Chest Xray Interpretation The Basics

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Chest X-ray InterpretationThe Basics

• Steven M. Koenig, MD, FCCP
• Professor of Medicine
• University of Virginia School of Medicine
• Division of Pulmonary Critical Care

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Outline

• Clinically relevant physics of radiology
• Organized approach to Chest X-ray interpretation
• Normal structures on Chest X-rays
• Lateral
• Basic patterns of disease
• Cases

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Case

• 18 year old M with a history of cancer
• Routine follow-up Chest X-ray

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Question

• Which of the following best
• describes the abnormalities on
• this Chest X-ray?
• No abnormalities
• Thoracic cage abnormality
• Metastatic disease
• Thoracic cage abnormality
• metastatic disease

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The Radiographic Image

• Blackening of the X-ray film
• Proportional to the amount of radiation which
  gets through the object
• X-ray absorption related to
• Density of the tissue
• Volume of the tissue

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The Radiographic Image
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The Radiographic Image

• The differential absorption of radiation by
  different tissues or diseases is responsible for
  all radiographic images.
• When two structures of different densities are in
  direct contact, an edge or border is created

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Bone/Calcium
Air (Gas)
Tissue/ Water
Metal
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13-Step Approach to Interpreting a Chest X- ray

• Prereading
• Correct Patient?
• Correct Date?
• Obtain old Chest X-rays

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13-Step Approach to Interpreting a Chest X- ray

• Views
• PA (Posterior-Anterior) versus AP
  (Anterior-Posterior)

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Geometric Effects
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13-Step Approach to Interpreting a Chest X- ray

• Views
• PA (Posterior-Anterior) versus AP
  (Anterior-Posterior)
• Supine versus Erect

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PA versus APErect versus Supine
Erect PA
Supine AP
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13-Step Approach to Interpreting a Chest X- ray

• Views
• PA (Posterior-Anterior) versus AP
  (Anterior-Posterior)
• Supine versus Erect
• Lateral

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13-Step Approach to Interpreting a Chest X- ray

• Views
• PA (Posterior-Anterior) versus AP
  (Anterior-Posterior)
• Supine versus Erect
• Lateral
• Decubitus

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10 mm
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13-Step Approach to Interpreting a Chest X- ray

• Quality of the film
• Rotation
• Inspiration
• Penetration
• Scapula

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Inspiratory versus Expiratory
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Organized Approach to Chest X-ray
Interpretation

• Are (Abdomen-diaphragm)
• There (Thoracic cage)
• Many (Mediastinum)
• Upper, hilum, cardiac
• Pulmonary (Pleura)
• Lesions (Lung)
• Individual, fissures, bilateral

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14-Step Approach to Interpreting a Chest X- ray

• Interpreting the film
• Thoracic Cage, abdomen
• Bone, soft tissue
• Mediastinum
• Upper
• Hilum
• Heart

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14-Step Approach to Interpreting a Chest X- ray

• Interpreting the film
• Pleura
• Diaphragmatic
• Lung fields
• Individual
• Fissures
• Bilateral (compare side to side)

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Upper Mediastinum
Thoracic Cage
Pleura
Hila
Cardiac
Lungs
Lungs
Abdomen-diaphragm
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Right Hemi-diaphragm
Left Hemi-diaphragm
Stomach Bubble
Abdomen
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Manubrium
Scapula
Body of Sternum
Spine
Ribs
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Trachea
Ascending Aorta
Descending Aorta
Aortic Arch (Knob)
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Left Pulmonary Artery
Right Pulmonary Artery
LUL Bronchus
Inferior Pulmonary Veins
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Hilum
RUL Bronchus
Left PA
Right PA
LUL Bronchus
Inferior PV
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Right Ventricle
Left Atrium
Left Ventricle
Inferior Vena Cava
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IVC
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Costophrenic Angle
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Retrosternal Clear (Air) Space
Minor fissure
Major fissure
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Amputated Right Shoulder
Metastasis
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Question

• Which of the following best
• describes the abnormalities on
• this Chest X-ray?
• No abnormalities
• Thoracic cage abnormality
• Metastatic disease
• Thoracic cage abnormality
• metastatic disease

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Case

• 62 yo M presents with a 1 day history of DOE, a
  nonproductive cough and substernal chest pain.

