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Terminology in Chest XRays

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Terminology in Chest XRays PA view- chest close to xray plate xray tube 6 feet from patient Pt erect AP view- back close to plate ... – PowerPoint PPT presentation

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Title: Terminology in Chest XRays


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Terminology in Chest XRays
  • PA view- chest close to xray plate
  • xray tube 6 feet from patient
  • Pt erect
  • AP view- back close to plate
  • xray tube 3 feet from pt
  • pt supine
  • PA sharper
  • less magnified
  • Both generally taken in full inspiration
  • Oblique- taken with pt standing obliquely. Right
    oblique is with right chest against the plate
  • Lateral decubitus side of supine pt on the
    plate with xray tube horizontal
  • Apical Lordotic- xray tube angled at 45
  • Sternal rib views

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HOW TO READ A CHEST X-RAY
  • Switch off all unnecessary lights.
  • 1.Identify patient name,age,sex,hosp . Date of
    xray and side marker (R or L)?
  • 2.. Check the adequacy and tech quality of film
  • Exposure- mid thoracic intervertebral disc should
    be clearly visible or a finger held behind the
    black part of the film should be just visible.
    Underexposed film is pale- lung appears
    consolidated/pulm edema. Overexposed film is
    black suggest emphysema
  • Position Supine or erect. PA,APor lat
  • Rotation (centered)- Spinous process of upper
    thoracic vertebrae should be central Medial
    ends of clavicles must be equidistant from the
    central spinous process
  • Lung volume (Degree of inspiration)- Right
    hemidiaphragm should reach the anterior end of
    6th / 7th rib or the 9th / 10th rib posteriorly
    on full inspiration
  • gt 6th rib in expiration indicates
    hyperinflation( emphysema)?
  • lt 5th rib indicates underinflation (
    crying infant)?
  • Film taken in expiration may simulate
    disease cardiomegaly, pulmonary congestion
  • 1

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(CONTD.)?
  • 3. Check the extrathoracic soft tissue-
  • Start at the top with the supraclavicular areas,
    neck, shoulder,- look for subcutaneous
    emphysema., calcified glands Continue down each
    side of the chest Assess breast shadows. Finally
    check under the diaphragm for air
  • 4.. Check the bony cage Ribs,clavicles,
    scapulae,shoulder jts,thoracic spine
  • 5..Check for medical equipment
  • like ET tube, CVP line -Tip of ET tube should be
    about 2 cm from carina
  • 6. F. Check the superior mediastinum for widening
    or abnormal masses and identify the trachea
  • thymus causes widening upto 2yrs
  • 7. Check the heart- its positioned with 1/3 of
    its diameter to the right and 2/3 to the left of
    the spinous process. A low diaphragm will cause a
    right shift and a high d a left shift. The
    hearts full dia should be less than ½ of the
    internal thoracic dia at its widest point (
    cardiothoracic ratio)?
  • 8.Check the diaphragms, Cp Cp angles.
  • R dia 3 cm higher than left. Outline should
    be smooth with highest point medial to the
    midline of the hemithorax
  • Gastric bubble seen under L diaphragm
  • 9.. Hilum
  • Hilar shadows- made up of pulm art and large
    veins. Left hilum normally 2 cm higher than right
  • 10.Lungs
  • Lung pattern- all the markings in a normal lung
    are vascular. They disappear 2 cm or less from
    the lung margin
  • Lung zones- Upper apex to 2nd costal
    cartilage,
  • Middle -2-4 cartilage
  • lower below 4th cartilage

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Features of Anatomy seen on PA VIEW
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LATERAL VIEW
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Normal PA view
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PA VIEW
  • Each lobe is covered by visceral pleura.The
    visceral pleura bordering adjacent surfaces of 2
    lobes form the septa,which separates the lobes.
  • The space between 2 adjacent septae is called the
    interlobar fissure- a fissure is a narrow space
    a septa is a divider. The 2 terms are used
    interchangeably
  • Right lung has 3 lobe-RUL,RML,RLL separated by
    septa or fissures
  • R major fissure runs obliquely downwards from 5th
    thoracic vertebra to the diapraghm to a point
    just behind the ant cp angle.
  • Not normally seen in PA view as it is not
    parallel to the x-ray beam
  • The Right minor fissure intersects the lateral
    chest wall at the level of anterior portion of
    4th rib(/_2)?
  • RUL made up of apical ,anterior posterior
    bronchopulmonary segments
  • RML made up of lateral and medial segments
  • RLL made of superior, medial basal, ant basal,
    lateral basal and post basal

