

immune affections

• Repeated infections

• Hemoptysis

• Significant and sometimes purulent sputum, (AFB negative)

•Bronchiectasis, Clinical Features:

Bronchiectasis Radiological Features:

• Round or cylindric opacities

• Sometimes with an air-fluid level if active infection

• Localised in one lobe or in a segment, or diffuse

Bronchiectasis

Bronchography (opacification of bronchi by iodine contrast fluid) is no more used

CT is not the gold standard to confirm the diagnosis of bronchiectasis

Bronchiectasis

Rail Picture: Cylindric Bronchiectasis

Lung field

PNEUMONIA

Lobar consolidation appears as extensive opacification of part or whole of a lobe. An air bronchogram is often seen in the consolidation. The lobar pneumonia is often demarcated by a fissure; the horizontal fissure separates the opacification from the middle lobe.

Dikutip dari Silbernagi, Lang. Color Atlas of Pathophysiology. 2000

TUBERCULOSIS

Young Tibetan Refugee, Worsening Condition,

Sputum and Fever, AFB positive

As in the

previous slide,

close to cavity

there are

infiltrates and

nodules, which

are highly

suggestive of

TB

Woman with Cough and

Recurrent Hemoptysis

Right Upper Lobe Pneumonia with two Cavities

and Draining Bronchus, AFB positive

SEL DATIA

LANGHANS

Pematangan lesi TB paru

Dartos V. The path of anti-tuberculosis drug: from blood to lesions to mycobacterial cell. Nat Rev

Microbiol. 2014

CONGESTIVE LUNG OEDEM

Chest X-ray showing alveolar oedema: airspace opacification

in the perihilar regions A producing a bat’s wing appearance.

Both costophrenic recesses are blunted B , indicating small

effusions.B

A

B

Silbernagl S, Lang F. Color Atlas of Pathophysiology.Thieme

Stuttgart.New York. 2000

Ware L. New England J Med 2005.

PLEURAL DISEASE

Pneumothorax on right hemithorax with avascular hyperluscent

94

Pleural effusion: Defined as fluid between visceral

and parietal membranes

lung

visceral serous

membrane

parietal serous

membrane

95

Effusion in pleural cavity

- Opacity not limited by fissure

- No air bronchogram

- Moves with change of position

The upper limit is curved with

a upperr concavity ascending

from the mediastinum to the

lateral thoracic wall

96

Small quantity (0.5 to 0.7 L)

97

Medium quantity

98

Substantial pleural effusion (1.5 to 2.5 L)

99

Right Sided Pleural Effusion

May push against the mediastinum on the opposite side

100

Pleural

effusion

Left sided

atelectasis

Mediastinum

pull

Pushing back

101

Pleural syndrome

Overlap of all the hemithorax

The mediastinum is pushed away

from the side of the pathology

The diaphragm is pressed down

Abundant effusion

102

Left pleural effusion and left atelectasis (pleural effusion associated with retraction)

Note that a pleural effusion is not retractile,

unless there is associated atelectasis

103

The supine position provides a different perspective on a pleural effusion

104

Effusion in fissure

PA view:

Effusion in the

small and in

the big fissure

Lateral view:

Opacities with

shuttle form

105

Effusion in the small fissure

106

Loculated pleural effusion

107

Scan view of the previous case

DISCUSSION

A 70-year-old chronic smoker for 50 years presented with

exertional shortness of breath for 1 year. His exercise

tolerance was limited to 1 flight of stairs.

Physical examination showed he was tachypnoeic with

central cyanosis.

Examination of respiratory system revealed use of accessory

muscles of respiration and hyperinflated chest on both sides.

Air entry was globally decreased in both lungs.

(1) What abnormality can you identify on CXR ?

(2) What is the clinical diagnosis ?

ANSWER

(1) What abnormality can you identify on CXR ?

- Hyperinflated, hyperlucent lungs

- Flat diaphragm

(2) What is the clinical diagnosis ?

• Frontal chest radiograph showing bilateral hyperlucent, hyperinflated lungs of chronic obstructive airway disease. There is some minor fibrosis in the right upper zone from previous TB.

Sibernagl S, Florian L. Color Atlas of Pathophysiology. Thieme Stuttgart-New York.

2000

KERJA PERNAFASAN OTOT DIAFRAGMA

KERJA PERNAFASAN OTOT INTERKOSTA

PRE TEST

CASE 1

• A 35-year-old man presented with fever and productive cough for 3 days. He was febrile, hypoxic and physical examination showed focal decrease in air entry and coarse crepitations over the right lower chest.Laboratory investigations revealed leukocytosis and a CXR was performed

1. A. What abnormalities do you see on this CXR ?

B. What is the most likely diagnosis ?

CASE 2

A 65-year-old man presented to the Accident and

Emergency Department with crushing chest pain and shortness of breath and a CXR was performed

CASE 2

(1) What are the chest radiograph findings ?

