Introduction in chest radiology

Techniques - Projection
P-A (relation of x-ray beam to patient)

Techniques - Projection (continued)

ateral

 Orientation: In this !e are ma"ing reference to the position of the patient and the xray beam# A PA radiograph is obtained !ith the x-ray tra$ersing the patient from posterior to anterior and stri"ing the film# %imilarly an AP radiograph is positioned !ith the xray tra$ersing the patient from anterior to posterior stri"ing the film# The cardiac border or silhouette !ill appear larger on an AP radiograph due to the magnification effect of the more anteriorly located heart relati$e to the film# Typically portable radiographs are obtained AP& as the patient is not able to stand# %tanding radiographs in the department are typically obtained PA !ith a corresponding lateral radiograph# The PA and lateral radiograph best demonstrate the actual cardiac si'e !ith minimal magnification compared to the AP exam#

(rientation

PA

AP

 Inspiration: The $olume of air in the hemithorax !ill affect the configuration of the heart !ith question of cardiac enlargement !ith a shallo! le$el of inspiration# The $ascular pattern in the lung fields !ill be accentuated !ith a shallo! inspiration since the same amount of blood flo! is no! distributed to a smaller $olume of lung# The le$el of inspiration can be estimated by counting ribs# )isuali'ation of nine posterior ribs& or se$en anterior ribs on an upright PA radiograph projecting abo$e the diaphragm !ould indicate a satisfactory inspiration#

Inspiration

*xpiration

 Penetration: +efers to adequate photons tra$ersing the patient to expose the radiograph# This is often limited in patients of large si'e such that there is poor $isuali'ation of structures in the lo!er lung fields and in a retrocardiac location# The lac" of penetration renders the area ,!hiter- than !ith an adequate film and can simulate pneumonia or effusion# In an ideal radiograph the thoracic spine should be barely perceptual $ie!ing through the cardiac silhouette# The soft tissues at the shoulder can also gi$e an estimate of the relati$e degree of penetration of the film#

Penetration

 Rotation of the patient distorts mediastinal anatomy and ma"es assessment of cardiac chambers and the hilar structures especially difficult# .hest !all tissue also contributes to increased density o$er the lo!er lobe fields simulating disease# +otation of the radiograph is assessed by judging the position of the cla$icle heads and the thoracic spinous process# Ideally the cla$icle heads should be equidistant from the spinous process#

+otation

+otation

(continued)

+otation

/o! to approach an 0-ray1

+eading a .hest 0-ray

2irst thing3
4 .orrectly put of the film

Then perform your search pattern

4 !hich you al!ays follo! !hen loo"ing at any film 4 this !ay you !ill miss fe!er findings

+eading a radiograph
%tart reading e$ery radiograph by scanning the areas of least interest first& !or"ing your !ay to the more important areas# 5ou !ill be less li"ely to miss important secondary findings#

.hest 2ilm %earch Patterns

ABCs
4 4 4 4 Abdomen 6one .hest %oft tissues

ATMLL
4 4 4 4 4 Abdomen Thorax 7ediastium ung ung

These are the t!o main search patterns that people use !hen e$aluating a chest film#

,AT7

- %earch Pattern

+emember A 8 Abdomen T 8 Thorax 7 8 7ediastinum 8 ungs (unilaterally) 8 ungs (bilaterally)

%earching the ,Abdomen %can across the upper abdomen se$eral times *$aluate normal gas containing structures3 %tomach /epatic flexure of the colon %plenic flexure of the colon *$aluate the li$er and on occasion one can $isuali'e the spleen

Structures Visualized3 %tomach gas bubble %plenic flexure i$er /emidiaphragms Abdomen dz that can mimic Lun disease include3 %ubphrenic abscess 9iaphragmatic hernia /iatal /ernia

%earching the 6ony ,Thorax %tart at the right base& loo" at the soft tissues of the chest !all& ribs& spine and shoulder girdle :o up one side and come do!n on opposite side +emember3
4 Posterior ribs descend medial to lateral 4 Anterior ribs descend lateral to medial

Structures Visualized3 6reast Tissue Posterior +ibs Anterior +ibs %capula .la$icle %pine Thora! ca e dz that ma" stimulate chest dz3 6ony metastasis +ib ; .la$icle fractures

%earching the ,7ediastinum An organi'ed search of the mediastinum is complicated because of all the o$erlapping structures# %tart !ith a global loo" for contour abnormalities& then follo! !ith a more detailed search

Three searches o# the mediastinum: <# Trachea Trachea and andcarina carina

$% Aorta =# Aorta and andthe theheart heart

># 'ilum &% /ilum

%earching the , ungs %ince most chest x-rays are ordered to e$aluated for lung disease& so the lungs are examined last# They are important& so their e$aluation should be more through& therefore !e e$aluate them t!ice#
4 (nce indi$idually 4 %econd time comparing right and left

