Introduction to Chest Interpretation ADIS

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Introduction to Chest InterpretationADIS
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With radiographic professional development, skill
mix, extended roles and introduction of reporting
as core modules, there is on-going need for more
structured training. After all, the chest is the
second most common examination after extremity
radiography, and radiographers are exposed to
such examinations in everyday practice. The
College of Radiographers (CoR) recommends that
image interpretation should be part of
undergraduate courses and should allow for
informed comment by 2010. Hughes. K Reporting
on... chest x-ray technique and analysis .
Synergy Sept 2008. SOR London
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The thorax

• A bony cage containing the heart and lungs -
  the rib cage

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Regions of the thorax

• Lungs- consist of lobes separated by fissures
• right - upper, middle and lower lobes
• left - upper and lower - Cardiac notch
• Mediastinum - central compartment between lungs
  containing
• Heart and great vessels
• Airways - Trachea, right and left main bronchus
• Oesophagus
• Nerves and lymphatics

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The mediastinum

• Divided into superior (above heart) and inferior
  portions
• Inferior subdivided into
• Anterior
• Middle
• Posterior

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The diaphragm seen from below
L1 L2 L3
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The diaphragm

• Highest point 1 inch above xiphisternal joint
  (nipple level in males) in neutral expiration
• 3 openings allow passage of
  important structures
• Vena caval orifice
  vertebral level T8
• Oesophageal hiatus T10
• Aortic hiatus T12

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Airway branching
Fig. 23.08
Conducting zone
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Fig. 23.10
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Bronchopulmonary segments
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Structure of primary lung lobule
Fig. 23.11
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• Perfusion gravity dependent - lower lobes receive
  3/4 of cardiac output

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Key anatomy
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Lat CXR
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Systematic Analysis

• The heart and mediastinum.
• The lungs
• Lobar facts.
• R Mid loss of Rt heart border
• R Diaphragm loss Lower lobe
• L heart border loss Lingula of L upper lobe
• L Base Lower lobe.
• The diaphragm should be smooth and sharp.
• The chest wall. s, metastases, mastectomy.
• Soft tissues of the neck.

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Review Areas

• Apices of lungs. Often obscured by ribs.
• Behind the heart.
• Below the diaphragm.
• Neck soft tissues.

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Technical Aspects of CXR

• PA or AP
• Significant magnification of the heart shadow can
  occur on AP chest films.
• Rotation
• The distance between the medial ends of the
  clavicles and the spinous processes of the spine
  should be equidistant.
• Supine or Erect
• Significant effusions and pneumothorax can be
  missed on a supine film.

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AP
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PA
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• State of respiration
• At least 6-8 rib spaces. (pref 9-10 post quoted!)
• Exposure
• Penetration of the heart, range of densities.
• Film labelling
• Wrong diagnosis for wrong patient!
• Markers, is it really dextrocardia?

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6 Anterior ribs and 10 Posterior
ribs demonstrated.
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PA CXR Taken on Full Inspiration
a/b lt50 If over may represent cardiac
enlargement
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Fluid Collections
200 300 ml
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1 2 litres
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Thyroid Goitre
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Obstructive airways disease

• Chronic bronchitis
• chronic productive cough without a demonstrable
  cause
• Inflammation of bronchi
• usually due to smoking
• can lead to emphysema
• Asthma
• characterised by a reversible constriction of
  bronchi in reaction
• to irritants, allergenic agents
• Emphysema

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Emphysema

• Loss of lung surface area due to fusion of
  alveolar spaces
• Smoking, coal mining
• Chest over inflated

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• Bronchiectasis
• permanent abnormal dilatation of bronchi
• due to severe, recurrent or chronic infection
• localised or generalised

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Pneumonia

• Bronchopneumonia
• inflammation centred on airways, patchy
  consolidation, due to wide range of bacteria or
  viruses, common in patients debilitated through
  age or serious disease
• Lobar pneumonia
• affects diffusely an entire lobe
• terminal air spaces
• smaller range of bacterial causes, pneumococcus,
  klebsiella

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Pulmonary Embolism. P.E
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Direct visualisation of PE

• Radiological appearance of truncated pulmonary
  arteries or filling defects within them depending
  on whether embolus complete or partial
• Pulmonary angiography
• Sens and Spec - 98 and 97
• CTPA
• increasingly useful as faster rotation times and
  increased detector number lead to increased
  temporal and spatial resolution
• may miss subsegmental emboli - does this matter?

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Pulmonary Angiogram
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CTPA
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Chest radiography in PE

• Findings with low sensitivity and relatively high
  specificity
• Peripheral oligaemia (Westermarks sign)
• Enlargement of central pulmonary artery
  (Fleishners sign)
• Pleural based opacity ( Hamptons hump)
• Elevated hemidiaphragm

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Westermarks sign
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Hamptons hump
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Infarcts

• Infarcts typically assume a wedge shaped
  appearance due to the branching nature of the
  arterial supply

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Lung infarcts
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