Basic Technique of Chest X-Ray Reading 馬偕醫院胸腔內科 郭許達醫師 2017/12/26

Transcription

1 Basic Technique of Chest X-Ray Reading 馬偕醫院胸腔內科 郭許達醫師 2017/12/26 1

2 Technique of Chest X-Ray Reading A. Check the request form and data on the film B. Check the the technical quality of chest x-ray Patient s position --PA, sternal end Depth of breathing -- diaphragm level Exposure of film C. Find abnormal picture D. Interpretation Hsu-Tah Kuo,MD 2

3 The Effect of Standing and Supine Position 3

4 Effects of Body Position on CXR Standing Sitting Supine 4

5 同一病人在相同時間呼氣和吸氣之影像 5

6 Checkpoints to Evaluate Technical Quality 1.Medial tips of clavicle equidis- tant from spinous process 2. Diaphragm at least as low as the 10th posterior rib 3. Intervertebral spaces visible through mediastinal shadow 4. Symmetrical radiodensity of shoulder and soft tissues 5. Clavicles overlying 3-4th posterior interspace Mackay Memorial Hospital Hsu-Tah Kuo,MD

7 Technique of Chest X-Ray Reading Read the film systemically Soft tissue and bony structure A. Airway -- trachea B. Blood vessels -- aorta, hilar vessels C. Cardiac & mediastinum D. Diaphragm -- level, shape E. Effusion -- CP angle F. Field --lung fields symmetric bilaterally. G. Gas shadow -- stomach gas Mackay Memorial Hospital Soft tissue and bone A F B C D E Bone Soft tissue G 7 Hsu-Tah Kuo,MD

8 Trachea Anatomical Landmarks on Chest X-Ray Central, slightly to r t in lower 3rd Hilar Level: R t opposite 6th rib in ax, L t 1.5 cm higher Size: R t basal artery 9-16 mm Lung Vessels Larger in lower, roughly symmetrical bilaterally Horizontal Fissure Level: 6th rib in axilla Mackay Memorial Hospital 6th Fissure Tr. Hilar Lung vessels Hsu-Tah Kuo,MD 8

9 Contours of the Mediastinum SVC Tr. L subclavian Aortic knob Bi rmb lmb Pulm a. As aorta Cardiac changes in the contours of mediastinal pleural at its interface with adjacent lung. Concave contours to straight or convex Loss of sharp margins about such anatomic structures Widening of spaces between mediastinal boundaries and mediastinal contents 9

10 Cardiac silhouette and mediastinum 10

11 Hilar and Blood Vessels 11

12 Mediastinal window on chest CT contrast media 12

13 Airway and Blood Vessels A B 13

14 Hilar and Blood Vessels 14

15 Anatomical Landmarks on Chest X-Ray Heart Size: TD < 16 cm, change < 2 cm Shape: Classical Position: Central, 2/3 to the left of mid-line Diaphragm Level: Ant rib, R t cm higher than L t Curve: Vertical line > 1.5 cm Outline: shape, CP angle acute Background Blacking Same at equivalent level Mackay Memorial Hospital Hsu-Tah Kuo,MD

16 Anatomical position -- PA & Lat view a. division of the lungs into 1= hilar portion 2= central portion 3= peripheral portion b.division of the lung zones 1= apex 2= upper lung field 3= middle lung field 4= lower lung field c.anatomical division red= upper lobes yellow= middle lobe blue= lower lobe 16

17 Lateral View 2 Clear Spaces Retrosternal Retrocardiac 17

18 Lateral Chest X-ray Image 1. Judge the size and shape of the lungs and position and shape of the diaphragms. Flattening of the diaphragms (height of < 2.7cm) 2. Follow the airway from neck to the hilum Tracheal position, Center of hilar structures - left main bronchus anterior RPA; Posterior - LPA. 3. Fissure lines 4. Retrosternal, retrocardiac darkening 5. Trace around the periphery of the image. Bowel gases, pneumoperitoneum, 18

19 Lordotic view 19

20 利用正面和側位判斷病灶位置 15% of the lung can be hidden by cardiovascular structures and the diaphragm. The lateral image can be helpful in looking for these obscure lesions on PA films. 20