(2) What is the diagnosis?

CASE 3

• A 45-year-old woman with poorly controlled diabetes mellitus, presented with productive cough for 1 month. She also noticed low grade fever, night sweating and weight loss during this period.

Examination of the chest showed a dull percussion note, decreased air entry and coarse crepitations in the right upper zone.

Laboratory investigations revealed raised ESR, normal white cell count and a CXR was performed.

CASE 3

(1) What radiological abnormalities can you identify ?

(2) What is the radiological diagnosis ?

CASE 4

A 53-year-old non-smoker presented with fever, dyspnoea and productive cough for 3 days. A

physical examination of the respiratory system revealed decreased air entry over the right chest

where the percussion note was stony dull in nature. Laboratory investigations showed leukocytosis,

sputum culture grew Staphylococcus pneumonia and a CXR was performed

CASE 4

(1) What radiological abnormality can you identify ?


CASE 5

• A 23-year-old man with good past health, presented with sudden onset left sided chest pain and shortness of breath. The pain was sharp in nature and more severe on inspiration. Physical examination showed decreased air entry in the left upper chest which was hyperresonant on percussion. Laboratory investigations were essentially normal. A CXR was performed for further evaluation


(2) What is the most likely diagnosis ?

POST TEST

CASE 1

• A 35-year-old man presented with fever and productive cough for 3 days. He was febrile, hypoxic and physical examination showed focal decrease in air entry and coarse crepitations over the right lower chest.Laboratory investigations revealed leukocytosis and a CXR was performed

1. A. What abnormalities do you see on this CXR ?

B. What is the most likely diagnosis ?

ANSWER

1. A. Area of increased opacity with ill-defined borders

Faint air bronchogram within the area of opacification

2. Pneumonia.

CASE 2

A 65-year-old man presented to the Accident and

Emergency Department with crushing chest pain and shortness of breath and a CXR was performed

CASE 2

(1) What are the chest radiograph findings ?


CASE 2

(1) What are the chest radiograph fi ndings ?

- Cardiomegaly

- Upper lobe venous diversion

- Septal lines (Kerley B lines) best seen in the right lower zone

- Sharply outlined haziness in the right upper zone with no evidence of an air bronchogram suggestive of fluid in the right horizontal fissure


Congestive cardiac failure.

CASE 3

• A 45-year-old woman with poorly controlled diabetes mellitus, presented with productive cough for 1 month. She also noticed low grade fever, night sweating and weight loss during this period.

Examination of the chest showed a dull percussion note, decreased air entry and coarse crepitations in the right upper zone.

Laboratory investigations revealed raised ESR, normal white cell count and a CXR was performed.

CASE 3



CASE 3 - ANSWER


- Multiple areas of air-space opacification in the right lung also involving the apex

- Cavitation and air-fluid level within the opacified areas

Blunting of right CP angle due to exudative effusion


Frontal chest radiograph showing air-space opacification in the right lung with cavitating lesions (arrows) due to caseous necrosis in tuberculosis.

CASE 4

A 53-year-old non-smoker presented with fever, dyspnoea and productive cough for 3 days. A physical examination of the respiratory system revealed decreased air entry over the right chest where the percussion note was stony dull in nature. Laboratory investigations showed leukocytosis,

sputum culture grew Staphylococcus pneumonia and a CXR was performed

CASE 4



ANSWER


- Complete opacification of the right mid and lower zoneseffacing the right heart border and right hemidiaphragm

- Blunting of the right costophrenic angle

- No evidence of mediastinal shift


Erect chest radiograph showing large right pleural effusion opacifying the right mid and lower zone

CASE 5

• A 23-year-old man with good past health, presented with sudden onset left sided chest pain and shortness of breath. The pain was sharp in nature and more severe on inspiration. Physical examination showed decreased air entry in the left upper chest which was hyperresonant on percussion. Laboratory investigations were essentially normal.

• A CXR was performed for further evaluation


- Hyperlucent zone devoid of vascular marking in periphery of left hemithorax.

- Shift of midline to the right.


Large left pneumothorax with mediastinal shift to the right. Note the collapsed left lung (arrows) and thehyperlucent left hemithorax.

TERIMA KASIH

chest x ray intepretation in pulmonology thomas handoyo - chest x ray... · workshop thomas handoyo...

Documents