Undergraduate Teaching

Transcription

1 Prof. James F Meaney Undergraduate Teaching Chest X-Ray Understanding the normal anatomical by reference to cross sectional imaging

2 Radiology? It s FUN! Cryptic puzzle Sudoku (Minecraft?) It s completely logical (c.f. anatomy)

3

4 Systematic approach Firstly Identity of patient Date of film Type of film- PA or AP Orientation (look for L/R) Ensure medial ends of clavicles equidistant from spines of vertebrae Describe obvious abnormality..then Airways Bones Cardiac - Heart size and borders Diaphragm Equal volume Fields (lung fields) Gastric bubble Hilum

5 Normal versus abnormal Normal (Anatomy) Abnormal (Pathology) Radiology Plain radiographs CT MRI Ultrasound Nuclear medicine/pet Interventional Radiology

6 Heart Mediastinum Lungs Airways Blood vessels Bones Extrathoracic Common Indications for Chest X ray Chest pain Shortness of breath Wheeze Haemoptysis Trauma Pre-op screening

7 Basic rules: Air is black Bones are white (brightest structure on the image) Everything else is a shade of grey (not so black) Structures overlap Old rule need 2 views at right angles (defunct)

8 CXR: Good overview Single shot only (Can do lateral also) Everything compressed onto one image Some limitations Only plain radiograph you need to evaluate in practice (apart from trauma X-Rays of extremities) Make the best of it: Examine systematically Pay particular attention to difficult areas Behind the heart Behind the diaphragm Cardiophrenic angles Costophrenic angles Hila Apices Bones Extrathoracic structures (Gastric air-bubble/soft tissues/kidneys/spleen)

9 Hemidiaphragms

10 Costophrenic Angles

11 Cardiophrenic Angles

12 Gastric Bubble

13 Clavicle

14 Clavicle

15 Sixth Rib

16 Trachea

17 Tracheal Bifurcation

18 Heart Border

19

20

21 SVC 2. Brachiocephalic artery 3. Trachea 4. Left brachiocephalic vein 5. Left common carotid artery 6. Left subclavian artery 7. Oesophagus

22 Ascending aorta 2. SVC 3. Rt Pulmonary artery 4. Rt Main bronchus 5. Pulmonary trunk 6. Lt pulmonary artery 7. Lt main bronchus 8. Descending aorta

23 1. Right atrium 2. Left atrium 3. Rt pulmonary vein 4. Rt ventricle 5. Aortic valve 6. Descending aorta

24 Heart Border Arch SVC PA Ao RA LV

25

26 Lung Fields

27 Upper zone

28 Mid zone

29 Lower zone

30

31 Hila Bronchi Arteries Veins Lymph nodes

32

33

34

35

36

37

38 What s hidden?

39

40

41

42

43 UL ML LL

44 UL ML LL

45 Aortic Arch Right Hemidiaphragm Left Hemidiaphragm

46

47

48 What s a good CXR?

49 Film Film

50 PA AP Heart appears larger on AP CXR

51 Cardiothoracic ratio (<50%) Only valid on a PA CXR Rough indicator of cardiac size only

52 Cardio-thoracic ratio <50%

53 AP PA

54

55 Inspiration Expiration

56 Inspiration Expiration

57 What does it matter? Inspiration Expiration

58 Erect CXR (AP, portable)

59 Causes of lung abnormality on CXR Infection Tumours Abscess Lymphadenopathy Pleural effusion Fibrosis Collapsed Lung Pneumothorax MisplacedNG/ETT/CVC Foreign body Pneumoperitoneum

60 Solitary pulmonary nodule -Rounded opacity - Well defined - <3cm

61 Infection Differential diagnosis? Neoplasm (Primary and secondary) Malignant vs benign Inflammatory eg sarcoid, organizing pneumonia Autoimmune/granuloma eg Wegener s, Sarcoid Vascular eg AVM, haematoma Congenital eg bronchogenic cyst

62

63 Work-up if malignancy suspected? Bronchoscopy vs CT guided lung biopsy Need follow up CXR to ensure there is no pneumothorax or haemothorax PFTs, ABG etc

64 Pneumonia Lobar pneumonia Bronchopneumonia (Non lobar) Pneumonia affecting a large part or an entire lobe of the lung. Inflammation of the bronchi and brochioles with spread to the peribronchiolar alveoli which can involve multiple pulmonary lobules.

65 Follow-up Need followup chest radiograph 6 weeks post tx for pneumonia to ensure resolution and rule out underlying cause such as malignancy

66 Teaching points Need to interpret the CXR If you understand what s normal (anatomy) the rest is easy! Next lectures The abnormal CXR (Abnormal anatomy = pathology)