Structures Visualized3 .ostophrenic angles ung fields Pulmonary $asculature +ight minor fissure

eft ateral .hest 2ilm

)aluable radiographic study /elps to better locali'e lesions Allo!s to $isuali'e o$erlapping tissues Allo!s the $isuali'ation of hidden pathology

%earching the ateral .hest 2ilm

The pattern is the same3 <) Abdomen =) Thoracic cage strutures >) 7ediastinum ?) ungs

Search Pattern3 Abdomen Abdomen Thoraciccage Thoracic ca eand and bones bones Mediastinum 7ediastinum Lun ungs s

6ut before that !e need to ha$e a good understanding of @ormal +adiographic Anatomy

eft /emidiaphragm %tomach gas bubble

Let(s loo) at some o# *isual abdominal structures +ight

i$er

%plenic flexure of the large intestines the /emidiaphragm

Let(s loo) at the Bon" thora!

+ibs %pine .la$icle %capula .hest !all

Let(s loo) at the Bon" thora!

+ibs %pine %ternum

Trachea on .0+ /ilum

etAs loo" at the normal 7ediastinal %tructures

%uperior )ena .a$a Ascending Aorta +ight Atrium Inferior )ena .a$a

)essels Aortic Arch Pulmonary Artery eft Atrium eft )entricle

Aortic Bnob;Arch 9escending Aorta eft Atrium eft )entricle Inferior )ena .a$a Ascending Aorta +ight )entricle

CT - mediastinum

Imagine toracica normala. (liniile numerotate indica nivelurile la care au fost facute sectiunile de mai jos)

1. Traheea. 2. Esofag. 3. Muschiul trapez. 4. Clavicula stanga. 4*. Clavicula dreapta. 5. Muschiul subscapular. . Muschiul infraspinos. !. Muschiul supraspinos. ". Marele pectoral. #. Micul pectoral. 1$. Muschiul dintat anterior. 11. %atissi&us dorsi. 12. Muschiul erector spinae. 13. 'rtera subclavie stanga. 13a. 'rtera subclavie dreapta. 14. 'rtera carotida co&una stanga. 14*. 'rtera carotida co&una dreapta. 15. (ena )ugulara interna stanga. 1 . *capula. 1!. Coasta +. 1". Manubriul sternal. 21. (ena brahiocefalica dreapta. 2 . (ena a,ilara stanga.

1. Traheea. 2. Esofag. 3. Muschiul trapez 5. Muschi subscapular. . Muschi infraspinos. !. Muschi supraspinos. ". Marele pectoral. #. Micul pectoral.

11. %atissi&us dorsi. 12. Muschiul erector spinae. 13. 13a. 'rtere subclavii. 14. 14*. 'rterele carotide co&une. 1 . *capula. 1". Manubriul sternal. 21. 21*. (ene brahiocefalice. 2!. 'rtera brahiocefalica.

1. Traheea. 2. Esofag. 3. Muschiul trapez. 5. Muschi subscapular. ". Marele pectoral. 11. %atissi&us dorsi. 12. Muschiul erector spinae. 13. 'rtere subclavii. 14. 'rterele carotide co&une. 1 . *capula. 1"*. Corpul sternului. 21. 21*. (ene brahiocefalice. 24. Muschiul rotund &are. 2!. 'rtera brahiocefalica.

1. Traheea. 2. Esofag. 3. Muschiul trapez. 5. Muschiul subscapular. . Muschiul infraspinos. ". Marele pectoral. 11. %atissi&us dorsi. 12. Muschiul erector spinae. 13. 'rterele subclavii. 14. 'rterele carotide co&une. 1 . *capula. 1"*. Corpul sternului. 1#. 'rcul aortei. 1#*. 'orta ascendenta. 21. 21*. (ene brahiocefalice. 22. (ena cava superioara. 24. Muschiul rotund &are. 25. Muschiul rotund &ic. 2!. 'rtera brahiocefalica.

1. Traheea. 2. Esofag. 3. Muschiul trapez. 5. Muschiul subscapular. . Muschiul infraspinos. 11. %atissi&us dorsi. 12. Muschiul erector spinae. 1"*. Corpul sternului. 1#. 'rcul aortei. 22. (ena cava superioara. 24. Muschiul rotund &are. 25. Muschiul rotund &ic.

1. Traheea. 2. Esofag. 3. Muschiul trapez. 5. Muschiul subscapular. . Muschiul infraspinos. 1$. Muschiul dintat anterior. 11. %atissi&us dorsi. 1 . *capula.

1"*. Corpul sternului. 1#*. 'orta ascendenta. 1#-. 'orta descendenta. 2$. (ena az.gos. 2$*. 'rcul venei az.gos. 22. (ena cava superioara. 24. Muschiul rotund &are. 25. Muschiul rotund &ic.

