Course Structure
Video 1
First video
Indications for Chest X Ray
Not necessary - prior to surgery, screening for cancer??
How does CXR work?
Digital detector? why arms on hips?
Factors that determine shadow brightness on an x-ray? (density and thickness and duration of exposure)
why flip plain radiograph?
Views = orientation relative to rays
Lesson 2 - A Systematic Method and Anatomy
Learning objectives
Principles of the systemic approach
The ABCDEF System (lessons arranged like that)
recurrent laryngeal nerve and lymphnodes => aortapulmonary window
C XRAY Veideo series
First three videos QARindications of chest x ray
reciever
views 4
how colour changes
factor affecting colour change
and corresponsind tissue
system to interpret
airway 3
bones 4
cardiac silhouette and mediastinum 9
diaphragm and pleura 7
fissures and lobes
Importance to know what lobe how
AP vs PA view
3 factors affecting technical quality
3 types of rotation.
How to spot and consequences of each
Lordotic view when?
adequate inpsiration assessment and importance
precaution in inspiratpry effort
3 factors determining exposure
SID ideal?
How to assess exposure
how to summarise technical quality
AP window
Lesson 3 - Assessing Technical Quality RPS
Learning objectives
Technical quality in PA (ambulatory in radiology department) vs AP films (more uncontrolled)
Factors affecting technical quality
Rotation
>> types of rotation
>> consequences
....
...
Inadequate Inspiration
be careful to conclude poor inspiratory effort without having another xray (restrictive lung disease?!)
Suboptimal penetration
PA films distance is 6 feet
These factors should be constant for consistent
5 - Cardiac Silhouette and Mediastinum
what does it include?
PA vs AP films?
List of cardiac silhouette abnormalaties?
Cardiomegaly
Left atrial enlargement
right ventricle enlargement
pericardial effusion and aetiologies
Dextrocardia
widened mediatinum
mediastinum masses DD
hilar enlargement
how to determine
Calcified walls?
Abnormalaties of cardac silhouette
Abnormalaties of the mediatinum and hila
Calcified wall - only vascular structures or cysts
Usually a mass in hilum obscures the pulmonary vessels. So if vessels can still be seen then not in hilum. In this case, calcified walls also!
Lesson 4 - Airways, Bones, and Soft Tissues
Learning objectives
4
3 airway problems and breakdown
precaution
local dsiplacement
Bone 6 stuff
fracture 4
deformed 3
sclerosis 5
lytic lesions 5
one other
soft tissues 3
Airways
steeple sign?
Soft tissues
Objects external to patients
Video 6 : DIAPHRAGM AND PLEURA
Video 6
Pneomothorax 4 and etiology
Pleural effusion 2
Characteristics
Loculated 4
2 confusing subtypes and how to distinguish
Etiology of
Precaution
Misc pleural diseases 3 and explaination
Elevated hemi diaphragm
Pathological locations of air 5 + how to identify + eitiology
PNEUMOTHORAX
can check out a line on the lung margin
inverse film and expiratory film can make it more easier
PLEURAL EFFUSIONS
pleural effusion is first seen on lateral films and then PA. Can take several hundred ccs for it to appear on PA.
Because of capillary action it tracks upwards along pleural surface
Left image is right pleural effusion
Loculated are like in seperate compartment
formed from long standing inflammatory or from heamothorax
difficult to drain this
If big diffiuclt to DD it from a pleural mass. Use CT.
loculated will be random and like defying gravity
in lateral decubitus view it will shift sightly or not at all
2 subtypes that can be mistaken
1
horizontal fissure high because lung is compressed
2
usually not possible to distinguish etiolgy on plain x ray
Miscellenous pleural diseases
plaques => bilateral, multi focal, relativey symmetric. Scalloped shaped front on but linear edge on. Apices and costophrenic angle spared.Cause ; Prior asbestos exposure
(not the same as asbestosis which is a lung disease)
thickening => pleural fibrosis and fat deposition
Does not typical involve all the pleura but obliterates costophrenic angle.