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Question

• What is the most appropriate next step?
• Chest Tube
• Prednisone nebulizers
• Prednisone nebulizers antibiotics
• Spiral Chest CT (CT angiogram)
• Careful follow-up

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Basic Patterns of Disease

• Increased transradiancy
• Radiolucency
• Increased blackness
• Pulmonary opacity
• Abnormal whiteness
• Signs
• Silhouette
• Air bronchogram

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Radiolucency

• Decreased tissue to absorb radiation
• Lung
• Pneumothorax
• Emphysema
• Blood vessels
• Chest wall
• Bilateral, unilateral, focal

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Question

• What is the most appropriate next step?
• Chest Tube
• Prednisone nebulizers
• Prednisone nebulizers antibiotics
• Spiral Chest CT (CT angiogram)
• Careful follow-up

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Case

• 63 yo M admitted in pulmonary edema secondary to
  an STEMI
• 2 days after admission
• Sudden development of hypotension worsening
  hypoxemia

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Question

• What is the most appropriate next step?
• STAT electrocardiogram
• STAT echocardiogram
• Emergency cardiac catheterization
• Aortic balloon pump
• Fluid resuscitation
• Vasopressors
• Disconnect patient from ventilator
• Chest tube

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Question

• What is the most appropriate next step?
• STAT electrocardiogram
• STAT echocardiogram
• Emergency cardiac catheterization
• Aortic balloon pump
• Fluid resuscitation
• Vasopressors
• Disconnect patient from ventilator
• Chest tube

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Case

• 58 yo W presents with a several month history of
  DOE and a nonproductive cough.

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Question

• What is the best interpretation of this
• Chest X-ray?
• Paralyzed right hemi-diaphragm
• RLL atelectasis
• Right-sided pleural effusion
• RLL pneumonia R-sided pleural effusion
• Bilateral pleural effusions

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Lateral displacement, diaphragm apex
Blunted costophrenic angle
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Lateral displacement, diaphragm apex
Blunted costophrenic angle
Stomach bubble sign
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Blunted costophrenic angles
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10 mm
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Elevated Hemi-Diaphragm

• Subpulmonic pleural effusion
• Phrenic nerve paralysis
• Lung volume loss
• Atelectasis
• Upper abdominal process
• Diaphragmatic process

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Question

• What is the best interpretation of this
• Chest X-ray?
• Paralyzed right hemi-diaphragm
• RLL atelectasis
• Right-sided pleural effusion
• RLL pneumonia R-sided pleural effusion
• Bilateral pleural effusions

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Case

• 54 yo W, presents with a 5-day history of
  dyspnea, non-productive cough and fever
• Nasal congestion, rhinorrhea
• 40 pack-year smoking history
• Moderate COPD

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Question

• What is the most appropriate next step?
• Prednisone nebulizers
• Prednisone nebulizers antibiotics
• Regular Chest CT
• Spiral Chest CT (CT angiogram)
• Careful follow-up

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Silhouette Sign

• The heart, aorta diaphragms normally have sharp
  margins
• All are tissue (water) density in direct contact
  with lung (air) density
• When different densities adjoin, there is a
  border or edge

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Silhouette Sign

• When two substances of the same density come in
  direct contact, there will be no border or edge
• Cannot be differentiated from each other on an
  X-ray
• Silhouette sign
• Loss of a normal radiographic border or
  silhouette
• Helps localize the abnormality

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Silhouette Sign
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Silhouette Sign
RML
Lingula
RLL
LLL
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RUL or LUL
Minor fissure
Major fissure
RML or Lingula
RLL or LLL
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Question

• What is the most appropriate next step?
• Prednisone nebulizers
• Prednisone nebulizers antibiotics
• Regular Chest CT
• Spiral Chest CT (CT angiogram)
• Careful follow-up

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Case

• 68 yo W, with a 50 pack-year
• history of cigarette smoking,
• presents with a 2-day history
• of fever, DOE and a cough
• productive of purulent sputum.

