Introduction To CXR Evaluation

With lessons learned from my conversations

with the greatest detective of them all….

RADIOLOGY

What is your greatest pearl for potential detectives?

“Not invisible but unnoticed Watson. You did not know where to look so you missed all that was important.”

?A Case of Identity?

“In order to know where to look – a map is needed -know your geography” he said
In the case of the CXR – Knowledge of Anatomy

 

THE HEART, LUNGS, PLEURA, DIAPHRAGM, ARTERIES, VEINS, PROXIMAL TRACHEOBRONCHIAL TREE and SKELETON
Ashley Davidoff MD
Parts of the Lungs-  Basics

Left Lung – Left Upper Lobe – Frontal Projection

LEFT UPPER LOBE IN THE FRONTAL PROJECTION
Ashley Davidoff MD

Frontal Projection Left Lower Lobe

LEFT LOWER LOBE IN THE FRONTAL PROJECTION
Ashley Davidoff MD

Lateral Examination – Major Fissure on the Left 

LATERAL PROJECTION – FISSURE DIVIDES THE LEFT UPPER LOBE (INCLUDING LINGULA) AND LEFT LOWER LOBE
Ashley Davidoff MD
MAJOR FISSURE ON THE LEFT
Ashley Davidoff MD

Lateral Projection – Left Upper Lobe

LATERAL PROJECTION, LEFT UPPER LOBE
Ashley Davidoff MD

Lateral Projection left Lower Lobe

LATERAL CXR SHOWING LEFT LOWER LOBE
Ashley Davidoff MD

 

Right Lung – Right Upper Lobe – Frontal Projection
RIGHT UPPER LOBE IN THE FRONTAL PROJECTION
Ashley Davidoff MD
Right Middle Lobe – Frontal Projection

 

RIGHT MIDDLE LOBE IN THE FRONTAL PROJECTION
Ashley Davidoff MD
Right Lower Lobe – Frontal Projection

 

RIGHT MIDDLE LOBE IN THE FRONTAL PROJECTION
Ashley Davidoff MD

 

Major and Minor Fissures on the Right

ANATOMIC SPECIMEN SHOWING MAJOR and MINOR FISSURES DIVIDING THE RIGHT LUNG INTO 3 LOBES
The right lung has a small right upper lobe (RUL) separated from the middle lobe (RML) by the minor fissure (pink,lower image) . Both the RUL and RML are anterior and are separated from the lower lobe  by the major fissure (orange line)
Ashley Davidoff MD
LATERAL X-RAY SHOWING MAJOR and MINOR FISSURES DIVIDING THE RIGHT LUNG INTO 3 LOBES
The right lung has a relatively small right upper lobe (RUL) separated from the middle lobe (RML) by the minor fissure (pink,lower image). Both the RUL and RML are anterior and are separated from the lower lobe  by the major fissure (orange line)
Ashley Davidoff MD
Right Upper Lobe – Lateral  Projection
LATERAL CXR SHOWING RIGHT UPPER LOBE
Ashley Davidoff MD
Right Middle Lobe – Lateral Projection

 

LATERAL CXR SHOWING RIGHT MIDDLE LOBE
Ashley Davidoff MD
Right Lower  Lobe – Lateral Projection
LATERAL CXR SHOWING RIGHT LOWER LOBE
Ashley Davidoff MD
Summary

CXR of LEFT LUNG
Ashley Davidoff MD

CXR of RIGHT LUNG
Ashley Davidoff MD

Trachea, Main Stem Bronchi, and Carina

 

NORMAL FRONTAL CXR NORMAL ASYMMETRIC BRANCHING OF MAINSTEM BRONCHI
The normal CXR shows the characteristic asymmetric branching of the main stem bronchi. The right is short and stout and slightly more vertical while the left is long and thin and slightly more obtuse.
The normal carinal angle is between 40-80 degrees.
Ashley Davidoff MD

ASYMMETRIC BRANCHING PATTERN – RIGHT SHORT AND STOUT AND THE LEFT LONG AND THIN
CARINAL ANGLE – 40-80 degrees
Ashley Davidoff MD
THE RIGHT – SHORT STOUT AND CUTE
THE LEFT – TALL THIN AND GRACILE
The carinal angle
OLIVER HARDY AND STAN LAUREL IN THE 1939 FILM – THE FLYING DEUCES
SCREW IN THE RIGHT MAIN STEM
http://www.wikiradiography.net/
N-G TUBE IN RIGHT MAIN STEM BRONCHUS
Courtesy Radiopaedia
ET TUBE IN RIGHT MAIN STEM BRONCHUS
Courtesy Radiopaedia
Carinal Angle – Normal

