pulmonary radiology for blog1

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Published on September 11, 2008

Author: drmdarif

Source: authorstream.com

Pulmonary Radiology : Pulmonary Radiology Rui Domingues, MD Lincoln Mental and Medical Center September 2008 Pulmonary Imaging : Pulmonary Imaging Imaging techniques used to investigate pulmonary pathology include: Plain film Computed Tomography Magnetic Resonance Imaging Ultrasound Angiography Keys to reading X-rays well : Keys to reading X-rays well A good understanding of normal anatomy A good search pattern But before we can do this we need to understand how x-rays are produced. Things to cover… : Things to cover… Radiographic basics How to approach a chest x-ray Normal radiographic anatomy Radiographic Basics : Radiographic Basics What causes the blacks, whites and grays of an x-ray image? : What causes the blacks, whites and grays of an x-ray image? X-ray beams contains x-ray photons of differing energies As these photons pass through a patient… Some are absorbed completely Some penetrated directly to the plain film Some are absorbed partially, and While others are deflected (Scatter) Tissue Density : Tissue Density A product of the type of tissue and the thickness of that tissue Results in differential absorption Differential Absorption : Differential Absorption Penetration of the x-ray beam is dependent on tissue density Denser object = less penetration Less beam striking the film (more absorption) = WHITER More beam striking the film = BLACKER Slide 9: Glass Test Tube Air Fat Water Bone + Water Metal Differential Absorption : Differential Absorption Black Air (Lungs / Trachea / Outside the body)  Fat (Perirenal fat / Fascial plane)  Water (Muscle / Organs)  Bone (Bone / Atherosclerotic plaquing) White Metal (Fillings / Markers / Ortho devices) Radiographic Image : Radiographic Image Adjacent structures of similar densities are not visualized Kidney (water density) against liver (water density) Radiographic Image : Radiographic Image Adjacent structures of different densities are visualized Liver (water density) next to Bowel (air density) Chest Films : Chest Films Minimum Diagnostic Series PA Left Lateral Additional Views Apical Lordotic Inspiration / Expiration Slide 15: PA CXR Left Lateral CXR Slide 16: Apical Lordotic CXR Allows for better visualization of the Apices of the lungs Slide 17:  Expiration Inspiration Visualizes respiratory excursion Inspiration study Normal positioning for PA Chest Expiration study Helps visualize: - Small Pneumothorax - Air Trapping Dz (Emphysema) - Bronchial obstruction How to approach an X-ray? : How to approach an X-ray? Reading a Chest X-ray : Reading a Chest X-ray First thing: Correctly put of the film Then perform your search pattern which you always follow when looking at any film this way you will miss fewer findings Reading a radiograph : Reading a radiograph Start reading every radiograph by scanning the areas of least interest first, working your way to the more important areas. You will be less likely to miss important secondary findings. Chest Film Search Patterns : Chest Film Search Patterns ABCs Abdomen Bone Chest Soft tissues ATMLL Abdomen Thorax Mediastium Lung Lung These are the two main search patterns that people use when evaluating a chest film. “ATMLL” Search Pattern : “ATMLL” Search Pattern Remember A = Abdomen T = Thorax M = Mediastinum L = Lungs (unilaterally) L = Lungs (bilaterally) Searching the “Abdomen” : Searching the “Abdomen” Scan across the upper abdomen several times Evaluate normal gas containing structures: Stomach Hepatic flexure of the colon Splenic flexure of the colon Evaluate the liver and on occasion one can visualize the spleen Slide 25: Structures Visualized: Stomach gas bubble Splenic flexure Liver Hemidiaphragms Abdomen dz that can mimic Lung disease include: Subphrenic abscess Diaphragmatic hernia Hiatal Hernia Searching the Bony “Thorax” : Searching the Bony “Thorax” Start at the right base, look at the soft tissues of the chest wall, ribs, spine and shoulder girdle Go up one side and come down