Title: hinhanhnguc
1Chest Imaging
2IMAGING MODALITIES
- Plain chest Radiograph
- Fluoroscopy
- Computerized tomography
- Radionuclide lung scan
- MRI
- Ultrasound
- Pulmonary angiography
3Plain chest radiograph
- Diagnostic in 80 cases
- Standard views
- Postero-anterior(P/A)
- Lateral (right/left)
- Additional views
- Oblique view(ribs)
- Apical lordotic view
- Expiration view
- Decubitus view
4Computed Tomography
- Numerous protocols/techniques depending on
clinical history - Helical/spiral versus high resolution
- Contrast
- Renal failure
- Allergy
5Computed Tomography
- Role of CT
- Main further investigation for most CXR
abnormality (eg nodule/mass) or to exclude
disease with normal CXR - Main investigation for certain scenarios (PE,
dissection, trauma)
6MRI
- Multiple planes
- No radiation
- Common Indication
- Pancoast tumour
- Brachial plexus
- Cardiac
- Vascular (aorta)
- Usually targeted examination (unlike CT)
Coronal
7Nuclear Medicine
- Variety of tests functional rather than anatomic
- V/Q specific to chest imaging
- Others bone scan, gallium, WBC etc.
8Ultrasound
- Limited use in thorax (non cardiac) due to air in
lungs - Assess pleural effusions
- Mainly used for procedures
9Chest Radiographs
- PA (posterior to anterior) and Lateral (left)
- Minimizes magnification of heart (heart closest
to film) - Portable (nearly always AP)
- Supine or Erect
- Specialized Views
- Lordotic
- Lateral decubitus (for effusions, pneumothorax)
10Lordotic View
Better assess apices without bone overlap
11Postero-anterior view (PA)
1
Check technique
1 Adequate penetration of the mediastinum-is the
thoracic spine seen?
4
a
a
2 Has the patient taken a good inspiratory
effort? About 8-10 posterior thoracic ribs should
be seen through the lungs
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3 Is there any rotation of the chest?
Assessed by checking the upper thoracic spinous
process (oval) in relation to the medial ends of
the clavicles (lines a) - this CXR is rotated
to left
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14Retro cardiac space
Retro sternal space
15Chest Radiograph Approach andNormal Anatomy
- THERE IS NO ONE APPROACH BE SYSTEMATIC
- Bone and Soft Tissue including abdomen
- Heart
- Mediastinum-aorta, trachea
- Hila
- Pulmonary Vasculature
- Lungs
- Pleura
16Sequence For X Ray Reading
- 5 Ds
- Detect
- Describe
- Differential Diagnosis
- Discuss
- Diagnosis
17CXR Superimposition
18CT Coronal Reconstruction
Right Brachiocephalic Vein
Left Brachiocephalic Vein
Superior Vena Cava
Right Atrium
Inferior Vena Cava
19Heart Size
- Normal is lt50 on PA upright radiograph
20Increased Cardiac Size
Normal for comparison
Cardiomegaly (Big heart)
21Aorta
MRI of Aorta
PA view
Aortic arch
Descending Aorta
22Aorta
CXR Lateral View
Ascending Aorta
Descending Aorta
23Case Aorta can be enlarged (aneurysm)
24Pulmonary Artery
Coronal Image
PA
25inspexp
- Spine Sign Lungs posteriorly should get darker
as you go down more inferiorly
26Case (Look at the trachea)
Trachea is Deviated by large mass (goiter)
27Abnormal Cases
- Bone
- Cardiovascular
- Airspace Disease including Silhouette Sign
- Interstitial Disease and Pulmonary Edema
- Atelectasis
- Pulmonary Nodule
- Pleura and Diaphragm
- Mediastinal Mass
28Terminology used in the interpretation of CXR
29ACINAR PATTERN (CXR) Radiology Round or
elliptical ill-defined 4-8mm opacities in
lung Microscopic Portion of lung distal to
terminal bronchial (respiratory bronchial,
alveolar duct, alveolar sac and alveoli) is the
acinus
CXR close up of acinar pattern
30ACINAR PATTERN (CT SCAN) Round or elliptical
ill-defined 4-8mm opacities in lung
CT scan of right upper lobe showing typical
acinar pattern (arrow)
31AIR BRONCHOGRAM Air containing bronchus
peripheral to the hilum surrounded by airless
lung
CXR
CT Scan
Air Bronchogram
32NODULAR PATTERN Collection of innumerable small,
linear and nodular opacities together producing
a net with small superimposed nodules.
CT
CXR
Close up of nodular pattern
33EMPHYSEMA Abnormally expanded air spaces distal
to terminal bronchiole with destruction of walls
of involved air spaces..
BULLA Gas containing avascularity of lung
measuring 1cm or more in diameter, 1mm thickness
Bulla
CT of bulla
34Pneumonia (consolidation)
-
- Air bronchograms would confirm an alveolar
process. - The lung volume should not be lost (may even be
increased). - Usually all radiographic abnormalities should
disappear after 6 weeks of appropriate antibiotic
therapy.