21 Identify the lesion-- PA & Lat Mackay Memorial Hospital Hsu-Tah Kuo,MD 21

22 22

23 23

24 Apical lesion -Lordotic View Lordotic PA CT 24

25 Adjust Digital Imaging 1. Adjust contrast and density to maximize visualization of all structures 2. Measure the size of the lesion 3. Compare with the prior films 25

26 Terms use in chest x-ray interpretation 1. Atelectasis, collapse 2. Bulla 3. Circular, ovoid shadow multiple fine, nodular, coarse mottling small large circular shadow 2cm 4. Consolidation 5. Density- low, fairly high, very high 6. Disseminated, diffused nodular shadow Hsu-Tah Kuo,MD 26

27 Terms use in chest x-ray interpretation 7. Effusion 8. Honeycomb shadow 9. Ill-defined opacity 10. Linear, band-like shadow 11. Patchy clouding 12. Reticulation 13. Cavity 14. Septal line 15. Thickened pleura 16. Tubular shadow Hsu-Tah Kuo,MD 27

28 Terms use in chest x-ray interpretation 28

29 Terms use in chest x-ray interpretation 29

30 Blind Area at Chest PA Film 15% of the lung can be hidden by cardiovascular structures and the diaphragm. The lateral image can be helpful in looking for these obscure lesions on PA films. 1. Behind the inner end of the clavicle or anterior end of 1st rib 2. Apex of lower lobe on either side 3. Left lower lobe 4. Posterior costophrenic recess 5. Central part of the mediastinum 30

31 Silhouette 31

32 Adjacent Structures whose interfaces create a Radiographic Silhouette PA view 1.Diaphragm & lower lobe 2.R t cardiac border & RML 3.L t cardiac border & Lingual segment 4.Ascending aorta & anterior segment RUL 5.Aortic knob & apical-post. Segment LUL 6.Descending aorta & superior posterior segment LLL 7.Left ventricle & LLL Lateral view 1.Diaphragm & lower lobe 2.Inferior vena cava & medial basal segment RLL 3.Left ventrilce & LLL Hsu-Tah Kuo,MD

33 Silhouette Sign 33 Hsu-Tah Kuo,MD

34 Silhouette Sign 34

35 Pattern of Chest Lesion 1. Chest wall lesion 8. Diffuse air-space opacity 2. Pleural lesion 9. Multifocal ill-defined opacity 3. Diaphragmatic lesion 10. Diffuse fine nodular opacity 4. Mediastinal lesion 11. Fine reticular opacity 5. Hilar enlargement 12. Coarse reticular opacity 6. Atelectasis 13. Solitary nodule 7. Segment and lobar opacity 14. Multiple nodules 15. Hyperlucent abnormality 35

36 Steps of CXR reading

37 This is a plain, PA chest radiograph of Mr. Clause taken on the 25 December at the North Pole General Hospital. The most obvious abnormality is the appearance of cardiomegaly. I will focus on this after I have first studied the radiograph systematically. The radiograph is correctly oriented and the exposure is satisfactory. The patient is not rotated, There are no obvious abnormalities within the bones. The trachea is not deviated. The mediastinum has clearly defined borders and there is no enlargement or change in density of it or the hilar regions. There is no CXR pathology in the lung and they are expanded normally. The diaphragms are clearly seen although there is blunting at the right costophrenic angle with a meniscus suggesting a small effusion. There are no abnormalities below the diaphragm or within the soft tissues. The cardiothoracic ratio exceeds 1:2. As this is a PA film, this confirms the heart is enlarge. With regard to the cardiomegaly, four causes are IHD, VHD, pericardial effusion, and cardiomyopathy.

