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Pulm > Lecture 2: Intro to CXR > Flashcards

Lecture 2: Intro to CXR Flashcards

1
Q

Describe the basic process of a XRAY beam.

A
  1. X-ray tube shoots a cone of radiation towards a detector.
  2. The beam grows through the person, which alters the image that is returned.
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2
Q

What appears black on an xray? Dark gray? Gray? White?

A
  • Black is air.
  • White is metal.
  • Dark gray is soft tissue.
  • Gray is bone.
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3
Q

What is more magnified on an xray: closer or farther image from the beam?

A

The farther the image is from the BEAM, the smaller it is.

Ex: a PA xray has a smaller heart on xray, since the heart is farther from the beam. This also means a PA xray is better to show an accurate heart size.

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4
Q

Why would a CXR be ordered for a constitutional symptoms like unexplained fever or unexplained LAN?

A

Possible cancer.

FUO is common in cancer.

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5
Q

What are the two standard CXR views?

A
  • PA
  • Lateral

This constitues a 2-view CXR.

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6
Q

How is a standard lateral CXR performed?

A

Left side AGAINST the detector with arms up.

Right side is therefore more magnified.

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7
Q

Image of a standard CXR

A
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8
Q

When are lateral decubitus CXR ordered?

A
  • Pleural effusion vs consolidation.
  • Loculated effusions vs free pleural fluid
  • Small pneumothorax eval
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9
Q

To evaluate if the right side of the lung has a pleural effusion, I should have the patient lay on what side?

A

Right lateral decubitus.

You want the fluid to pool DOWNwards so it is most visible.

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10
Q

To evaluate if the left side of the lung has a pneumothorax, what side should the patient be positioned?

A

Right lateral decubitus.

Air will rise, so left side of the lung needs to be facing UPWARDS.

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11
Q

A 56-year-old male presents with complaints of chest pain and shortness of breath that was sudden in onset 1 hour ago. Initial PA CXR shows is suspicious for a small right pneumothorax vs artifact.
What would be the most appropriate follow up x-ray you would want to order?

A

Left lateral decubitus CXR.

The R next to decubitus means it is the right side of the body, not right decubitus position. Both are radiologic tags for reference.

Knife can be visualized in the right axillary region.

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12
Q

What would prompt us to have an expiratory CXR?

A
  • FB with air trapping, which should present the affected side as LARGER.
  • Small pneumothorax will be more pronounced.
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13
Q

Which side of this CXR is abnormal? Why?

A

The left side is slightly smaller. The smaller lung is NORMAL. The right side therefore might have obstruction that is preventing it from exhaling fully.

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14
Q

What is a lordotic CXR and what is it for?

A

Oblique CXR beam. Shows lung apices better.

C is the lordotic view (Bottom)

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15
Q

When is an AP CXR used?

A

Patient that is unable to stand erect. It is performed supine/sitting.

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16
Q

What 4 things distinguish a PA CXR from an AP?

A

For a PA CXR:

  • Clavicle IN the lung field.
  • Ribs are SLANTED
  • Scapula is OUTWARD of lung
  • Heart shadow is SMALLER
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17
Q

A 42-year-old female presents with complaints of cough and shortness of breath that was has progressively worsened over the last week. Initial x-ray shows a blunted costophrenic angle on the left. The radiologist is concerned about a pleural effusion.
What would be the most appropriate follow up x-ray you would want to order?

A

Left lateral decubitus

Need to r/o consolidation in left lower lobe vs pleural effusion.

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18
Q

What is the systematic approach to evaluating CXR image quality?

A
  • Penetration
  • Artifact
  • Inclusion
  • Rotation

PAIR

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19
Q

What is the systematic approach to CXR interpretation?

A
  • Air: central airways, lung parenchyma
  • Bones: Ribs, clavicles, spine, shoulder, scapulae
  • Circulation: Heart, blood vessels, and mediastinum
  • Diaphragm and pleura
  • Extra features: medical interventions, soft tissues
  • Gastric bubble/free air
  • Hilum

ABCD EF GH

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20
Q

What should we look for to determine good penetration?

A
  • Vertebrae slightly visible behind the heart.
  • Left hemidiaphragm visible to the edge of the spine.
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21
Q

What would an underpenetrated image look like? Overpenetrated?

A

Underpenetration will appear very white, with the vertebral bodies unable to be distinguished from one another.

Overpenetration will appear extremely dark, with the lung fields pitch black and the ribs not visible within the lung fields.

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22
Q

What 3 things can result in radiologic artifact specifically?

