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CCA SERIES: CXR Interpretation ISOC MedEd Introduction ● Who are we? ● Our mission ● Our team ● Our plan Upcoming MedEd Events ● Respiratory Crash Course - Tues 15th Oct 5-8pm Chest X-Ray Interpretation Noorulanne Younis – ISOC MedEd 10cm Why Are Chest X-Rays Important? 10cm 5 Why Are Chest X-Rays Important? Detecting Lung Diseases 10cm 6 Why Are Chest X-Rays Important? Detecting Lung Diseases Assessing Heart Health 10cm 7 Why Are Chest X-Rays Important? Detecting Lung Diseases Assessing Heart Health Monitoring Respiratory Symptoms 10cm 8 Why Are Chest X-Rays Important? Detecting Lung Diseases Assessing Heart Health Monitoring Respiratory Symptoms Identifying Injuries 10cm 9 Why Are Chest X-Rays Important? Detecting Lung Diseases Assessing Heart Health Monitoring Respiratory Symptoms Identifying Injuries 10cm Guiding Medical Procedures 10 Why Are Chest X-Rays Important? 10cm 11 Session Outline Basic Interpretation Skills Must Know X-Rays Previous CCA Stations Practice X-Rays 12 1. Check Patient Details • Name and ID • DOB • Date X-Ray was taken • Any previous X-Rays to compare to? 13 1. Check Patient Details Date: 10/20/2024 Name: Noorulanne Younis DOB: 11/06/2003 Date Acquired: 10/10/2024 Name: Noorulanne Younis Time Acquired: 15:05 NHS Number: 1083424 DOB: 11/06/2003 Miss Younis, a 21-year-old female presents to ED with complaints of increasing shortness of breath over the last two days and sharp chest pain that worsens with deep inspiration. 14An X-Ray is a Mirrored Image… Right Side Left Side 152. Assessing Quality - Pneumonic R I P E 16Assessing Quality - Pneumonic Rotation I P E 17Assessing Quality - Rotation 18Assessing Quality - Rotation Equidistance of clavicles from the spine 19Assessing Quality - Rotation Equidistance of clavicles from the spine Spinous processes are vertical 20Assessing Quality - Pneumonic Rotation I P E 21Assessing Quality - Pneumonic Rotation Inspiration P E 22Assessing Quality - Inspiration Should see 5-6 anterior ribs OR at least 9 posterior ribs 23Assessing Quality - Inspiration Should see 5-6 anterior ribs OR at least 9 posterior ribs Costophrenic angles 24Assessing Quality - Inspiration Should see 5-6 anterior ribs OR at least 9 posterior ribs Costophrenic angles 25Assessing Quality - Pneumonic Rotation Inspiration P E 26Assessing Quality - Pneumonic Rotation Inspiration Projection E 27Assessing Quality - Projection Front to back (AP) Back to front (PA) Most are PA! 28Assessing Quality – AP Labelled as AP Scapulae projected over the lung fields 29Assessing Quality – AP AP view will exaggerate heart size due to magnification – PA view is required to confidently diagnose cardiac enlargement! 30Assessing Quality - Pneumonic Rotation Inspiration Projection E 31Assessing Quality - Pneumonic Rotation Inspiration Projection Exposure 32Assessing Quality – Exposure Vertebrae visible behind the heart 33Assessing Quality - Pneumonic Rotation Inspiration Projection Exposure 34Assessing Quality - Summary Rotation – equidistant clavicles and vertical spinous processes Inspiration – 5-6 anterior ribs and costophrenic angles Projection – PA/AP Exposure – vertebrae visible behind the heart 35 Assessing Quality - Example Patient ID: 1083424 PA L Name: Noorulanne Younis DOB: 11/06/2003 Date Acquired: 10/10/2024 Time Acquired: 15:05 36X-Ray Physics – Tissue Densities Thicker or heavier tissues block more X-rays For example, bones block more X-rays than soft tissue, so they show up whiter on an X-ray 383. Interpretation - ABCDE A B C D E 39Interpretation - ABCDE Airway B C D E 40Airway - Trachea Is trachea visible? 41 Airway - Trachea Is trachea visible? Is it midline (central) or deviated to one side? 42 Airway - Deviation Deviated? Must be being pushed or pulled by something 43 Airway - Deviation Right Pneumothorax 44 Airway - Deviation Right Pneumothorax Right Lung Collapse 45Airway - Bronchi Check carina and bronchi 46 Airway - Bronchi Check carina and bronchi Right bronchus is straighter and wider than the left Making it more likely for aspiration of fluids or food particles 47 Airway – Hilar Regions Check hilar regions for abnormal vessels or enlarged lymph nodes 48 Airway – Hilar Regions Check hilar regions for abnormal vessels or enlarged lymph nodes Bilateral enlargement – TB or Sarcoidosis Unilateral enlargement - Cancer 49Interpretation - ABCDE Airway B C D E 50Interpretation - ABCDE Airway Breathing (Lungs) C D E 51Anatomical Lobes 52Anatomical Zones 53Breathing (Lungs) - Mass 54Breathing (Lungs) - Mass Mass in right middle zone 