Objectives
y Identify the radiographic landmarks on a chest radiograph
y Recognize identifiers of poor quality on the chest radiograph
CAPA 2011
Christy Wilson, PA‐C
Georgia Lung Associates
y Outline an approach to interpretation of frontal or lateral chest radiographs
y Recognize common identifiable infections including pneumonia, fungi and tuberculosis
y Recognize the spectrum of common cardiovascular disease processes
y Recognize patterns of primary or metastatic carcinoma of the lung
y Recognize normal and abnormal placement of chest tubes and lines
CXR Workshop
y This workshop will provide a guided review of the anatomy of the thorax and demonstrate the radiographic image correlating to that anatomy. A sequential approach to chest radiographs will be demonstrated and practiced at the view box. Disease processes affecting the heart and lungs will be discussed, using visual correlations on radiographs. This didactic portion will be followed by hands‐on practice at view boxes, with the actual films, demonstrating a wide range of pathology and some normal films for comparison.
What is a Chest X‐Ray? y Definition (diagnostic tool/internal PE)
y Types
y Portable
y PA and Lat
y Decubitus
y Cost
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Indications for Chest X‐rays
y Screening Tool
y Pulmonary complaints
y Pre‐op Clearance
y Trauma
y Line Placement
Ten Rules for Reading a Chest X‐ray
y 1. The only way to learn to read CXRs is to read CXRs. Daily!
y 2. Always check the name and date on the film. 5% of the time it is wrong.
y 3. When confronted with an abnormal CXR, always compare with prior films.
y 4. Don’t ignore the lateral film. It can often clarify the presence or absence of lower lobe dz.
10 Rules con’t
y 5. Don’t confuse “technique” with change on a CXR.
y 6. Consider everything on a CXR that might be useful, ie. FB, ET tubes, etc.
y 7. The presence of clear lung fields and normal heart size rules out CHF as a cause of patient’s sx.
10 Rules con’t
y 8. Lung fields can never be called clear on a PCXR until one has identified the left hemi‐diaphragm and lack of infiltrate behind the heart.
y 9. The Chest X‐ray never lies!
y 10. Ask for help, it is always available!
y ***The obvious is not always the most important finding!
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Anatomy of the Lungs
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Find these locations!
y Cardiac notch
y Lingula of Left Lung
y Oblique Fissure
y Anterior Border
Step 1: Is it a Good CXR?
How to read a CXR? Step 1:
y Placement of CXR
y Verify the XR
y Name
y Date
y Position markers
y Type of CXR
y Patient History ex: surgical hx
A Good Chest X‐ray????
y Film Quality
y Over vs.. under penetration
y Patient Placement
y rotation
y Body Habitus
y Maximize inspiration
y Nipple markers
y Adequate Inspiration
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Normal Chest X‐ray
ABC’s of Reading a CXR
y A = Appliances and Airway
y B = Bones
y C = Circulation / Cardiac
y D = Diaphragm
y E = Everything Else
Step 2: Airway and Appliances
Appliances /Placement
y Airway ‐ Mediastinum
y Tracheal positioning
y Aortic calcifications
y Foreign Body
y Lines, cardiac monitor, ET tube, Chest tubes, prosthesis, FBs etc.
y Central Line Placement
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Central Line Placement
Chest Tube Placement
Central Line Placement
Step 3: Bones
y Examine the bones
y Count the ribs
y Clavicle alignment
y Spine alignment
y Alignment of Clavicles
y Lateral View ‐ vertebrae
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Bones
Left Sided Chest Pain
y Look at the ribs
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Step 4: Circulation/Cardiac
y Cardiomegaly
y Pulmonary Edema
y Dextrocardia
y Pericardial effusion
Pulmonary Edema
Dextrocardia
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Pericardial Effusion
Step 5 = Diaphragm
y Diaphragm
y Compare elevation, gas patterns, hiatal hernia
Pneumoperitoneum
Elevated Right Hemidiaphragm
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Step 6 = Everything Else
y Soft Tissue
y Breast tissue
y Lung Parenchyma
y Description of Infiltrates
y ***Always compare to previous CXRs
Everything Else
y Pulmonary vasculature
y Pulmonary edema
y Costophrenic angles
y Pleural effusions
y Inflation
y Count the ribs
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y Masses/nodule
y Consolidation
y Parenchyma
y Compare lung fields to each other
emphysema
Reading a Chest X‐ray
Describing a Chest X‐ray
y Lines
y Aorta
y Unilateral vs. Bilateral
y Bones
y AP window
y Focal vs. Diffuse
y Soft Tissue
y Heart
y Location y Trachea
y Diaphragm
y Peripheral vs. Central
y Air
y Hilum
y Interstitial vs. Alveolar Infiltrates
y Mediastinum
y Lungs
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Lung Nodules‐ What to do?
