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22nd Annual Intensive Review of Internal Medicine

June 7th, 2010
Cleveland Clinic

Chest X-Ray Interpretation

Scott D. Flamm, M.D.
Cardiovascular Imaging Laboratory
Imaging, and Heart and Vascular Institutes
Cleveland Clinic, Cleveland, Ohio

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Outline:
First things first
Normal Anatomy
Vascular Patterns
Chamber Enlargement
Cases

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First Things First:

Right patient
Right date and time
Right orientation

Use of PACS lessens errors

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First Things First:

What next?
Pneumothorax
Free air under the diaphragm

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Normal Anatomy:

http://radresidents.ccf.org/omar/Anatomicguide/Mainpagecxr.htm

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Normal Anatomy:

http://radresidents.ccf.org/omar/Anatomicguide/Mainpagecxr.htm

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Normal Anatomy:

http://radresidents.ccf.org/omar/Anatomicguide/Mainpagecxr.htm

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Normal Anatomy:

http://radresidents.ccf.org/omar/Anatomicguide/Mainpagecxr.htm

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Normal Anatomy:

http://radresidents.ccf.org/omar/Anatomicguide/Mainpagecxr.htm

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Pulmonary Vasculature in Cardiac Disease:

Normal:
No LR shunting:
Pulmonary artery or vein obstruction
(PA SysP: 30 mm Hg)
Aorta or Aortic Valve obstruction
w/o LV dysfunction or MV disease
PCWP < 13 mm Hg

LR shunting:
Qp:Qs < 1.5:1.0

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Question #1:
What is the abnormality?
1) CXR is backward
2) Right aortic arch
3) Free air under left diaphragm
4) None the CXR is normal

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Pulmonary Vasculature in Cardiac Disease:

Decreased:
CHD:
RL or complex shunting
TOF, PA, Severe PS (+ASD),
Ebsteins (+ASD), TA (+ASD+PS),
ccTGV (+VSD+PS),
admixture lesions (+VSD+PS), etc.

Acquired:
RV dysfunction: e.g., ARVD

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Pulmonary Vasculature in Cardiac Disease:

Increased:
Pulmonary Venous Hypertension:
Stage I: Redistribution
WP: Acute 13-18 mm Hg; Chronic 18-22 mm Hg

Stage II: Redistribution + Interstitial Edema

WP: Acute 18-25 mm Hg; Chronic 23-30 mm Hg

Stage III: Redistribution + Interstitial +

Alveolar Edema
WP: > 25 mm Hg; Chronic > 30 mm Hg

Stage IV: Chronic Pattern + Hemosiderin/Ca++

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Pulmonary Vasculature in Cardiac Disease:

Pulmonary Capillary Wedge
Pressures
< 12 mmHg
Normal
Cephalization
Kerley B lines

12-18 mmHg

Interstitial Edema

18-25 mmHg

Alveolar Edema

> 25 mmHg

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NL (MS)

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PVH 1 (MS)

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PVH 2

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PVH 3 (Acute MI)

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Pulmonary Vasculature in Cardiac Disease:

Chest X-Ray Features of Pulmonary Edema:

Heart Size
Vascular Pedicle
PBF Distribution
Pulmonary Blood Volume
Septal Lines
Peribronchial cuffing
Air bronchogram
Edema distribution
Pleural Effusions

Cardiac
Increased
NL or
Reversed
NL or
Not common
Common
Not common
Even
Common

Renal
Increased
Increased
Balanced
Increased
Not common
Common
Not common
Central
Common

Injury
Normal
NL or
NL or Bal.
Normal
absent
Not common
Common
Peripheral
Not common

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Alveolar Air-space Filling Etiology?

PVH 3
(Acute MI)

Pulmonary
hemorrhage

Pneumonia

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Pulmonary Vasculature in Cardiac Disease:

Pulmonary Arterial Hypertension:

Pulmonary Arterial Pressures:
Mild:
Moderate:
Severe:

35-50 mm Hg
50-75 mm Hg
> 75 mm Hg

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Pulmonary Vasculature in Cardiac Disease:

Pulmonary Arterial Hypertension:

Etiologies:
Obstructive (Pulmonary Vascular Disease)
Idiopathic (Primary), Thromboembolism,
Arteritis, Schistosomiasis

Obliterative (Pulmonary Parenchymal Ds.)