55Breathing (Lungs) – Lung Markings Check lung markings extend completely to the edges of the lung fields 56Breathing (Lungs) – Lung Markings 57Breathing (Lungs) – Lung Markings Right pneumothorax 58 Breathing (Lungs) – Pleura Pleura are typically not visible unless they become thickened or there is an accumulation of fluid 59 Breathing (Lungs) – Pleura Pleura are typically not visible unless they become thickened or there is an accumulation of fluid Pleural thickening – accumulation of blood, mesothelioma 60Interpretation - ABCDE Airway Breathing (Lungs) C D E 61Interpretation - ABCDE Airway Breathing (Lungs) Cardiac D E 62 Cardiac (Heart) - Size Check size – heart should occupy less than 50% of the thoracic window 63 Cardiac (Heart) – Size Check size – heart should occupy less than 50% of the thoracic window Greater than 50% - cardiomegaly (check its not AP first!) 64 Cardiac (Heart) – Atria and Vessels Check right atrium and left ventricle – make up most of heart border 65 Cardiac (Heart) – Atria and Vessels Check right atrium and left ventricle – make up most of heart border Usually, consolidation causes disturbance to these areas 66Interpretation - ABCDE Airway Breathing (Lungs) Cardiac D E 67Interpretation - ABCDE Airway Breathing (Lungs) Cardiac Diaphragm E 68 Diaphragm - Position Diaphragm is normally higher on the right due to the presence of the liver 69Diaphragm – Costophrenic Angles Where diaphragm meets the ribs – costophrenic angle 70Diaphragm – Costophrenic Angles Where diaphragm meets the ribs – costophrenic angle Should be well defined and acute 71 Diaphragm – Costophrenic Angles If angle is considerably larger or lost altogether – costophrenic blunting 72 Diaphragm – Costophrenic Angles If angle is considerably larger or lost altogether – costophrenic blunting Can be caused by hyperinflation or fluid accumulation 73Diaphragm – Gastric Bubble Left side – fluid or gas level 74Interpretation - ABCDE Airway Breathing (Lungs) Cardiac Diaphragm E 75Interpretation - ABCDE Airway Breathing (Lungs) Cardiac Diaphragm Everything Else 76 Everything Else – Bony Involvement Rib fractures, dislocations, lytic lesions (destruction ) or extra features 77 Everything Else – Bony Involvement Rib fractures, dislocations, lytic lesions (destruction ) or extra features Right broken clavicle 78Everything Else – Tubes and Devices PacemakerEverything Else – Tubes and Devices Pacemaker ECG WiresEverything Else – Tubes and Devices Pacemaker ECG Wires Artificial Heart Valve 81 ABCDE – Summary Airway – trachea visible, deviation, carina and bronchi, hilar regions Breathing (Lungs) – zones, masses, lung markings, pleura Cardiac – size and structures Diaphragm – costophrenic angles, gastric bubble Everything Else – bony involvement, tubes and devices 82Bringing It All Together - Example Patient ID: 1083424 PA L Name: Noorulanne Younis DOB: 11/06/2003 Date Acquired: 10/10/2024 Time Acquired: 15:05 834. Common Chest X-Rays 85Normal Chest X-Ray 86Normal Chest X-Ray 87Normal Chest X-Ray 88 Pneumonia Fluid (such as pus) in the alveoli 89 Lobar Pneumonia Homogenous opacification confined to one lobe of the lung (strep) 90 Lobar Pneumonia Homogenous opacification confined to one lobe of the lung (strep) 91 Atypical Pneumonia Widespread patchy changes within the interstitium 92 Atypical Pneumonia Widespread patchy changes within the interstitium Caused by an unusual bug that cannot normally be cultured 93 Atypical Pneumonia Widespread patchy changes within the interstitium Caused by an unusual bug that cannot normally be cultured 94 Aspiration Pneumonia Solids or liquids are aspirated into the respiratory tract 95 Aspiration Pneumonia Solids or liquids are aspirated into the respiratory tract Erect patients - move into the middle and basal lobes 96 Aspiration Pneumonia Solids or liquids are aspirated into the respiratory tract Erect patients - move into the middle and basal lobes Recumbent patient - posterior part of their upper lobe and the superior part of the lower lobe 97 Aspiration Pneumonia Solids or liquids are aspirated into the respiratory tract Erect patients - move into the middle and basal lobes Recumbent patient - posterior part of their upper lobe and the superior part of the lower lobe 98 TB Tuberculosis (TB) is a bacterial infection spread through inhaling tiny droplets from the coughs or sneezes of an infected person 99 TB Ghon focus/lesion – primary site of infection 15% of cases calcify (caseating granuloma) 100 TB Ghon focus/lesion – primary site of infection 15% of cases calcify (caseating granuloma) 101 Miliary