38 這是王大川先生今年 12 月 5 日在本院拍攝 PA view 的胸部 X 光片最明顯異常的地方是在左肺上肺野可以看到一個腫塊 先全部系統性讀完整個片子以後再來討論這個腫塊部分 拍攝時病人的位置正常, 沒有歪斜, 且在吸飽氣下拍攝, 肺組織的影像清晰 骨骼部份在鎖骨, 肋骨部分沒有看見異常 氣管在中央沒有偏移 Aortic arch, ascending aorta, SVC, 和肺門血管正常大小 心臟影像正常, mediastinum 沒有變寬 兩邊橫膈高度正常 肋膜腳尖銳, 沒有看見鈍化積水現象 肺野沒有異常病灶出現 橫膈下肺部沒有異常陰影

39 Chest X-Ray Reading 1. Give a Factual Report What you sees or think Position, size, shape, character, effect on surrounding 2. Diagrammatic Drawing 3. Interpretation Anatomical site, underlying pathological process Correlate any tentative conclusions with clinical picture Hsu-Tah Kuo,MD 39

40 Interpretation of Chest Lung Abnormality James C. Reed Chest Radiology 1. Find a true abnormality 2. Localize the abnormality soft tissue, chest wall, pleural, diaphragm, mediastinum, hilum, peripheral vessels, or the lung parenchyma 3. Classified or describe the pattern patterns of parenchymal lung: nodule, mass, diffuse opacity, cavity, calcification, atelectasis 4. Assess the distribution localized or diffuse, peripheral or central, in the upper vs. lower lobe, or alveolar vs. interstitial 40

41 Algorithmic Application of Chest Patterns James C. Reed Chest Radiology 1. Pattern identification 2. Differential diagnosis (all the categories of disease that might lead to the identified pattern) 3.Narrow the differential diagnosis by 1.Analysis of the film for additional radiologic findings 2.Evolving patterns of the disease by review of serial examinations 3.Correlation of the patterns with clinical and laboratory data 41

42 Mackay Memorial Hospital Large Air way Obstruction 42 Hsu-Tah Kuo,MD

43 Pneumothorax Inspiration, Expiration Mackay Memorial Hospital 氣胸呈現在胸腔的上方及外緣, 看到如髮絲, 不透亮的臟膜少量的氣胸時, 吐氣胸部攝影 Mackay Memorial Hospital Inspiration Mackay Memorial Hospital. HT Kuo,MD Expiration 43

44 Thoracic Cage & Soft Tissue Mammoplasty Kyphosis 44

45 Breast Shadow 45

46 Thoracic Cage & Soft Tissue Multiple myeloma Hepatoma and rib metastasis Mackay Memorial Hospital. HT Kuo,MD 46

47 47

48 Thoracic Cage & Soft Tissue 48 Mackay Memorial Hospital. HT Kuo,MD

49 Lung Collapse Mackay Memorial Hospital. HT Kuo,MD 49

50 Lung Collapse Mackay Memorial Hospital. HT Kuo,MD 50

51 Lung Consolidation after Epistaxis 51 Mackay Memorial Hospital. HT Kuo,MD

52 Mycoplasmal pneumonia 52

53 Klebsiella Pneumonia 訾 x 玲 2003/3/ /3/ /3/ /3/30 53

54 Pulmonary TB 病史 : 危險因素 : DM, Alcoholism, immune abn., Aborigines, Family TB 好發部位 : Apico-posterior seg., Superior segment of lower lobe 54

55 男, 51, DM, Persistent cough for 3 months; BW loss 7 kg in 4 months; poor intake(+), Fever (-) 55

56 Pulmonary Tuberculosis 肺結核 兩側上肺葉浸潤 肺結核 兩側上肺葉浸潤 重度肺結核 粟粒性結核 56

57 Productive Fibrotic Calcified Cavity Pleural Effusion Milinary 57

58 Severity of Pulmonary TB 0 ( 正常 ), 1( 輕度 ), 2( 中度無空洞 ), 3( 中度有空洞 ), 4( 重度無空洞 ), 5( 重度有空洞 ), 6( 肋膜積水 ), 7( 陳舊性肺結核 ) Far advanced degree 58

59 TB treat 朱哲 X

60 Follow up Chest x-ray 60

61 Severe Acute Respiratory Syndrome (SARS) 61

62 Radiographic Appearance of Cardiac Pulmonary Edema HCVD LA Myxoma MR ML 62

63 大量胸水會把氣管 縱膈 心臟推到他側沒有出現推移 (1)endobronchial obstruction (Foreign body,neoplasm) (2)Pleural adhesion, (3)Fixed mediastinum Mackay Memorial Hospital Mackay Memorial Hospital Mackay Memorial Hospital. HT Kuo,MD 63