The Wright Brothers Take a Walk (Take a look at the crotch angle)

WRIGHT BROTHERS IN 1910
Library of Congress

 

The branching pattern of the tracheobronchial tree is  like the asymmetric branching of most trees – just upside down
ASYMMETRIC BRANCHING PATTERN – RIGHT SHORT AND STOUT AND THE LEFT LONG AND THIN
The classical branching pattern of many trees
Ashley Davidoff MD

Widened Carinal Angle – The Enlarged Left Atrium

MITRAL STENOSIS WITH ENLARGED LEFT ATRIUM, WIDENED CARINAL ANGLE AND MITRAL VALVE PROSTHESIS
Origin Big Gallery

The Kick or the Dance – Widening of the carinal (crotch) angle
THE KICK INSTEAD OF THE WALK – LEFT ATRIAL ENLARGEMENT
Margot Fonteyn dancing with Rudolf Nureyev during a rehearsal of Roland Petit?s Paradise Lost at Covent Garden in London in 1967 (PA Archive/PA)
THE KICK
Jim Sullivan kicking for England, in a rugby league match against Australia, 1933

 

THE HEART ON THE FRONTAL CXR

FRONTAL CXR AND THE HEART
If we were to “crack open” the chest of the chest X-ray, the structures that would dominate this bloody, black and white scene, would be the right sided chambers. The right ventricle (RV) would be the dominant anterior chamber, and would form the dominant interface with the diaphragm. The right atrium (RA) would form the border with the right lung. The RA would of course be slightly posterior to the RV. The left border would be formed by the left ventricle. Most the left ventricle is hidden posteriorly in this view. The left anterior descending artery would be visible from this anterior view. It marks the position of the interventricular septum.
Ashley Davidoff MD
THE HEART ON THE LATERAL CXR
THE HEART ON THE LATERAL CXR
A normal lateral examination of the chest X-ray is shown to exemplify the positioning of the cardiac chambers showing the right ventricle(RV) right ventricular outflow tract (RVOT) and main pulmonary artery (MPA) anteriorly, the left ventricle LV) left atrium (LA) posteriorly with the SVC posterior to the ascending aorta (Ao) and the inferior vena cava (IVC) as a separate shadow posterior to the LV.
Ashley Davidoff MD

“So Mr Holmes,” I asked “how do you assess the gravity of the situation?”

“Your question”, he said,  “has ambivalence.
Do you mean – how to assess severity of a situation or how to  assess  the gravitational forces in place in the CXR and in the scenes of a crime?   I will answer the latter first since it also has relevance to the first thing we spoke about  – ie knowing where to look”

The Force of Gravity on Fluid and Air in the Supine and Upright and Semi Upright Positions

” Davidoff”  he said… ?The world is full of obvious things which nobody by any chance ever observes.?  (The Hound of the Baskervilles)

It is elementary –

Firstly – air rises and fluid falls

and secondly – the stronger force of two adjacent structures wins space

Air In the Upright Position

HIGHEST POINTS IN THE CHEST ARE THE APICES
In the upright position air will rise to the apex (as long as there are no pleura adhesions.
In the apex it will assume a sickle cell shape since it can exert force on the lung but not onthe chest wall so it assumes the shape of the apex of the lung
Ashley Davidoff MD
SMALL APICAL PNEUMOTHORAX IN AN UPRIGHT CXR TAKEN IN EXPIRATION.
In an upright position a pneumothorax rises to the apex of the lung and assumes the shape of the apex because it exerts pressure on the lung apex which yield to the greater pressure. The expiration film accentuates the pneumothorax because it further reduces the pressure in the lungs and increases the pressure difference between the PTX and the intraparenchymal pressure.
The PTX is barely seen in (a) and is better seen in the magnified views (b and c) and with increasing contrast (c) the faint line of the the pleura becomes better visualized (white arrowheads).
Ashley Davidoff MD
SMALL APICAL PNEUMOTHORAX IN AN UPRIGHT CXR TAKEN IN BOTH INSPIRATION AND EXPIRATION.
In an upright position a pneumothorax rises to the apex of the lung and assumes the shape of the apex because it exerts pressure on the lung apex which yields to the grater pressure. On the inspiration film (a) the pneumothorax is barely seen, even on the enhanced magnified view (b, white arrowhead) On the expiration film the pneumothorax is better seen (d white arrowhead) because it is larger and because the intraparenchymal pressure of the lungs is reduced thus allowing the pneumotorax to accumulate in the apical region and less spread out along the surface of the lung
Ashley Davidoff MD