TB Uncontrolled haematogenous spread of TB – very bad 102 Miliary TB Uncontrolled haematogenous spread of TB – very bad 103 Pneumothorax Air or gas in the pleural space (between lungs and the chest wall) 104 Pneumothorax Air or gas in the pleural space (between lungs and the chest wall) 105 Tension Pneumothorax Inspiratory valve created – gets bigger with each breath 106 Tension Pneumothorax Inspiratory valve created – gets bigger with each breath 107 Lobar Collapse Most commonly related to bronchial obstruction – causes resorptive atelectasis 108 Resorptive Atelectasis Because the bronchi are obstructed, ventilation to that lobe of the lung is reduced 109 Resorptive Atelectasis Because the bronchi are obstructed, ventilation to that lobe of the lung is reduced Any residual air that is left in the affected lobe is taken into the blood faster than it can be exchanged from fresh air from the outside 110 Resorptive Atelectasis Because the bronchi are obstructed, ventilation to that lobe of the lung is reduced Any residual air that is left in the affected lobe is taken into the blood faster than it can be exchanged from fresh air from the outside Causes volume in the affected lung to shrink and thus the lobe has a tendency to collapse 111 Lobar Collapse Typically takes on a triangular shape 112 Lobar Collapse Typically takes on a triangular shape 113Lobar Collapse – Sail Sign Associated with left lower lobe collapse 114Lobar Collapse – Sail Sign Associated with left lower lobe collapse 115 Pleural Effusion Fluid that develops in the pleural space 116 Pleural Effusion Fluid that develops in the pleural space Between the visceral and parietal layers of the pleura 117 Pleural Effusion Fluid that develops in the pleural space Between the visceral and parietal layers of the pleura Small amount of fluid in this space normally 118 Pleural Effusion Fluid that develops in the pleural space Between the visceral and parietal layers of the pleura Small amount of fluid in this space normally Costophrenic blunting 119 Pleural Effusion Fluid that develops in the pleural space Between the visceral and parietal layers of the pleura Small amount of fluid in this space normally Costophrenic blunting 120 COPD COPD is a broad term which describes chronic airflow limitation due to obstruction with irritation 121 COPD COPD is a broad term which describes chronic airflow limitation due to obstruction with irritation Commonly associated with bronchitis and emphysema 122 COPD Flat diaphragm - hyper expansion of chest and hyperinflation of lungs 123 COPD Flat diaphragm - hyper expansion of chest and hyperinflation of lungs Floating heart sign – see inferior border of the heart 124 COPD Flat diaphragm - hyper expansion of chest and hyperinflation of lungs Floating heart sign – see inferior border of the heart Bullae – patchy areas with thinning of the pulmonary vessels 125 Heart Failure Alveolar oedema – bat wing opacities, most easily seen in the middle 126 Heart Failure Alveolar oedema – bat wing opacities, most easily seen in the middle Kerley B lines – thickened interlobular septa which extend inwards 127 Heart Failure Alveolar oedema – bat wing opacities, most easily seen in the middle Kerley B lines – thickened interlobular septa which extend inwards Cardiomegaly – at least 50% of the total thoracic window 128 Heart Failure Alveolar oedema – bat wing opacities, most easily seen in the middle Kerley B lines – thickened interlobular septa which extend inwards Cardiomegaly – at least 50% of the total thoracic window Dilated vessels - upper lobe vessels 129 Heart Failure Alveolar oedema – bat wing opacities, most easily seen in the middle Kerley B lines – thickened interlobular septa which extend inwards Cardiomegaly – at least 50% of the total thoracic window Dilated vessels - upper lobe vessels Pleural effusion – fluid in the pleural space 130Heart Failure 131 Hiatus Hernia Abdominal contents such as the oesophagus or stomach herniate through the oesophageal hiatus of the diaphragm into the thorax 132 Hiatus Hernia Abdominal contents such as the oesophagus or stomach herniate through the oesophageal hiatus of the diaphragm into the thorax Sliding – 90%, GOJ comes through oesophageal hiatus 133 Hiatus Hernia Abdominal contents such as the oesophagus or stomach herniate through the oesophageal hiatus of the diaphragm into the thorax through oesophageal hiatus Rothrough oesophageal hiatusniates 134Bronchogenic Carcinoma 135Cannonball Metastases 136Pancoast Tumour 137Dextrocardia 138 Jzk For Listening 10cm 140!!FEEDBACK!!Thanks for coming!