10/17/2016. Nuts and Bolts of Thoracic Radiology. Objectives. Techniques

Transcription

1 Nuts and Bolts of Thoracic Radiology October 20, 2016 Carleen Risaliti Objectives Understand the basics of chest radiograph Develop a system for interpreting chest radiographs Correctly identify thoracic anatomy visible on chest radiograph and the region of chest abnormalities Identify common chest radiograph abnormalities Know the indications for obtaining a CT chest v. CXR Develop a system for reading chest CTs Identify common chest CT abnormalities 2 Techniques PA Standard CXR format (usually includes lateral) AP Portable Magnifies anterior structures (i.e. heart) 3 1

2 PA film v. AP film PA AP 4 5 Film Quality Inclusion Penetration Inspiration Rotation Angulation 6 2

3 Inclusion Apices of lungs (first ribs) Costophrenic angles Lateral edges of ribs 7 Penetration Should be able to see: The thoracic spine through the heart Left hemidiaphragm up to the spine Lung tissue behind the heart 8 Penetration Under-penetration Over-penetration 9 3

4 Inspiration Should be able to see 8-10 posterior ribs Reminder: Posterior ribs run more horizontal (anterior ribs run at 45 degree angle downward) 10 Rotation Compare spinous processes and medial clavicular heads 11 Technique? Quality? 12 4

5 Technique? Quality? 13 Chest Radiograph Interpretation Ensure correct film is of the correct patient Are there old ones to compare? Read each film in the same way (develop a systematic approach) Interpret the film based on the patient s clinical picture (i.e. atelectasis v. PNA) 14 Lung fields Right lung Right upper lobe (RUL) Right middle lobe (RML) Right lower lobe (RLL) Left lung Left upper lobe (LUL) Left lower lobe (LLL) 15 5

6 16 Fissures A: Minor fissure B: Major fissures

7 Fissures 19 Heart borders 20 Radiology assistant Which diaphragm is which? Right diaphragm (red arrow): Can be followed posteriorly to anteriorly Left diaphragm (blue arrow): Lost at the point where it borders the heart 21 Radiology assistant 7

8 In which lobe is the abnormality? 1. LUL 2. LLL 3. LUL and LLL In which lobe is the abnormality? 1. RUL 2. RML 3. RLL 4. Multiple lobes 24 8

9 Silhouette Sign Loss of silhouette or lung/tissue border due to change in density of the typically air-filled lung 25 Pick an Approach: ABCDE(FGH) A Airway (Trachea midline?) B Bones (ribs, clavicle, humerus) C Cardiac silhouette (Obscured? Enlarged?) D Diaphragms (Obscured? Elevated?) E Edges (Check apices) F - Fields lung (Opacities? Masses?) G Gadgets (Line, tubes, drains) H Hila (Lymphadenopathy? Enlarged vessels?) 26 Pick an Approach: Inside-Out Trachea Cardiac border Costophrenic angles Bony structures Compare bilateral lung fields Examine each lung field individually 27 9

10 28 What Should You Do Next? 1. Chest tube 2. Needle decompression 3. Bronchoscopy 4. IV antibiotics 5. Diuresis 29 Pneumothorax Pleural stripe Absence of pulmonary markings Tracheal shift 30 10

11 Pleural Effusion v. Atelectasis 31 Pleural effusions: Meniscus 32 Pulmonary edema Diffuse alveolar infiltrates Cephalization of pulmonary vessels Kerley B lines Peribronchial cuffing Bat wing appearance Cardiomegaly? Pleural effusions? Bilateral blunting of costophrenic angles 33 11

12 Pulmonary edema What should you do next? 1. Ultrasound 2. Needle decompression 3. Chest tube 4. Call surgery 5. Relax, normal CXR 36 12

13 Free air! 37 So now that I m an expert with CXRs, when would I need a chest CT? 38 Why get a CT? CT without contrast Pulmonary nodules Follow-up consolidations, ground glass opacities, etc Better look at lung parenchyma (compared to CXR) CT with contrast Lymphadenopathy Pleural evaluation Pulmonary emboli (need appropriate timing of bolus) HRCT Interstitial lung disease 39 13

14 Assessment Lung parenchyma Pleura Airways Lymphadenopathy/mediastinum Vessels Heart/Pericardium Soft tissues Bones 40 Chest CT: Views: Coronal, Transverse (axial), Sagittal 41 Chest CT: Windows 42 14

15 Chest CT Dominant pattern Reticulation (septal lines) Nodules Attenuation Distribution in secondary lobule Random Centrilobular Perilymphatic Distribution in lung Bilateral Upper v. lower Central v. peripheral 43 CT Patterns Septal lines Nodules High attenuation Ground glass opacities (GGO) Consolidation Low attenuation Emphysema Cysts 44 Secondary Pulmonary Lobule 45 15

16 Septal Lines Septal lines: Fluid, cells Nodular, irregular Smooth 46 Nodules Nodules Random Centrilobular Perilymphatic 47 Tree-in-bud 48 16

17 High Attenuation Blood, pus, water, cells Consolidation Ground glass opacities (GGO) 49 High Attenuation: Consolidation 50 High Attenuation: GGO 51 17

18 Low Attenuation Emphysema Cysts Honeycombing Bronchiectasis Cavities Mosaic pattern 52 Low Attenuation: Emphysema 53 Low Attenuation: Cysts 54 18

19 Low Attenuation: Honeycombing 55 Low Attenuation: Bronchiectasis 56 Mosaic Pattern 57 19

20 CT PE 58 Mediastinal Adenopathy 59 Pleural Evaluation 60 20

21 Summary Use the same method for interpreting all of your films CXR ABCDE or inside-out CT chest: Look at lung and mediastinal windows to assess both parenchyma and adenopathy, respectively Determine dominant pattern(s) Comment on distribution of patterns (i.e. bilateral, peripheral v. central, upper lobe v. lower lobe) 61 Case 1 71 year-old woman presents with acute respiratory failure and requiring MV 62 Case 2 70 year-old man presents with worsening fatigue and shortness of breath 63 21

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23 67 Need some practice? Radiology assistant: /chest-x-ray-basic-interpretation.html Introduction to Chest Radiology, UVa (online tutorial): 68 Questions? 69 23