A
  • Abnormal rotation of patient.
  • Incomplete inspiration.
  • Incorrect penetration.
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23
Q

What 4 things should be included in a good quality PA CXR?

A
  • 5-7 anterior ribs (Angled for PA)
  • 10 posterior rubs (Horizontal for PA)
  • Costophrenic angles
  • Lateral angles of ribs

Anterior should be more transparent, since this is a PA view.

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24
Q

What 2 aspects are considered good quality rotation on a CXR?

A
  • Spinous processes of thoracic vertebrae are midline posterior.
  • Medial ends of clavicle form a vertical line and are equidistant from midline.
25
Q

How should the trachea/bronchi appear on a good CXR?

A
  • Trachea should be midline and darker gray due to air presence.
  • Left main bronchus should branch horizontally, while right goes down.
26
Q

How should we inspect the lung parenchyma?

A
  • By ZONES.
  • Right to left.
  • Upper to Middle to Lower.

Comparing symmetry.

27
Q

What is unique about right lung lobes vs left?

A
  • Left only has 2 lobes with an oblique fissure.
  • Right has 3 lobes with a horizontal and oblique fissure.
28
Q

What are we looking for in terms of bone pathology on a CXR?

A
  • Fracture
  • Arthritic changes
  • Dislocation
  • Metastatic pathology
29
Q

What is CTR and what is abnormal CTR?

A

Cardiothoracic ratio.

The heart should be less than 50%, and can only be assessed confidently in a PA CXR.

Cardiac width: Thoracic width.

Must use PA CXR!. AP view will enlarge it due to XRAY beam proximity.

30
Q

How should the borders of the mediastinal structures appear?

A

Sharp.

31
Q

How do we document the location of a mediastinal mass?

A

We use compartments, differentiated by the sternal notch because there are no soft tissue planes that differentiate them.

32
Q

Why is the right side of the diaphragm higher than the left?

A

The liver sits on the right side, and it is a very solid organ.

33
Q

Which hemidiaphragm can be seen all the way to the anterior chest wall on a lateral CXR? Why?

A

Right side, because it is higher and does not blend with the heart.

34
Q

What is considered a normal Costophrenic angle (CPA)? What is it called when it is abnormal and what is the MCC?

A
  • < 30 deg.
  • Blunting is when it becomes > 30 deg, usually due to pleural effusion.
35
Q

If the pleura is visible on a PA CXR, what does this indicate?

A

Pathology. It should normally stretch to the lateral chest wall.

36
Q

What does a gastric air bubble suggest on PA CXR?

A

Normal, seen in 70% of all CXRs.

Ensure which side it is, because free air on the right side is abnormal.

37
Q

What does free air under the right hemidiaphragm suggest?

A

Perforated abdominal organ.

38
Q

Which hilum sits higher and why?

A

Left sits higher due to the heart.

39
Q

What is consolidation?

A

Solidification of lung tissue in an area that normally contains air.

40
Q

What are the primary etiologies of lung consolidation?

A
  • Atelectasis
  • Infection/Exudate
  • Pulmonary Edema
  • Inflammatory Exudate
  • Inhaled water
  • Blood
  • Tumor
41
Q

Based on the two CXR views presented, what does the PA CXR suggest? What does the lateral CXR suggest?

A

The PA view suggest a lower consolidation of the UPPER left lobe.

However, the lateral view suggests that the consolidaiton is more posterior, which makes the LOWER left lobe more likely.

On a PA view, the left upper lobe takes up most of the lung field.

42
Q

What happens to a PA CXR in hyperexpansion of the lungs?

A
  • Flattening of the hemidiaphragm.
  • Space between the heart and the diaphragm.
  • Elongation of the lung fields.
43
Q

What is hyperexpansion of the lungs and the most common cause?

A

Excessive amount of air trapped in alveoli due to reduced elasticity of the lungs.

MCC: COPD

44
Q

What is the most common cause of CPA blunting?

A

Pleural effusion.

45
Q

What is pulmonary edema and what typically suggests it?

A

Collection of fluid in the alveoli of the lungs.

It typically presents bilaterally.

46
Q

What is an air bronchogram?

A

Tubular outline of an airway made visible due to the surrounding alveoli being filled up.

47
Q

What is a pneumothorax?

A

Collapsed lung, due to air leaking into the pleural space.

Trachea deviating to the left as well.

48
Q

What is a pleural effusion?

A

Buildup of fluid in pleural space.

Usually results in CPA blunting.

49
Q

What do we use to determine cardiomegaly on CXR?