Emphysema, Pulmonary Fibrosis

Constrictive (Hyperkinetic)
Hypoxia, Shunts

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PAH

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1o PAH

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PAH - Chronic PE

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Valve Disease by CXR

General causes:
Volume overload
Typically valvular regurgitation

Pressure overload
Typically valvular stenosis

Volume overload = overall increase in

cardiac size, while pressure overload
usually not until later in disease.

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Valve Disease by CXR

Signposts

Left atrial enlargement

Left ventricular enlargement
Ascending aortic enlargement
Right atrial enlargement
Right ventricular enlargement

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Valve Disease by CXR

Left atrial enlargement:
Radiographic signs:

Right retrocardiac double density (or L)

Straightening of left heart border
Straightening, elevation of LMB
Posterior displacement of LMB on lateral
> 7cm. from R lateral wall of LA to LMB
Increased carinal angle (>100 deg)
Prominent left atrial appendage

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Valve Disease by CXR

Left atrial enlargement:
Small heart
Big heart

mitral stenosis
mitral regurgitation

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MS

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MR

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Valve Disease by CXR

LAE notes:
Mitral stenosis
PVH out of proportion to LAE
Right heart enlargement if signif. PAH

Mitral regurgitation
PVH much less frequently
LAE out of proportion to PVH
LA appendage enlargement = ? rheumatic

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Valve Disease by CXR

Left ventricular enlargement:
Radiographic signs:
Downward displacement of the apex
Posterior displacement of the cardiac
border on lateral view
Hoffman-Rigler sign

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Valve Disease by CXR

Ascending aortic enlargement:
Radiographic signs:
Prominence of Asc. Ao. on lateral film
Tortuosity (to the right) of the Asc. Ao.
on the PA film
Small heart
Big heart

aortic stenosis
aortic regurgitation

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Valve Disease by CXR

Right atrial enlargement:
Radiographic signs:
Lateral bulging of right cardiac border
elongation of right cardiac border

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Valve Disease by CXR

Right atrial enlargement:
Big heart

tricuspid regurgitation

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Ebstein anomaly

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Valve Disease by CXR

Right ventricular enlargement:
Radiographic signs:
Lateral or upward displacement of the
cardiac apex
Filling in of the retrosternal space on
the lateral film
(note: not reliable in patients s/p
median sternotomy)

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Case: Abnormal Air?

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Question #2:
What is the abnormality?
1) Pneumothorax
2) Pneumomediastinum
3) Pneumopericardium
4) None the CXR is normal

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Pearls:
Pneumomediastinum
Air in mediastinum
Air around heart

Pneumopericardium
Cannot diagnose on CXR without
seeing air on undersurface of heart

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Case: Abnormal Air?

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Question #3:
What is the diagnosis?
1) Pneumomediastinum
2) Pneumothorax
3) Tension pneumothorax
4) Selective intubation of the LMB

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Pearls:
Pneumothorax
Hyperlucency
Deep lateral sulcus

Tension Pneumothorax
Shift of heart and mediastinum
Hyperexpansion
Clinical, not x-ray diagnosis

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Case: Shortness of Breath

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Question #4:
What is the diagnosis?
1) Aortic dissection
2) Pneumonia
3) Pneumothorax
4) Pulmonary embolism

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Pearls:
Pulmonary Embolism
Most common CXR: Normal

Can look for:

Segmental oligemia
Hamptons hump
CT now gold
standard

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Case: Acute Chest Pain

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Question #5:
What is the diagnosis?
1) Type A dissection
2) Type B dissection
3) Type II dissection
4) Motion artifact in non-gated scan

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Aortic Dissection:
A

II

III

Classifications:
Stanford
Type A, B
Debakey
Type I, II, III

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Pearls:
Aortic Dissection
CXR may be:
Normal
Widened mediastinum
Pleural effusion
Pericardial effusion

To definitively exclude pts need CT or

MRI

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Pearls:
Aortic Dissection
CT scan must be ECG-gated