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PA view
  • Left lung is made of
  • LUL LLL
  • The LUL is made up of apicoposterior and anterior
    segments
  • The lower or lingular division of the LUL is made
    up of sup inf seg
  • The LLL is made up of the sup, medial basal, ant
    basal, lat basal and postbasal

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NORMAL CXR
  • Trachea is central
  • Dome of R diapraghm is at the level of 6th rib
  • L hemidiapraghm is 3cm lower than the R
  • Heart size is lt 50 of the thoracic diameter. 2/3
    of the heart lies to the L and 1/3 to the R of
    the spine
  • Cardiac apex gastric bubble are to the left
  • Horizontal fissure lies at the level of the 4th
    costal cartilage.
  • Mediastinum is lt 25 of the chest width

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HEART BORDERS
1.Aortic knuckle 2.Pulm. Artery 3.L.atrial
appendage 4.L ventricle 5.R atrium 6.trachea
7.R dome of diaphragm 8.gas bubble in stomach
9.horizontal fissure
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CT ratio
  • MRDmaximum R
    diameter

  • MLD maximum L diameter.

  • ID internal diameter

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USEFUL RULES SIGNS
  • The Silhouette Sign
  • Contiguous objects of the same density are not
    seen separately
  • The 4 basic densities are air, fat, water and
    metal
  • The silhouette sign is seen when a border of the
    heart, aorta, or diaphragm is obliterated
  • The heart and ascending aorta are anterior
    structure

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Causes of confluent opacification of a hemithorax
  • There are four main causes of confluent
    opacification of a hemithorax -
  • consolidation (that is, material within the
    air-spaces and
  • pleural effusion - that is, material within the
    pleural space, which could be serous fluid,
    blood, or pus.
  • Complete collapse of one lung with the
    mediastinum shifting over the the abnormal side
    can also cause a "white out" on the abnormal
    side.
  • Finally, after a pneumonectomy the mediastinum
    shifts to the empty hemithorax and the residual
    pleural space fills with fluid and fibrotic
    material leaving the patient with a complete
    "white out" on the side that has been operated
    on. Consolidation and pleural effusion are the
    two most common, and it can be difficult to
    distinguish between them - of course, they can
    coexist.

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Collapse-RML
  • Silhouette sign

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RML COLLAPSE-LATERAL
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RML collapse..graphic
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Collapse
  • Collapse of a lobe is caused by proximal
    obstruction
  • for example, by a neoplasm, mucus plug, such as
    in a postoperative patient, or foreign body, such
    as in a child.

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AIR BRONCHOGRAM
  • The bronchi are not normally seen on the xray as
    they are thin walled, contain air and are
    surrounded by air in the alveoli
  • Visualisation of air in the bronchi is known as
    an air bronchogram
  • Air- filled bronchi can be seen if surrounded by
    diseased lung which contains no air (eg
    pneumonia, hyaline membrane disease,RDS)?

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RDS
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SAIL SIGN
  • The normal thymus lies in the sup, ant
    mediastinum. In the infant , it may appear to
    widen the mediastinum in a PA view, being largest
    at about 2 years of age
  • The inferior border of the R thymic lobe is a
    straight line. When it rests on the R horizontal
    fissure it produces an appearance referred to as
    the sail sign

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sail sign
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RUL collapse..graphic
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LLL COLLAPSE
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LLL COLLAPSE
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Medial segment of R middle lobe CONSOLIDATION
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RMLL PNEUMONIA
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TB HILAR ADENOPATHY
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APICAL TB
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MILIARY TB
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Pl. effusion R
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