35Pneumonia RML
36Right Upper Lobe Pneumonia
37Left Lingular Pneumonia
38Left Lower Lobe Pneumonia
39Pneumonia RLL
40Consolidation and follow-up X-rays
- Recommendations are, repeat film at 1, 3 and 7
days to check for the development of
complications. -
- Resolution of the X-ray signs always lags behind
the clinical findings - The X-ray should therefore be repeated 4 weeks
later to check for resolution. - If there is persistent consolidation at this
stage, further investigation is necessary to
exclude an obstructive lesion.
41SIGNS OF COLLAPSE
- DIRECT SIGNS
- Displacement of fissures
- Loss of aeration
- Vascular bronchial signs
- INDIRECT SIGNS
- Mediastinal Hilar displacement
- Elevation of Hemidiphragm
- Compensatory hyperinflation
42Collapse RUL
43Collapse LUL
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48Left lower lobe collapse
49Diagnosis LLL Collapse
- Collapse secondary to central obstructing tumour
50Pleural Effusion
51Small Pleural Effusion
52Small Pleural Effusion
Normal Sharp Angles
Blunted posterior costophrenic sulcus
53Pleural Effusion
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55Tension Pneumothorax
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57ptxinspexp
Expiration
Inspiration
58hugeptx
Collapsed Right Lung
What would you do with this patient?
Tension Pneumothorax Requires chest tube
59Causes of a pneumothorax
- Spontaneous
- Iatrogenic/trauma,
- Obstructive lung disease, e.g. asthma, COPD
- Infection, e.g. pneumonia, tuberculosis Cystic
fibrosis - Connective Tissue Disorders, e.g. Marfans,
Ehlers-Danlos
60Pneumomed
61Diagnosis Pneumomediastinum
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63Coin Lesion
64Causes of single coin lesions
- Benign tumor, e.g. hamartoma
- Malignant tumor, e.g. bronchial carcinoma, single
secondary - Infection, e.g. pneumonia, abscess, tuberculosis,
hydatid cyst - Infarction
- Rheumatoid nodule
65Solitary Pulmonary Nodule can be
Benign Densely calcified nodule
Malignant Adenocarcinoma
66Cavitating lung lesion
67Causes of cavitating lung lesions
- Abscess
- Neoplasm
- Cavitating pneumonia
- Cavitations in infarct
- Rheumatoid nodules (rare)
68Left Ventricular Failure
69CASE 1
1What is your diagnosis 2 Give differential
diagnosis for upper lobe fibrosis
History Young patient with cough and night sweats
70Normal
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72Severe heart failure
- Severe pulmonary edema gives confluent alveolar
shadowing which spreads out from the hilum giving
a 'bat's wing' appearance. - If this is the cause of generalized shadowing
then upper lobe blood diversion and Kerley B
lines should be present. - In pulmonary edema hilum may appear distended and
the vessels close to the hilum may be blurred.
73Severe heart failure vs. non-carcinogenic
pulmonary edema
- In non-cardiogenic pulmonary edema the heart size
is likely to be normal and there will not
necessarily be sparing of the peripheries.
74COPD
75Bronchiectasis
76Causes of Bronchiectasis
- Structural, e.g. Kartagener syndrome,
- obstruction (carcinoma, foreign body)
- Infection, e.g. childhood pertussis or measles,
tuberculosis, pneumonia - Immune, e.g. hypogammaglobulinaemia, allergic
bronchopulmonary aspergillosis - Metabolic, e.g. cystic fibrosis
- Idiopathic to stasis
77Unilateral Hilar enlargement
78Unilateral Hilar Enlargement
- Causes of hilar lymphadenopothy
- Neoplastic, e.g. spread from bronchial carcinoma,
primary lymphoma - Infective, e.g. tuberculosis
- Sarcoidosis (rarely unilateral)
- Causes of hilar vascular enlargement
- Pulmonary artery aneurysm
- Poststenotic dilatation of the pulmonary artery
79Bilateral Hilar Enlargement
80Bilateral Hilar Enlargement
- Causes of bilateral hilar lymphadenopathy
- Sarcoid
- Tumors, e.g. lymphoma, bronchial carcinoma,
metastatic tumors - Infection, e.g. tuberculosis, recurrent chest
infections, AIDS - Berylliosis
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- Causes of pulmonary hypertension
- Obstructive lung disease, e.g. asthma, COPD
- Left heart disease, e.g. mitral stenosis, left
ventricular failure - Left to right shunts, e.g. ASD, VSD
- Recurrent pulmonary emboli
- Primary pulmonary hypertension
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82NORMAL
83Sarcoidosis
84benignthymoma
85Lateral shows mass is anterior
NORMAL
86Computed Tomography
Thymoma
Do you know of any associated clinical syndrome?
87Presenting CXR
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89MRI
Computed Tomography
90pulmedema
SOB
91Same Patient
92baseline
Same Patient Baseline
93Rul collapse
RUL Collapse
94Lul consolidation
95Diagnosis LUL Consolidation
96Paratracheal ln
97Right Paratracheal Lymphadenopathy
98Rml consolidation
RML Consolidation
9950 y.o female with progressive SOB. What can you
do to improve SOB?
100Volume loss with atelectasis
Mass effect with large effusion
101baseline
Mastectomy
102hh
Hiatus hernia
103Where is the Lymphadenopathy?
104Nipple Shadow