 

The supine position is a different story
PNEUMOTHORAX IN THE SUPINE POSITION
The highest point in the chest is anterior and inferior

 

So in a Frontal Projection

DEEP SULCUS SIGN
When the a patient with a pneumothorax is in the supine position air will accumulate in the sulcus and appear as a lucency in the sulcus. This is called the deep sulcus sign
DEEP SULCUS SIGN
Portable supine examination in the ICU shows a pneumothorax in the right subpulmonic region
Ashley Davidoff MD
Deep sulcus sign. Anteroposterior supine radiograph of the chest in a patient with bilateral pneumothoraces. The costophrenic angles are lucent and extend inferiorly, signifying pleural air that has risen to the dependent portion of the thorax in these regions.
Source
Signs in Thoracic Imaging
Journal of Thoracic Imaging 21(1):76-90, March 2006.
DEEP SULCUS SIGN
CT scout film (above) shows a lucency of air accumulation in the left deep sulcus that also extends to the lateral margin of the left lung. The axial CT image confirms the presence of a large pneumothorax, dominant at the highest point in the chest in the supine position Portable supine examination in the ICU shows a pneumothorax in the right subpulmonic region
Ashley Davidoff MD
TENSION PNEUMOTHORAX
This is the type of CXR that sends shivers down the spine. The overall blackness of the left chest cavity, in association with a nubbin of lung tissue in the ipsilateral hilum and rightward mediastinal shift is characteristic of a tension pneumothorax with total atelectasis of the left lung. Immediate and urgent decompression with a chest drain is indicated.
Courtesy of: Ashley Davidoff, M.D.
“And now Davidoff , for gravity, forces, fluid and spaces in the upright projection” said Holmes

 

UPRIGHT CXR – FLUID DROPS INTO THE COSTOPHRENIC ANGLES
When the a patient  is in the upright position fluid  will accumulate in the costophrenic angles.  However because the angles are deeper posteriorly the best examination to identify smaller effusions is on the lateral examination.
UPRIGHT CXR in the LATERAL PROJECTION- FLUID DROPS INTO THE COSTOPHRENIC ANGLES
When the a patient  is in the upright position fluid  will accumulate in the costophrenic angles.  However because the angles are deeper (more inferior) posteriorly the best examination to identify smaller effusions is on the lateral examination. Note the relatively inferior positioning of the costophrenic angles
Ashley Davidoff MD

 

SMALL EFFUSION ONLY IDENTIFIED ON THE LATERAL EXAMINATION
A small effusion is not identified on the PA chest since it is hidden by the diaphragm and the effusion first fills the posterior recess because it is most inferior. The lateral examination is required to identify the effusion
Courtesy How to Interpret CXR Strong Medicine

And the pleural in the supine projection
EFFUSION IN THE SUPINE POSITION
Ashley DAvidoff MD

 

VEILING OPACITY OF LARGE RIGHT PLEURAL EFFUSION
On supine projections, pleural effusions produce a “veiling opacity”, which is due to pleural fluid preferentially collecting posteroinferiorly in the pleural space.
Courtesy RADIOPAEDIA
SMALL BILATERAL PLEURAL EFFUSIONS LAYERING POSTERIORLY IN THE POSTERIOR PLEURAL RECESSES
Ashley Davidoff MD
LARGE RIGHT PLEURAL EFFUSION SITUATED POSTERIORLY CAUSING COMPRESSIVE ATELECTASIS
Ashley Davidoff MD
Pericardial Effusion
WATER BOTTLE HEART
X-ray shows the typical appearance of a “water bottle heart? characteristic of a pericardial of a large pericardial effusion.
Ashley Davidoff MD

 

“So Mr Holmes – What is your method of analysis?
Said Holmes
“Did your mother ever tell you to practice your scales on the piano ?  Well I use the same methodical method to develop my skills
The path to excellence in any skill has a simple formula”

“NOTES, SCALES AND MUSIC”

Perfecting the art – any art, any skill

Notes

The Parts

Scales

Putting the Parts Together in a logical and fluid way –

Then Practice Practice Practice!

Bring in the Cerebellum

Music

Game Day, Show! Time, Bring it On!

Pursuit of Excellence in the Piano
THE ART OF PERFECTING MUSIC
Ashley Davidoff
Scales from MusicNotes.com
Pursuit of Excellence in the Dance
THE ART OF PERFECTING DANCE
Ashley Davidoff
Pursuit of Excellence in the Tennis
THE ART OF PERFECTING TENNIS
Ashley Davidoff
Method of Chest X-ray Evaluation
Notes = parts = anatomy
Scales – Practice looking at the X-ray in a logical and methodical way and then …..practice practice practice

30397gn.jpg

 NORMAL CXR


UPSIDE DOWN

“So Mr Holmes tell us about the dark side of your work?”

