X-Ray RoundsX-Ray RoundsPlain Chest RadiographsPlain Chest Radiographs

Garry W. K. Ho, M.D.Garry W. K. Ho, M.D.

VCU / Fairfax Family PracticeVCU / Fairfax Family Practice

July 13, 2005July 13, 2005

The 12-Step ProgramThe 12-Step Program

11: : NameName22: : DateDate33: Old films: Old films

44: What type of : What type of view(s)view(s)55: Penetration: Penetration66: Inspiration: Inspiration77: Rotation: Rotation88: Angulation: Angulation99: Soft tissues / bony structures: Soft tissues / bony structures1010: Mediastinum: Mediastinum1111: Diaphragms: Diaphragms1212: Lung Fields: Lung Fields

Quality Control

Findings

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Pre-ReadingPre-Reading

11. . Check the nameCheck the name

22. . Check the dateCheck the date

33. . Obtain old films if availableObtain old films if available

44. Which . Which view(s)view(s) do you have? do you have?– PA / AP, lateral, decubitus, AP lordoticPA / AP, lateral, decubitus, AP lordotic

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55. . PenetrationPenetration

– Should see ribs Should see ribs through the heartthrough the heart

– Barely see the spine Barely see the spine through the heartthrough the heart

– Should see pulmonary Should see pulmonary vessels nearly to the vessels nearly to the edges of the lungsedges of the lungs

Overpenetrated Film

• Lung fields darker than normal—may obscure subtle pathologies

• See spine well beyond the diaphragms

• Inadequate lung detail

Underpenetrated Film•Hemidiaphragms are obscured

•Pulmonary markings more prominent than they actually are

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66. . InspirationInspiration

– Should be able to Should be able to count 9-10 posterior count 9-10 posterior ribsribs

– Heart shadow should Heart shadow should not be hidden by the not be hidden by the diaphragmdiaphragm

1

2

3

4

5

6

7

8

9

10

9-10 posterior ribs are showing

9

About 8 posterior ribs are showing

8

Poor inspiration can Poor inspiration can crowd lung crowd lung

markings producing markings producing pseudo-airspace pseudo-airspace

diseasedisease

With better inspiration, the “disease process” at the lung bases has cleared

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77. . RotationRotation

– Medial ends of Medial ends of bilateral clavicles are bilateral clavicles are equidistant from the equidistant from the midline or vertebral midline or vertebral bodiesbodies

If spinous process appears closer to the right clavicle (red arrow), the patient is rotated toward their own left side

If spinous process appears closer to the left clavicle (red arrow), the patient is rotated toward their own right side

Quality ControlQuality Control

8.8. AngulationAngulation

– Clavicle should lay Clavicle should lay over 3over 3rdrd rib rib

1

2

3

Pitfall Due to AngulationPitfall Due to Angulation

A film which is apical lordotic (beam is angled up toward A film which is apical lordotic (beam is angled up toward head) will have an unusually shaped heart and the usually head) will have an unusually shaped heart and the usually

sharp border of the left hemidiaphragm will be absentsharp border of the left hemidiaphragm will be absent

Apical lordotic Same patient, not lordotic

FindingsFindings

99. . Soft tissue and Soft tissue and bony structuresbony structures– Check for Check for

SymmetrySymmetry

DeformitiesDeformities

FracturesFractures

MassesMasses

CalcificationsCalcifications

Lytic lesionsLytic lesions

FindingsFindings

1010. . MediastinumMediastinum

– Check for Check for CardiomegalyCardiomegaly

Mediastinal and Mediastinal and Hilar contours for Hilar contours for increase increase densities or densities or deformitiesdeformities

FindingsFindings

1111. . DiaphragmsDiaphragms

– Check sharpness of Check sharpness of bordersborders

– Right is normally Right is normally higher than lefthigher than left

– Check for free air, Check for free air, gastric bubble, pleural gastric bubble, pleural effusionseffusions

FindingsFindings

1212. . The Lung Fields!The Lung Fields!– To help you determine To help you determine

abnormalities and their abnormalities and their location…location…

Use silhouettes of other Use silhouettes of other thoracic structuresthoracic structures

Use fissuresUse fissures

Lung Fields: Using Structures / Lung Fields: Using Structures / SilhouettesSilhouettes

Silhouette / Structure Contact with Lung

Upper right heart border/ascending aorta

Anterior segment of RUL

Right heart border RML (medial)

Upper left heart border Anterior segment of LUL

Left heart border Lingula (anterior)

Aortic knobApical portion of LUL

(posterior)

Anterior hemidiaphragms Lower lobes (anterior)

Lung Fields: Using Structures / Lung Fields: Using Structures / SilhouettesSilhouettes

Upper right heart border / ascending aorta (anterior RUL)

Right heart border(medial RML)

Anterior hemidiaphragms(anterior lower lobes)

Upper left heart border(anterior LUL)

Left heart border(lingula; anterior)

Aortic knob(Apical portion of LUL )

Lung Fields: FissuresLung Fields: Fissures

The fissures can also help you to The fissures can also help you to determine the boundaries of pathologydetermine the boundaries of pathology

Major Oblique FissureSeparates the LUL from the

LLL

Right Major FissureSeparates the RUL/RML from

the RLL

Right Minor FissureSeparates the RUL from the

RML

Now for the Cases…Now for the Cases…

Remember… be systematic!Remember… be systematic!

PA view: RML consolidation and loss of right heart silhouette

Lateral View: RML wedge shaped consolidation

RML pneumonia

RUL infiltrate / consolidation, bordered by minor fissure inferiorly

Patchy LLL infiltrate that obscures the left hemidiaphragm; right and left heart borders obscured

RUL and LLL pneumonia

Underpenetrated; possible nonspecific obscuring of left heart border; mostly normal

Multiple bilateral cavitary lesions with air-fluid levels c/w pulmonary abscesses

Tuberculosis

28 y/o female with sudden onset SOB while jogging this morning

Well demarcated paucity of pulmonary vascular markings in right apex

Left spontaneous pneumothorax

RML consolidation that appears wedge shaped on lateral view

RML pneumonia

RLL infiltrate / consolidation

RLL pneumonia

Increased vascular markings; otherwise normal

Patient BIBA to ER s/p airplane crash.

Widened mediastinum

Concern for aortic injury

Explain the prominence of the right atrium on this AP radiograph

Patient rotated to their right (left shoulder forward)

Dilatation of the main pulmonary artery with decreased peripheral vascular

markings

?? Pulmonary embolism ??

Obscuring of the right and left heart borders; infiltrate at the bases

Bilateral aspiration pneumonia

Diffuse bilateral fluffy interstitial infiltrates

Pneumocystis carinii pneumonia

LUL pneumonia

Severe pulmonary TB

Left lung opacity

Later diagnosed as lung cancer

Cardiomegaly, increased pulmonary vascular markings, fluid in the horizontal fissure

CHF

Kerley B Lines

Short (1 -2 cm) white lines at the lung bases, perpendicular to the pleural surface representing distended interlobular septa

What do the arrows indicate?

The 12-Step ProgramThe 12-Step Program

11: Name: Name22: Date: Date33: Old films: Old films

44: What type of : What type of view(s)view(s)55: Penetration: Penetration66: Inspiration: Inspiration77: Rotation: Rotation88: Angulation: Angulation99: Soft tissues / bony structures: Soft tissues / bony structures1010: Mediastinum: Mediastinum1111: Diaphragms: Diaphragms1212: Lung Fields: Lung Fields

Quality Control

Findings

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The EndThe End

Questions?Questions?