Lecture 2- CXR Basics

Question 1

Viewing CXR

steps for viewing

Answer 1

1. position radiograph correctly
2. view as a whole for obvious abnormality
3. view systematically

Question 2

within the body… radidation is

3

Answer 2

1. completely absorbed
2. transmitted unchanged through the pt
3. scattered within the body

Question 3

Views

4 typical views

Answer 3

1. posterior anterior (PA)
2. lateral
3. anterior posterior (AP)
4. lateral decubitus

Question 4

Views

describe CXR PA view

4 components

Answer 4

• gold standard for front view of lungs
• pt stands upright with the anterior of chest placed against the front of the film (radiation goes through the back to the front)
• shoulders are rotated forward to touch the film to ensure the scapula are out of the way
• take image with full inspiration

Question 5

Views

describe CXR AP view

4 components

Answer 5

• used when the pt is immobilized or unable to do PA procedure
• patient is supine with patient’s back against the film
• heart is at a greater distance from the film so it will be enlarged
• scapula are visible

Question 6

Views

describe CXR lateral view

3 components

Answer 6

• pt standard upright with one side of the chest against the film
• allows the viewer to see behind the heart and diaphgragmatic dome
• done in conjunction with PA view to help determine 3D location of anormalities

Question 7

Views

describe CXR lateral decubitus view

Answer 7

• pt lies on the L or R side (ensure it’s labelled properly)
• often used to reveal pleural effusion that can’t be observed in upright view

Question 8

what constitutes the hilum

Answer 8

• pulmonary arteries & branches
• pulomnary veins
• adjacent airways

Question 9

Views

which CXR view shows the truest size of the heart?

Answer 9

• PA view
• AP view magnifies the heart

Question 10

Views

t/f the heart may also seem enlarged if the pt doesn’t take a full breath

Answer 10

TRUE- must take full breath in to truly gauge heart size

Question 11

Chest Anatomy

go to ppt and label the components of the mediastinum.

Answer 11

ok

Question 12

define

• radiolucent
• radio-opaque

Answer 12

• radiolucent: allows xray to go through (black/air)
• radio-opaque: blocks xray from going through (white/bone)

Question 13

CXR Interpretation

ABCs of CXR Interpretation

Answer 13

• Assess the quality of the CXR
• Airway
• Bones/Borders
• Cardiac Assessment
• Diaphragms
• Effusions
• Fields

Question 14

CXR Interpretation

Describe components of assessing the quality of an image

Answer 14

PIER
* Positioning (PA, Lat, AP, decubitus)
* Inspiratory Effort (8-10 countable ribs)
* Exposure/penetration (vertebrae are just visible behind the heart)
* Rotation (clavicular heads equi-distant from spinous process; clavicular head attached at T4)

Question 15

CXR Interpretation

A-Airway: what are you assessing?

Answer 15

• trachea - look for midline/shifting/narrowing
• maybe can see where trachea splits at the carina?
• want to see through to the aortic arch

Question 16

CXR Interpretation

B- Bones, Borders, Soft Tissues
what do we evaluate here?

Answer 16

Bones:
* look at each rib
* clavicles
* lower cervical and thoracic spine
* scapulae/humeri if visible
* are there bone lesions? spinous processes lined up?

Soft Tissues
* abnormalities of the skin/breast/body parts?

Borders
* supraclavucular fossae (nodes)
* Lateral chest wall
* Under diaphragm

Question 17

CXR Interpretation

what can breast tissue obscure?

Answer 17

costophrenic angles

Question 18

CXR Interpretation

what may lucencies within soft tissue represent?

Answer 18

gas

Question 19

CXR Interpretation

C- Cardiac
what do we evaluate here?

Answer 19

• 2/3 of heart should lie on L side of chest w/ 1/3 on the R side
• heart should take up less than 1/2 of the thoracic cavity (measured horizontally)
• LA and LV create L heart border
• RA creates R heart border

Question 20

CXR Interpretation

D- diaphragm
what do we evaluate here?

Answer 20

• both diaphragms should form a sharp margin w/ the lateral chest wall
• both diaphragm contours should be clearly visible medially to the spine

Question 21

CXR Interpretation

E- effusions
what do we evaluate here?

Answer 21

• effusion: fluid where fluid shouldn’t be (outside border of lung)
• the pleura and pleural spaces will only be visible when there is an abnormalities present

Question 22

CXR Interpretation

F- fields
what do we evaluate here?