“Again this elementary  I need the light to see the dark side” said Holmes

HOW MANY SQUARES 3 OR 4?
Courtesy Ashley Davidoff
HOW MANY SQUARES 3 OR 4?
Courtesy Ashley Davidoff

SILHOUETTING

NORMAL AND SILHOUETTING OF THE LEFT DIAPHGRAGM

 

Silhouette sign, right middle lobe pneumonia. Initial frontal (A) and lateral (B) radiographs in a patient with clinical suspicion of pneumonia demonstrate obliteration of the right heart border. Follow-up radiographs the next day (C, D) illustrate dense opacification on the lateral view and persisting loss of the right heart border, confirming the presence of a right middle lobe pneumococcal pneumonia.
Source
Signs in Thoracic Imaging
Journal of Thoracic Imaging 21(1):76-90, March 2006.
PNEUMONIA IN THE SUPERIOR SEGMENT OF THE RLL
Ashley Davidoff MD
LINGULAR INFILTRATE
Superior segment
Ashley Davidoff MD
“So Mr Holmes – How do you decide whether something is normal or abnormal? – What is your method of analysis?
“Elementary my dear Dr Davidoff ” he said  “I focus on the structure or part that I think is abnormal and look at 5 basic elements
Size
Shape
Position
Character
How it changes with time

 

Air Bronchograms and Ground Glass
AIR BRONCHOGRAMS AND GROUND GLASS

 

“So now Dr Davidoff I need you to teach me about failure – Oops I mean heart failure”

Heart Failure
Elementary I said –

The first two things to look at in heart failure is the carinal angle and the size of the upper lobe artery to bronchus ratio

Normal Carinal Angle

CARDIOMEGALY, CEPHALIZATION, INCREASE ARTERY TO BRONCHUS RATIO, MILD HAZINESS OF THE VESSELS, ENLARGED PULMONARY ARTERY
This patient is in heart failure with cephalization of the vessels, increase in the artery to bronchus ratio in the upper lobe bronchovascular bundle, (lower image – teal = bronchus and royal blue = artery) and perhaps mild early interstitial edema characterized by fuzziness of the right lower pulmonary artery.
The heart is enlarged and the pulmonary artery is enlarged characterizing pulmonary hypertension.
Ashley Davidoff MD
UPPER LOBE ARTERIOLE TO BRONCHIOLE SIZE
Ashley Davidoff MD

 

 

WRIGHT BROTHERS IN 1910
Library of Congress
THE KICK
Jim Sullivan kicking for England, in a rugby league match against Australia, 1933
MITRAL STENOSIS WITH ENLARGED LEFT ATRIUM, WIDENED CARINAL ANGLE AND MITRAL VALVE PROSTHESIS
Origin Big Gallery

web-radiology-assistant-CHF-002.jpg

 CEPHALISATION
ARTERIOLE TO BRONCHIOLE RATIO
Courtesy Radiology Assistant
batwing alveolar edema
Courtesy Start Radiology
NORMAL, CEPHALIZATION, INTERSTIAL EDEMA, ALVEOLAR EDEMA
Ashley Davidoff MD

 

NORMAL, CEPHALIZATION, INTERSTITIAL EDEMA, ALVEOLAR EDEMA
Ashley Davidoff MD
SECONDARY PULMONARY LOBULE
lung pulmonary lobule secondary lobule arteriole venule interlobular septa bronchovascular bundle mosaic pattern air trapping fx ground glass XCTscan
Davidoff MD

 

 

Summary

“Not invisible but unnoticed. You did not know how to look nor what to look for, so you missed all that was important.”

 

Notes Scales and Music –

Perfecting the art – any art, any skill

Notes

The Parts (where to look)

Scales (how to look)

Putting the Parts Together –

Then Practice Practice Practice!

Bring in the Cerebellum

Music (what to look for)

Game Day, Show! Time, Bring it On!

“Again this elementary  I need the light to see the dark side” said Holmes

 

4 Most Important Diseases

pneumothorax

pleural effusion

pneumonia

heart failure

 

Principles Evaluation of Structure

Size
Shape
Position
Character
Time

Judgement

 

References and Links

CXR Map

Sherlock Holmes TCV

Arthur Conan Doyle

Polysplenia Syndrome TCV

 

 

 

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