Skill Lab

RIZKI ALIANA AGUSTINA

Identitas pasien Exposure Overexposure Underexposure Overexposure causes a film to be too dark. Under these circumstances, the thoracic spine, mediastinal structures, and retrocardiac areas are well seen, but small nodules and the fine structures in the lung cannot be seen. Underexposure causes the film to be quite white. This is a major problem for adequate interpretation. It will make small pulmonary blood vessels appear prominent and may lead you to think that there are generalized infiltrates when none is really present.

Sex of Patient Male Female

The major difference between male and female chest x-rays is caused by differences in the amount of breast tissue. Breast tissue absorbs some of the xray beam, essentially causing underexposure of the tissues in the path.

 Path

of x-ray beam

PA AP
Patient

Position

Upright Supine

 First

determine is the film a PA or AP view.

PA- the x-rays penetrate through the back of the patient

on to the film

AP-the x-rays penetrate through the front of the patient

on to the film.
All x-rays in the ICU are portable and are AP view

Portable (AP or Antero-posterior)

PA (Postero-anterior)

For interpretive purposes, the main difference is that the heart will be magnified on an AP projection. This is because in the AP projection the heart is farther from the film and the x-ray beam diverges as it goes farther from the tube. The amount of inspiration is greater in an upright film, which allows for spreading of the pulmonary vessels and allowing clearer visualization. Another reason for preferring upright films is that small pleural effusions tend to run down into the normally deep costophrenic angles. A patient lying down is unable to take a full inspiration; the liver and abdominal contents are pushing up on the lungs and heart, and the result is that the pulmonary vessels are crowded. On a supine film, the standard AP projection combined with the cephalic push of the abdominal contents will make a normal heart appear large.

PA

AP

Breath Inspiration Expiration Count the number of ribs above the diaphragm. Anterior end of 6-7th rib should be above the diaphragma Post end of 9-10th rib Poor inspiration will: make the heart look larger, give the appearance of basal shadowing & cause the trachea to appear deviated to the right.

Good Inspiration

Poor Inspiration

 Bony

Framework Soft Tissues Lung Fields and Hila Diaphragm and Pleural Spaces Mediastinum and Heart Abdomen and Neck

PA View:
1. 2. 3. 4. 5. 6. 7. 8. 9.

Aortic arch Pulmonary trunk Left atrial appendage Left ventricle Right ventricle Superior vena cava Right hemidiaphragm Left hemidiaphragm Horizontal fissure

Lateral View:
1. Oblique fissure 2. Horizontal fissure 3. Thoracic spine and

retrocardiac space 4. Retrosternal space

How to look at the lateral film

Check name & date. Identify diaphragms:

1: right hemidiaphragm: can be

seen to stretch across the whole thorax & clearly seen passing through the heart border.
2: left hemidiaphragm: seems

to disappear when it reaches the post border of the heart.

Costophrenic angles.

3: Gastric air bubble.

To accurately localize a lesion on CXR, we need to look at both the PA & lateral films. PA film: Horizontal fissure.

Borders of the lesion: if the lesion is next to a dense (white) structure, the border will be lost silhouette sign.
RML lesion obscures part of

the heart border.

RLL lesion obscures the

border of the diaphragm.

PA film: Right heart border up from the diaphragm: Edge of right atrium. Above the hilum: SVC.
Left heart border up from the diaphragm: Left ventricle. Concavity: left atrial appendage. At the level of the hilum: pulmonary artery. Aortic knuckle.

Cardiac Silhouette

1. R Atrium 2. R Ventricle 3. Apex of L Ventricle

4. Superior Vena Cava 5. Inferior Vena Cava 6. Tricuspid Valve

7. Pulmonary Valve 8. Pulmonary Trunk 9. R PA 10. L PA

Ant border: Right ventricle.

Post border: Left ventricle.

Draw an imaginary line from the apex of the heart to the hilum.
The pulmonic & aortic valves generally sit above this line and the tricuspid & mitral valves sit below.

 Most

disease states replace air with a pathological process Each tissue reacts to injury Lung injury or pathological states can be either a generalized or localized process

Liquid density

Increased air density

Generalized

Localized

Infiltrate Diffuse alveolar Consolidation Diffuse interstitial Cavitation Mixed Mass Vascular Congestion Atelectasis

Localized airway obstruction Diffuse airway obstruction Emphysema Bulla

1. 2. 3. 4. 5.

Identification of abnormal shadows Localization of lesion Identification of pathological process Identification of etiology Confirmation of clinical suspension

Complex problems
Introduction of contrast medium CT chest MRI scan

 Nodules

and masses Cysts and cavities

 Nodule:

any pulmonary lesion represented in a radiograph by a sharply defined, discrete,nearly circular opacity 2-30 mm in diameter Mass: larger than 3 cm

 Qualifiers:

single or multiple size

border definition
presence or absence of calcification location

NODULES

MASSES

Cysts & Cavities

Cyst: abnormal pulmonary parenchymal space, not containing lung but filled with air and/or fluid, congenital or acquired, with a wall thickness greater than 1 mm epithelial lining often present

Benign Lung Cyst : PCP Pneumatocele Uniform wall thickness 1 mm Smooth inner lining