Answer 22

• normally, there are visible markings throughout the lungs due to the pulm arteries/veins which continue to the chest wall
• both lungs should be scanned starting at the apex and working downward

Question 23

CXR Interpretation

describe lung fissures on CXR

Answer 23

• likely not visible but can be seen
• horizontal & transverse on R lung/transverse on L lung
• the major fissures are not usually seen on a PA view because they are viewed obliquely

Question 24

CXR Interpretation

go to ppt and label the lobar anatomy.

Answer 24

ok

Question 25

# Lung Disease 6 basic patterns of lung disease

Answer 25

1. air space opacities 2. interstitial opacities 3. nodules/masses 4. lymphadenopathy 5. cysts/cavities 6. pleural abnormalities

Question 26

# Lung Disease what might cause air space opacities

Answer 26

* replacement of air in the alveolar space by inflammatory cells, pus, blood, water, tumor cells

Question 27

# Lung Disease what is an air bronchogram?

Answer 27

* characteristic manifestation of air-space opacity which refers to the phenomenon of air-filled bronchi (dark) being made visible by the opacification of surrfounding alevoli * looks like a dark spot (literally just an air space)

Question 28

# Lung Disease what are interstitial opacities?

Answer 28

* involvement of the supporting tissue of the lung parenchyma * generalized miliary patterns, Kerley B lines, reticular/septal lines, peribronchovascular thickening, nodules

Question 29

# Lung Disease what does generalized miliary pattern mean?

Answer 29

innumerable amount of small opacities in the interstitial space

Question 30

# Lung Disease differentiate Kerley A and B lines

Answer 30

* A: around hilum * B: around bases/lateral sides

Question 31

# Lung Disease what are reticular formations typically seen with?

Answer 31

pulmonary fibrosis

Question 32

# Lung Disease differentiate nodules and masses

Answer 32

* nodules: < 3 cm * masses: > 3 cm * both: clearly defined opacities

Question 33

# Lung Disease describe solitary pulmonary nodules

Answer 33

* common clinical probelm (>50% of smokers aged 50+) * single, small (< 3cm), well-circumscribed, radiographic round opacity on chest imaging surrounded by normal lung * not associated with infiltrate, atelectasis, or adenopathy

Question 34

# Lung Disease describe multiple pulmonary nodules

Answer 34

* more worrisome for malignancy than SPNs * same risk factors for malignancy, but more likely to be metastatic than a SPN

Question 35

# Lung Disease which cancers are most likely to metastasize | 5

Answer 35

* colorectal * breast * renal cell * uterine leiomyosarcoma * head/neck squamous cell carcinoma

Question 36

# Lung Disease describe lymphadenopathy

Answer 36

* abnormal contouring of mediastinal shadows (LOOK AT THE HILUM!) * characteristic locations: R paratracheal area, hilar regions, aortopulomary window, subcarinal region, superior mediastinum

Question 37

# Lung Disease describe cysts/cavities

Answer 37

* occur in the pulmonary parenchymal space and when abnormal they contain air/fluid/both (normal = lung tissue) * cysts: thin walled filled with cellular elements * Cavities: created by tissue necrosis within a lung nodule/mass (become air-filled when the internal necrotis elements are expelled into the tracheobronchial tree)

Question 38

# Lung Disease what pleural abnormalities can be seen? | 3

Answer 38

* pleural effusion * pleural thickening * pleural calcifications

Question 39

# Lung Disease describe pleural effusion findings on CXR

Answer 39

blunting of the costophrenic angle to form a crescent shaped opacity

Question 40

# Lung Disease describe pleural thickening CXR findings

Answer 40

nondependent and non free flowing

Question 41

# Lung Disease describe when pleural clacifications are seen?

Answer 41

* asbestos-related pleural disease * sequelae of prior hemothorax or tuberculosis

Question 42

infiltrates vs consolidation

Answer 42

* infiltrate: fluid in the lung * consolidation: hardening or thickening of the infiltration

Question 43

# Lung Disease pneumothorax

Answer 43

* no lung markings in pleural space * mediastinum shifts to the CONTRALATERAL side * deep sulcus sign: the costophrenic sulcus is significantly lower than on the ipsilateral side * prominent vascular markings in the opposite lung (because it is receiving entire cardiac output)