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What is this?
Loculated Effusion
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Pneumoperitoneum
Miliary TB
Honeycombing
What do you see?
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The Lobes of the Lungs
y Left Lower Lobe
y Right Lower Lobe
y Lt. Diaphragm border lost with LLL infiltrate/consolidation
y Rt. Diaphragm border lost
y Right Middle Lobe
y Rt. Heart border lost but able y Left Upper Lobe
to see rt. Costophrenic angle
y Lt. Heart border is lost with a LUL infiltrate/consolidation
Lateral View of CXR
y Right Upper Lobe
y Lingular portion
y Rt. Apex shows consolidation
y Lt. Heart border lost but apex is clear
Lateral View of CXR
Lateral Films
1.Rib 2.Sternum 3.Breast 4.Position of oblique fissure 5.Position of horizontal fissure 14
Pneumonia
y When to admit to the hospital and when to treat as an outpatient?????
CURB‐65
y The CURB‐65 score is based upon five easily measurable factors y Confusion (based upon a specific mental test or new disorientation to person, place, or time) y Urea (blood urea nitrogen in the United States) >7 mmol/L (20 mg/dL) y Respiratory rate >30 breaths/minute y Blood pressure [BP] (systolic <90 mmHg or diastolic <60 mmHg) y Age >65 years
y Score of 2 or more: recommend admitting to the hospital
PSI‐ Pneumonia Severity Index
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Which Pneumonia is this?
What do you see?
45 yobw presents with fever and cough?
What do you see?
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Atelectasis vs. PNA
Recent Surgery‐‐
Pneumothorax with Chest Tube
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Metz. Cavitating Squamous Cell Carcinoma
Fungal Infection‐ cavitary mass
Examples of TB
Bronchiectasis
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Lung Nodule
Case Study #1
y WB 75 yo male presents with worsening SOB/dyspnea and LE edema
y Portable CXR
y Diagnosis
Case Study #2
y DL is a 70 yowm presents to ER via EMS after being involved in a head‐on collision. Pt states his chest hit the steering wheel.
y Portable CXR
y What do you see?
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Case #3
y YM is a 78 yo male with COPD was told he had an abnormal CXR.
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Case Study #4
y FC is a 67 yowm with PMHx of Head and Neck cancer, and chronic aspiration.
y He presented with worsening SOB and presumed aspiration PNA.
y Here is his initial CXR.
Case Study #4
y Patient’s respiratory status worsens and here is a follow up chest x‐ray.
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Case Study #4
Case Study #4
y Bronch is done and large amount of sputum is collected.
y Here is the follow up Chest x‐ray.
Case Study #5
Pt is a 47 yowm who presents with worsening SOB and approx. 20 lb. weight loss over 3 months.
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Case Study #5
Case Study #5
y CT Scan showed multiple pulmonary nodules
y What is the next step for diagnosis?
Case Study #6
y 73 yobf complains of SOB and hypoxemia in the recovery room after just having a THR.
y What do you see?
Case Study #7
y 44 yowf presents with fevers, cough and SOB for one week.
y She admits to a PMHx of Breast Cancer 5 years ago and was treated with bilateral mastectomies and chemo.
y Here is her initial Chest X‐Ray:
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Case Study #7
y Pt was started on antibiotics for pneumonia and underwent a L sided thorocentesis.
y The pleural fluid was sent to the lab – cytology was pending, initial report showed an exudative effusion.
y One day after the procedure, a following chest x‐
ray showed worsening L effusion.
y What did cytology show?
Case Study #7
y CT Scan what done to evaluate the recurrent pleural effusion.
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Case Study #7
y A PET Scan was obtained for staging work‐up.
y The Patient underwent Pleuradesis.
Case Study #8
y WD is a pleasant 62 yowm who presented with Right y
y
y
y
LE edema x 1 week and some L‐sided pleuritic chest discomfort.
PMHx is unremarkable
Labs: Unremarkable
US of RLE: positive for DVT
CT chest with PE protocol: ??????
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Case Study #8
Case Study #8
y What is the treatment?
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updated 6/31/11
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