Difficult to DD from soft tissue masses or unusual loculated effusion
Elevated hemidiaphragm.
Pathological locations of air
Also sub cut emphysema on the neck
band is single and more demarcated.
can be asymptomatic like hiatal hernia
CXR Video 7 - Diffuse Lung Processes
Reduced Lung Volume
Hyperinflation
n
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Diffucult to distingish. Most times both are involved.
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Alveolar Opacities
kirley B lines more common
batwing more common on cardiogenic oedma
cephalization more common on cardiogenic oedema but poor inter observer agreement
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(blood and pus)
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Interstitial opacities
Nodular usually lesss than 1 cm but if less than 2mm called milliary
For most part indistugishable on plain radiography, but sometimes features like in asbestosis.
Sarcoidosis can cause all 3 and can cause alveolar opacities. Radiographically shows prominent hilar lymadenopathies (known for this)
All of this can cause reticulo nodular patterns
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CXR - Video 8
CXR video 8 focal lung processes
Objectives
olbar anatomy and better descriptions
zones 4
opacities, infiltrates and comsolidation
desc of infiltrates
silhouette sign
spine sign
opacities DD
different radiographic patterns of penumonia
round penumonia DD
pulmonary nodules
vs lung mass
def
caution
DD
Multiple pulmonary nodues DD
pulmonary embolism
4 stuff
caviatatin
DD and appearance how
apergilloma
def, name, clinical manifestation
FOCAL LUNG DISEASES
Better called anterioir and posterioir lobes, not upper and lower in the left side
Most clinicans dont have luxury of lateral view.
Does not corelate with 1,2,3, zone for pulmoary physio, ventialtion and catheter placement
2 signs of opacities
normally should become less opaque as it goes down
Right middle lobe lobar pneumonia => silhoutter sign, air bronchogram, sharply demarcated by the fissure and costophrenix angle seen so nt lower lobe
Silhoutter sign and spine sign seen
Cant be distinguish from masses but from clinical history and that it resolves in days to weeks
Solitary Pulmonary Nodule
and bronchogenic cysts
If more than 3 cm then mass but similar DD
Contrast (dark) is important to spot it because mostly missed.
Metastasise from endometrium
echonococus sometimes called cannibal nodules
PE
HH = pleual based opacity due to infarction. Takes long time to resolve and can result in scarring
WS = focal redcution in lung markings = reduced blood flow in blocked and redistribution
FS = prominent centra artery caused by distension because of large PE
Cavitation
pneumonia = necrotising RLL pnewmonia due to aspiration
lng abcess = complication of pneumonia
TP= common cause
PM = SCC most common
SPE = IV drug abuser septic PR RS endocitis
PI = 5% cavitate
Granulo w polyangitis = wegerners granulomatosis thun and thick walled. very in size and can reolve.
pneumotcele = thin walled and aftermath of pnemonia. Can be asymptimatic and reolves over time if antibiotics was taken.
Aspergilloma
Interpretating chest X rays
Atlectasis, lines, tubes, devices and surgeries
Can mimick a mass so called pseudotumour. Can be DD from the shadow and previous history of asbestosis exposure.
tracheal deviation
diaphragmatic shift
juxtaphrenic sign
opacity
fissures
other stuff
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If too much can cause arrthymia, if too little won't measure properly and wont distrubute properly
can induce pneomitisi or full blown ARDS with only 22 ccs
Cardiac devices
ICD to shock heart out of arrythmias
LVAD which is implanted adjusting to failing heart till pt waits for heart transplant.
Complications
last one is with leads for temporarily pacing during surger
y
what remains is the sternotomy wires which are attached to both sides and appear like paper clips
Staples from graft also seen. wll be there forever and not significant.
The ball valve not used anymore because plot
Aortic vs mitral valve DD
1.
2. apparent direction of blood flow
3.
Misc 2
can get complicated with pneumonia
Mastectomy with a uni lateral transplant.