64 Radiographic Finding of Pleural Effusion Upright film Supine film MR ML 64

65 Empyema Streptokinase inj 65

66 Intrathoracic Goiter Well-defined mass 把氣管推到另一側 CT 可見甲狀腺自頸部延伸到縱膈甲狀腺影像密度不均勻, 會有局部鈣化注射顯影劑後, 甲狀腺的 CT 密度會增加 ; 放射碘核醫掃瞄 Mackay Memorial Hospital Mackay Memorial Hospital 陳 X 招 88 F Mackay Memorial Hospital. HT Kuo,MD 66

67 Mackay Memorial Hospital Lymphoma 游 X 婷 18 yrs. F Mackay Memorial Hospital 67 Mackay Memorial Hospital. HT Kuo,MD

68 Lung Cancer with Mediastinal Metastasis Mediastinal mass contiguous with a lung tumor; Tumor conduct > 1/4 circum of the aortic wall ; tumor conduct > 3cm ackay Memorial Hospital mediastinum LN > 1 cm Dx metastasis, Accuracy 70%. Lung Ca 30% mediastinoscopy (-) have LN metastasis at surgery. T 4 diagnosis Mackay Memorial Hospital Mackay Memorial Hospital. HT Kuo,MD 68

69 Sarcoidosis 兩側對稱性淋巴結腫大. 最常發生在支氣管肺部淋巴結 右側氣管旁淋巴結, aorticopulmonary window Mackay Memorial Hospital Mackay Memorial Hospital 69 Mackay Memorial Hospital. HT Kuo,MD

70 Aortic Aneurysm Mackay Memorial Hospital Atherosclerosis Hypertension age>40 Mass at aortic contour contiguous with the aorta. Aortic dissection identify an intimal flap 70 Mackay Memorial Hospital. HT Kuo,MD

71 Achalasia 27 yrs F. Freq. choking Mackay Memorial Hospital Mackay Memorial Hospital Bird beak appearance 71 Mackay Memorial Hospital. HT Kuo,MD

72 Hiatal Hernia, Para-esophageal 陳 X 娥 Mackay Memorial Hospital Mackay Memorial Hospital Mackay Memorial Hospital. HT Kuo,MD 72

73 Emphysema Hyperinflation 1. Increase lung height 2. Flattened diaphragm 3. Retrosternal space >2.5cm Hyperlucency of the lungs Rapid tapering of the vascular markings 73

74 Portable Chest X-ray Endotracheal tube 74

75 Malpositioned CVP catheter 75

76 Pulmonary Artery Catheter Tip in the interlobar pul artery: <2 cm lateral to hilum Complications: Malposition: too proximal or too distal (24%) Arrhythmia, cardiac damage Pulmonary hemorrhage, infarction 76

77 Malpositioned PA catheter 77

78 Pneumomediastinum and subcutaneous emphysema - The early sign of barotrauma 78

79 Cardiomegaly, pulmonary vessel cephalization 79

80 Try to read this film Thorax A Thorax A B C D E F G E D F B C G 80

81 Thorax Try to read this film Thorax A B C D E F G E D F A B C G 81

82 Try to read this film Thorax A Thorax A B C D E F G E D F B C G 82

83 Try to Read this film Thorax A Thorax A B C F B D E F C G E D G 83

84 Try to read this film Thorax A Thorax F A B B C D E F C G E D G 84

85 Try to read this film Thorax A Thorax A F B C B D E F G E D C G 85

86 Try to read this film Thorax A B C D E F G 86

87 Try to read this film Thorax A B C D E F G 87

88 Try to read this film Thorax A Thorax A B C D E F G F C B E D G 88

89 Try to read this film Thorax A B C D E F G 89

90 90

91 判讀胸部 X 光片 1. 說出攝影為 PA, AP,Lat. 如果照得不好指出缺失 2. 估計大約年齡或性別 3. 再按 ABCDEFG 讀出正常或異常點 4. 按照異常 pattern 說出可能的疾病診斷 5. 可能再進一步的檢查或方法會幫忙診斷 91