2. Esofag. 3. Muschiul trapez. . Muschiul infraspinos. 11. %atissi&us dorsi. 12. Muschiul erector spinae. 1 . *capula. 1"*. Corpul sternului. 1#*. 'orta ascendenta. 1#-. 'orta descendenta. 2$. (ena az.gos. 22. (ena cava superioara. 24. Muschiul rotund &are. 2#. Trunchiul pul&onar. 3$. 'rtera pul&onara dreapta. 3$* 'rtera pul&onara stanga.

2. Esofag. 3. Muschiul trapez. 1$. Muschiul dintat anterior. 11. %atissi&us dorsi. 12. Muschiul erector spinae. 1 . *capula. 1"*. Corpul sternului. 1#*. 'orta ascendenta.

1#-. 'orta descendenta. 2$. (ena az.gos. 22. (ena cava superioara. 24. Muschiul rotund &are. 2#. Trunchiul pul&onar. 3$. 'rtera pul&onara dreapta. 3$*. 'rtera pul&onara stanga. 32. Carina traheala.

2. Esofag. 3. Muschiul trapez. 1$. Muschiul dintat anterior. 11. %atissi&us dorsi. 1 . *capula. 1#*. 'orta ascendenta. 1#-. 'orta descendenta.

2$. (ena az.gos. 22. (ena cava superioara. 2#. Trunchiul pul&onar. 3$. 'rtera pul&onara dreapta. 33. (entriculul drept. 34. 'triul drept.

1"*. Corpul sternului. 1#*. 'orta ascendenta. 1#-. 'orta descendenta. 2$. (ena az.gos. 33. (entriculul drept. 34. 'triul drept. 35. 'triul stang. 3 . (entriculul stang. 3!. (ena pul&onara dreapta. 3!*. (ena pul&onara stanga. 3". *eptul interventricular.

1"-. /rocesul ,ifoid al sternului. 1#-. 'orta descendenta. 2$. (ena az.gos. 33. (entriculul drept. 34. 'triul drept. 35. 'triul stang. 3 . (entriculul stang. 3!. (ena pul&onara dreapta. 3!*. (ena pul&onara stanga. 3". *eptul interventricular. 3#. *inusul coronar. 4$. (alva tricuspida.

Lun +ields
Cpper

etAs loo" at the normal ung %tructures

7iddle

o!er

+etrosternal .lear %pace

+etrocardiac .lear %pace

ateral .ostophrenic %ulci (+ecesses& Angles) .ardiophrenic %ulci (+ecesses& Angles

Posterior .ostophrenic %ulci (+ecesses& Angles)

Dhat are the Pulmonary 2issures1

They are the coming together of the $isceral pulmonary pleura# +ight lung
4 (blique (major) fissure 4 /ori'ontal (minor) fissure

eft ung
4 (blique (major) fissure

+ight (blique 2issure

/ori'ontal 2issure eft (blique 2issure

+C

A closer loo" at the fissures

C +7

obes
+ight upper lobe3

obes (continued)
+ight middle lobe3

obes (continued)
+ight lo!er lobe3

obes (continued)
eft lo!er lobe3

obes (continued)
eft upper lobe !ith ingula3

Lung segments right lung

A. Lateral. I. Lo ul su!erior. 1. *eg&entul apical. 2. *eg&entul posterior. 3. *eg&entul anterior. II. Lo ul mijlociu. 4. *eg&entul lateral. 5. *eg&entul &edial.

B. Anterior III. Lo ul inferior. . *eg&entul apical. !. *eg&entul &ediobazal. ". *eg&entul anterobazal. #. *eg&entul laterobazal. 1$. *eg&entul posterobazal.

C. Posterior

". #edial

$. Basal.

Lun se ments , le#t lun

A. Lateral. I. Lo ul su!erior. 1. *eg&entul apical. 2. *eg&entul posterior. 3. *eg&entul anterior. 4. *eg&entul lingular superior. 5. *eg&entul lingular inferior.

B. Anterior

C. Posterior

". #edial

II. Lo ul inferior. . *eg&entul apical. !. *eg&entul &ediobazal. ". *eg&entul anterobazal. #. *eg&entul laterobazal. 1$. *eg&entul posterobazal. $. Basal.

CT - !ulmonar% &indo&
Lo ul su!erior dre!t Bronhia !rinci!ala drea!ta Lo ul su!erior stang

Traheea

Lo ul su!erior dre!t

Lo ul su!erior stang

Lo ul inferior dre!t

Bronhia !rinci!ala stanga

Lo ul inferior stang

Lo ul su!erior dre!t

Cordul

Lo ul su!erior stang

Lo ul mijlociu dre!t Cordul

Lo ul su!erior stang

Lo ul inferior dre!t

Bronhii lo are

Lo ul inferior stang

Lo ul inferior dre!t

Lo ul inferior stang