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Radiography
Interpretation
M Chadi Alraies, MD
Chief Medical Resident
Case Western Reserve University
SVCH
M C Alraies 1
Reading CXR’s
Have a structured method!
Be consistent with that method
Don’t take short cuts
LOOK AT ALL YOUR PATIENTS XRAYS
YOURSELF (and with your resident of
course!)
PRACTICE…PRACTICE… PRACTICE
What is a Chest Radiograph?
SHADOW
Start at the beginning
Identification
! Correct patient
Correct date and time
Correct examination
Projection – PA or AP
Position – Upright or Supine (Supine folks are
sick)
Inspiratory effort
9-10 posterior ribs
Penetration
thoracic intervertebral disc space just visible
Positioning/rotation
medial clavicle heads equidistant to spinous process
Projection
Portable (AP or Antero-
posterior)
FILM
PA (Postero-anterior)
FILM
Projection
PA AP
Low Lung Volumes
Over Exposure Proper Exposure
9
Mental Break
Anatomy
RUL
RML
RUL (Right Upper Lung)
RML (Right Middle Lung)
RLL (Right Lower Lung)
Right Sided Fissures
LUL (Left Upper Lung)
LLL (Left Lower Lung)
Left Side Fissure
LUL
LLL
What to Evaluate
Lungs
Pleuralsurfaces
Cardiomediastinal contours
Bones and soft tissues
Abdomen
Where to Look
Apices
Retrocardiacareas (left and right)
Below diaphragm
Apical TB
Left Retrocardiac Opacity
Normal Anatomy: Frontal CXR
Heart
Aorta
Pulmonary arteries
Airways
Diaphragm/costophrenic sulci
Normal Anatomy: Lateral
Heart
Aorta
Pulmonary arteries
Airways
Spine
Maximum x-ray Blackest
Transmission
air
(least dense tissue)
fat
soft tissue
calcium
bone
x-ray contrast
Maximum x–ray metal
Absorption
(densest tissue) Whitest
Chest Radiography: Basic Principles
Components:
airbronchogram: air-filled bronchus
surrounded by airless lung
confluent opacity extending to pleural
surfaces
segmental distribution
Air Space Opacity: DDX
Blood (hemorrhage)
Pus (pneumonia)
Water (edema)
hydrostatic or non-cardiogenic
Cells (tumor)
Protein/fat: alveolar proteinosis and
lipoid pneumonia
Interstitial Opacity: Small Nodules
Interstitial Opacity:
Lines
Interstitial Opacity: Lines & Reticulation
Interstitial Opacity
Hallmarks:
small, well-defined nodules
lines
interlobular septal thickening
fibrosis
reticulation
Interstitial Opacity: DDX
Idiopathic interstitial pneumonias
Infections (TB, viruses)
Edema
Hemorrhage
Non–infectious inflammatory lesions
sarcoidosis
Tumor
Well-Defined
Calcification
Ill-Defined Mass
Nodules and Masses
Qualifiers:
single or multiple
size
border definition
presence or absence of calcification
location
Right Paratracheal
Lymphadenopathy
Right Hilar LAN
Right Hilar LAN
Left Hilar LAN
Subcarinal LAN
*
AP Window LAN
Lymphadenopathy
Non-specific presentations:
mediastinal widening
hilar prominence
Specific patterns:
particular station enlargement
Cysts & Cavities
Characterize:
wallthickness at thickest portion
inner lining
presence/absence of air/fluid level
number and location
Pleural Effusion
Pleural Effusion
Pleural Calcification
Pleural Disease: Basic Patterns
Effusion
angle blunting to massive
mobility
Thickening
distortion, no mobility
Mass
Air
Calcification
Thoracic Aorta Aneurysm
Chest breast implants
◆ Rib fx’s
◆ Mediast. OK
◆Pulmonary
contusion
◆ Subcu air
◆ Chest tube
◆ NG tube
MVC victim
Tip of ET tube Carina
Pneumomediastinum
Potential X ray
findings
wide
mediastinum
obliteration of
aortic knob
Rt mainstem
shift up and
right
NG deviate
to right
pleural cap
Major Vessel Injury
Pneumothoraces
Expiration reduces lung volume,
making a small pneumo easier to see
Irregular linear opacities are present in both lungs, especially in the periphery
and the bases of the lungs. The heart is slightly enlarged, but this is not related
to the pulmonary abnormalities in this case.
Hodgkin’s Disease
Ao
SVC
Mediastinal Hematoma
ET tube
Obliterated aortic knob First rib fx
Chest tube
NG shift to Rt.
Lt. Internal Carotid
Rt. Subclavian Art. Artery
ET
Lt. Subclavian
Artery
NG
Aortic
Rupture
Tension Pneumothorax on CT
Tension Pneumo
Mediastinum
Rt. Lt.
Ao
Hemothoraces
Hemothorax
Supine Upright
Hemopneumothorax
Indistinct diaphragm
Elevated, irregular
hemidiaphragm
Clavicle fx
Suspicious
Rib fxs
Close-up
Indistinct, elevated diaphragm
Chest tube
Crushed right chest
After ventilated with PEEP