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Question

• What is the most appropriate next step?
• Prednisone nebulizers
• Prednisone nebulizers antibiotics
• Regular Chest CT
• Bronchoscopy
• Careful follow-up

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Pulmonary Opacities

• Pleural effusion
• Pulmonary mass
• Nodule lt 3 cm
• Atelectasis/lung collapse
• Pulmonary infiltrate
• Airspace filling/shadowing (alveolar) versus
  interstitial

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Pulmonary Opacities

• Ring shadows cysts
• Bulla
• Line band shadows
• Septal (Kerley) line
• Single or focal versus multiple, diffuse or
  multifocal

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RUL or LUL
RUL
LUL
Minor fissure
Minor fissure
RML or Lingula
Lingula
Major fissure
RML
RLL or LLL
RLL
LLL
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RML Atelectasis
RLL or LLL Atelectasis
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Question

• What is the most appropriate next step?
• Prednisone nebulizers
• Prednisone nebulizers antibiotics
• Regular Chest CT
• Bronchoscopy
• Careful follow-up

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Air Bronchogram Sign

• The trachea and mainstem bronchi are normally
  visualized
• Surrounded by the soft tissue (water density) of
  the mediastinum
• Intrapulmonary bronchi are normally not
  visualized
• Surrounded by air

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Air Bronchogram Sign

• Visualization of intrapulmonary bronchi
• Requires the bronchi to contain air and the
  adjacent lung to contain material of tissue
  (water) density
• Indicates that the process is in the lung and not
  the pleura or mediastinum
• Alveolar

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Case

• 28 yo M, presents with 2-day history of fever,
  DOE, and a nonproductive cough.

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Induced Sputum
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Question

• What is the most appropriate next step?
• Bronchoscopy
• Open lung biopsy
• High resolution CT scan of chest
• Broad spectrum antibiotics
• IV Solumedrol
• IV Solumedrol Cytoxan

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Induced Sputum
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Infiltrate

• Airspace filling/shadowing (alveolar) versus
  interstitial
• Single or focal versus multiple, diffuse or
  multifocal

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What can fill alveoli?
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What can fill alveoli?

• Water
• Cardiac pulmonary edema
• Protein
• ARDS, alveolar proteinosis
• Fibrous tissue
• COP (BOOP)
• Foreign material
• Lipoid pneumonia

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What can fill alveoli?

• Cells
• Neutrophils
• Infectious pneumonia
• Lymphocytes
• Hypersensitivity pneumonitis
• Macrophages
• Desquamative interstitial pneumonitis (DIP)

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What can fill alveoli?

• Cells
• Eosinophils
• Eosinophilic pneumonia
• Red blood cells
• Diffuse alveolar hemorrhage, lung contusion
• Malignant cells
• Bronchioloalveolar cell carcinoma, lymphoma

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Induced Sputum
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Question

• What is the most appropriate next step?
• Bronchoscopy
• Open lung biopsy
• High resolution CT scan of chest
• Broad spectrum antibiotics
• IV Solumedrol
• IV Solumedrol Cytoxan

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Case

• 65 yo M, presents with a 14-month history of DOE
  and a nonproductive cough

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Question

• Of the following, which is the most
• appropriate next step?
• Bronchoscopy
• Open lung biopsy
• ANA, RF, hypersensitivity
• pneumonitis screen
• No further evaluation

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Interstitial Lung Disease Differential Diagnosis

• Sarcoidosis
• Hypersensitivity Pneumonitis
• Idiopathic
• Tuberculosis

• Fungal
• Asbestosis
• Connective tissue disease
• Eos granuloma
• Drug

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Interstitial Lung DiseaseLimiting the
Differential Diagnosis
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Interstitial Lung DiseaseLimiting the
Differential Diagnosis

• Acute presentation
• Lower versus mid or upper lobe predominance
• Increased lung volumes
• Septal (Kerley) lines
• Miliary pattern

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Interstitial Lung DiseaseLimiting the
Differential Diagnosis

• Hilar lymph nodes
• Enlargement
• Calcification
• Pleural disease
• Effusion
• Thickening/calcification

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Question

• Of the following, which is the most
• appropriate next step?
• Bronchoscopy
• Open lung biopsy
• ANA, RF, hypersensitivity
• pneumonitis screen
• No further evaluation