A

CTR > 50%

50
Q

What are kerley lines?

A

Thickened interlobular septal lines between the alveoli.

51
Q

Describe where I can find the 4 kerley line types.

A
  • Kerley A: 2-6cm oblique towards hila.
  • Kerley B: 1-2cm horizontal in periphery of lungs.
  • Kerley C: 1-2cm horizontal in periphery of lungs but ventrally.
  • Kerley D: 1-2cm horizontal in periphery of lungs but retrosternal on LATERAL CXR.

A for apex (highest up)
B for Besides (laterally)
C for centrally (more central than B)

52
Q

Image of Kerley D lines

A

Retrosternal space only.

53
Q

What is mediastinal widening?

A

Enlargement of the mediastinal structures.

54
Q

Describe the image using the PAIR approach. Is there any specific pathology present?

AP View
A
  • Penetration: Overpenetrated due to inability to visualize vertebrae. Left hemidiaphragm appears to meet cardiac border but not spinous border well.
  • Artifact: None noted.
  • Inclusion: AP View, 7 anterior ribs noted, posterior difficult to visualize.
  • Rotation: cannot determine medial ends of clavicle. Spinous processes appear midline for the most part.

Pathology: Left sided pneumothorax, evidenced by the increased presence of air and the ability to visualize the border of the left lung, which should normally meet the lateral chest wall.

55
Q

Describe this image using PAIR and the systematic approach.

What is the suspected pathology?

COPD Patient
A
  • Penetration: Spinous processes and trachea present. Left hemidiaphragm meets spine.
  • Artifact: Breast lines noted.
  • Inclusion: 10 posterior ribs, 8 anterior ribs. Good inclusion.
  • Rotation: Clavicles are equidistant and in height. Spinous processes and trachea are midline.
  • Airway: Normal trachea and bronchi. Increased density on right bronchioles.
  • Bones: Normal.
  • Circulation: CTR is normal. Aorta and mediastinal structures are of appropriate width. No CPA blunting.
  • Diaphragm: Right sits higher than left as appropriate.
  • Extra features: None
  • Gastric bubble: Not present. (unsure)
  • Hilum: Normal, but slightly darker due to COPD.

Consolidation of right lung lobe, unknown which lobe without lateral view.

56
Q

Describe this image using PAIR and the systematic approach.

What is the suspected pathology?

A
  • Penetration: Underpenetrated, unable to visualize spinous processes or left hemidiaphragm meeting spine.
  • Artifact: device noted on right axillary region, as well as some clips and buttons present.
  • Inclusion: normal?
  • Rotation: Trachea midline with spirnous processes. Clavicles are not equidistant.
  • Airway: Normal.
  • Bones: Normal.
  • Circulation: Normal.
  • Diaphragm: CPA blunting on left.
  • Extra features: Hospital equipment.
  • Gastric bubble: Very large. No free air under hemidiaphragm.
  • Hilum: Normal.

Concerned for pulmonary edema given the bilateral nature of the consolidation.

57
Q

Describe this image using PAIR and the systematic approach.

What is the suspected pathology?

A
  • Penetration: Poor. Underpenetrated due to no distinction between any hemidiaphragm.
  • Artifact: none.
  • Inclusion: missing ribs
  • Rotation: Normal.
  • Airway: Normal but not well visualized. Lungs are symmetrical in terms of tissue.
  • Bones: Normal.
  • Circulation: Possible mediastinal widening given large aortic notch. CTR is not accurate as this is an AP view.
  • Diaphragm: Large right sided CPA blunting with minor left sided CPA blunting.
  • Extra features: none
  • Gastric bubble: none noted. No free air visible.
  • Hilum: normal.

This is a suspected bilateral pleural effusion, but image is of poor quality so cannot be conclusive.

AP View given the horizontal clavicles.

58
Q

Describe this image using PAIR and the systematic approach.

What is the suspected pathology?

A
  • Penetration: Good penetration; spinous processes vsisible and left hemidiaphragm meets spine.
  • Artifact: two buttons symmetrical.
  • Inclusion: all ribs visible.
  • Rotation: Trachea midline, clavicles equidistant
  • Airway: Trachea is good and midline. Kerley A,B, and C lines noted.
  • Bones: No fractures.
  • Circulation: Heart is normal sized given the large lungs. NO mediastinal widening.
  • Diaphragm: Flattened diaphragms.
  • Extra features: two buttons.
  • Gastric air bubble: none. No free air noted either.
  • Hilum: well visualized.

COPD with barrel chest.

Pulm (12 decks)

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