on opposite side Remember: Posterior ribs descend medial to lateral Anterior ribs descend lateral to medial Slide 28: Structures Visualized: Breast Tissue Posterior Ribs Anterior Ribs Scapula Clavicle Spine Thorax cage dz that may stimulate chest dz: Bony metastasis Rib / Clavicle fractures Searching the “Mediastinum” : Searching the “Mediastinum” An organized search of the mediastinum is complicated because of all the overlapping structures. Start with a global look for contour abnormalities, then follow with a more detailed search Slide 30: Three searches of the mediastinum: 1. Trachea and carina 2. Aorta and the heart 3. Hilum Three searches of the mediastinum: 1. Trachea and carina 2. Aorta and the heart 3. Hilum Three searches of the mediastinum: 1. Trachea and carina 2. Aorta and the heart 3. Hilum Three searches of the mediastinum: 1. Trachea and carina 2. Aorta and the heart 3. Hilum Searching the “Lungs” : Searching the “Lungs” Since most chest x-rays are ordered to evaluated for lung disease, so the lungs are examined last. They are important, so their evaluation should be more through, therefore we evaluate them twice. Once individually Second time comparing right and left Slide 33: Structures Visualized: Costophrenic angles Lung fields Pulmonary vasculature Right minor fissure Left Lateral Chest Film : Left Lateral Chest Film Valuable radiographic study Helps to better localize lesions Allows to visualize overlapping tissues Allows the visualization of hidden pathology Searching the Lateral Chest Film : Searching the Lateral Chest Film The pattern is the same: Abdomen Thoracic cage strutures Mediastinum Lungs Slide 36: Search Pattern: Abdomen Thoracic cage and bones Mediastinum Lungs Search Pattern: Abdomen Thoracic cage and bones Mediastinum Lungs Search Pattern: Abdomen Thoracic cage and bones Mediastinum Lungs Search Pattern: Abdomen Thoracic cage and bones Mediastinum Lungs Search Pattern: Abdomen Thoracic cage and bones Mediastinum Lungs What to look for… : What to look for… Abnormal density Usually air versus water Abnormal shape Lung field Mediastinum Abnormal size Lung field Mediastinum Abnormal location Hemidiaphragm, hila, mediastinum, trachea, fissure, vasculature But before that we need to have a good understanding of Normal Radiographic Anatomy : But before that we need to have a good understanding of Normal Radiographic Anatomy Slide 39: Let’s look at some of the visual abdominal structures Stomach gas bubble Splenic flexure of the large intestines Liver Left Hemidiaphragm Right Hemidiaphragm Slide 40: Let’s look at the Bony thorax Ribs Spine Clavicle Scapula Chest wall Slide 41: Let’s look at the Bony thorax Ribs Spine Clavicle Scapula Chest wall Slide 42: Trachea on CXR Let’s look at the normal Mediastinal Structures Hilum Slide 43: Vessels Aortic Arch Pulmonary Artery Left Atrium Left Ventricle Inferior Vena Cava Right Atrium Ascending Aorta Superior Vena Cava Slide 44: Descending Aorta Aortic Knob/Arch Ascending Aorta Right Ventricle Inferior Vena Cava Left Ventricle Left Atrium Slide 45: Upper Middle Lower Lung Fields Let’s look at the normal Lung Structures Slide 46: Retrosternal Clear Space Retrocardiac Clear Space Slide 47: Lateral Costophrenic Sulci (Recesses, Angles) Cardiophrenic Sulci (Recesses, Angles Slide 48: Posterior Costophrenic Sulci (Recesses, Angles) What are the Pulmonary Fissures? : What are the Pulmonary Fissures? They are the coming together of the visceral pulmonary pleura. Right lung Oblique (major) fissure Horizontal (minor) fissure Left Lung Oblique (major) fissure Slide 51: Horizontal Fissure Right Oblique Fissure Left Oblique Fissure Slide 52: LUL LLL RUL RML RLL A closer look at the fissures References : References Felson’s Principles of Chest Roentgenology: A Programmed Test, 2nd Edition. Goodman, Lawrence R.; W.B. Saunders Co., 1999. Pocket Atlas of Radiographic Anatomy. Moller, TB et al.; Thieme Medical Publishers, 1993 Clinical Imaging with Skeletal, Chest and Abdomen Pattern Differentials, Dennis Marchiori, ed. (WN 180 M317c)

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