 Cavity:

abnormal pulmonary parenchymal space, not containing lung but filled with air and/or fluid, caused by tissue necrosis, with a definitive wall greater than 1 mm in thickness and comprised of inflammatory and/or neoplastic elements

Benign Cavities : Cryptococcus

max wall thickness 4 mm minimally irregular inner lining

Benign Cavities : Cryptococcus

max wall thickness 4 mm minimally irregular inner lining

Indeterminate Cavities

max wall thickness 5-15 mm mildly irregular inner lining

Malignant Cavities: Squamous Cell Ca max wall thickness 16 mm Irregular inner lining

Alveolar space filled with inflammatory exudate WBC, bacteria, plasma, and debris

Increased

Large hila with indistinct markings Fluid in interlobar fissures Pleural effusions, alveolar edema

heart size: cardiothoracic ratio >0.5

 Congestion Interstitial

and alveolar edema Collapsed or distended alveoli Bilateral

No ventilation to lobe beyond the obstruction Trapped air absorbed by pulmonary circulation Segmental/lobar density Compensatory hyperinflation of normal lungs.

TUBERKULOSIS

kuliah terpadu

Infiltrat paru kiri atas dan TB kavitas

Pneumothoraks

Pleural Effusion

Fungus ball

Pneumonia lobaris

A single, 3cm relatively thin-walled cavity is noted in the left midlung. This finding is most typical of squamous cell carcinoma (SCC). One-third of SCC masses show cavitation

LUL Atelectasis: Loss of heart borders/silhouetting. Notice over inflation on unaffected lung

Right Middle and Left Upper Lobe Pneumonia

Cavitation:cystic changes in the area of consolidation due to the bacterial destruction of lung tissue. Notice air fluid level.

Cavitation

Tuberculosis

COPD: increase in heart diameter, flattening of the diaphragm, and increase in the size of the retrosternal air space. In addition the upper lobes will become hyperlucent due to destruction of the lung tissue.

Chronic emphysema effect on the lungs

Pseudotumor: fluid has filled the minor fissure creating a density that resembles a tumor (arrow). Recall that fluid and soft tissue are indistinguishable on plain film. Further analysis, however, reveals a classic pleural effusion in the right pleura. Note the right lateral gutter is blunted and the right diaphram is obscurred.

Pneumonia:a large pneumonia consolidation in the right lower lobe. Knowledge of lobar and segmental anatomy is important in identifying the location of the infection

CHF:a great deal of accentuated interstitial markings, Curly lines, and an enlarged heart. Normally indistinct upper lobe vessels are prominent but are also masked by interstitial edema.

24 hours after diuretic therapy

Chest wall lesion: arising off the chest wall and not the lung

Pleural effusion: Note loss of left hemidiaphragm. Fluid drained via thoracentesis

Lung Mass

Small Pneumothorax: LUL

Right Middle Lobe Pneumothorax: complete lobar collapse

Post chest tube insertion and re-expansion

Metastatic Lung Cancer: multiple nodules seen

Right upper lower lobe pulmonary nodule

Tuberculosis

Perihilar mass: Hodgkins disease

A.

Teknik pemeriksaan CT-SCAN thorax adalah teknik pemeriksaan secara radiologi untuk mendapatkan informasi anatomis irisan crossectional atau penampang aksial thorax.

Indikasi Pemeriksaan:
Tumor, massa Aneurisma Abses Lesi pada hilus atau mediastinal

Penggunaan media kontras dalam pemeriksaan CT-Scan diperlukan untuk menampakkan struktur-struktur anatomi tubuh seperti pembuluh darah dan organ-organ lainnya dapat dibedakan dengan jelas.

Teknik injeksi intravena : Jenis media kontras : media kontras dengan osmolaritas rendah Volume media kontras : 80 100 ml Injeksi rata-rata (kecepatan) : 2 ml / detik Waktu Scan : melakukan scanning pada saat 25 detik setelah pemasukan awal media kontras (delay).

Kasus seperti tumor dibuat foto sebelum dan sesudah pemasukan media kontras. Tujuan dibuat foto sebelum dan sesudah media kontras adalah untuk melihat apakah ada jaringan yang menyerap kontras banyak, sedikit atau tidak sama sekali.

Merupakan bagian paling superior dari thorax yang disebut apeks paru-paru. Kriteria gambar yang tampak adalah (A) vena jugularis interna kanan, (B) arteri karotis komunis kanan, (C) Trakhea, (D) Sternum, (E) Sternoklavikula joint, (F) klavikula, (G) Vena jugularis interna kiri, (H) arteri subklavikula kiri, (I) arteri karotis komunis kiri, (J) vertebra thorakal II thorakal III, (K) arteri subklavia kanan, (L) prosesus acromion dari scapula, dan (M) caput humerus.

Kriteria yang tampak antara lain (A) vena brachiocephalic kanan (dengan media kontras), (B) arteri innominata, (C) manubrium sterni, (D) Vena brachiophelic kiri, (E) Arteri komunis karotis kiri, (F) arteri subklavia kiri, (G) oesofagus, (H) vertebra thorakal III-thorakal IV, dan (I) trakhea.

Kriteria gambar yang tampak adalah (A) vena kava superior, (B) Aorta ascenden, (C) Corpus sternum, (D) Window aortopulmonary, (E) oesoagus, (F) aorta descenden, (G) vertebra thorakal IV-thorakal V, dan (H) Trakhea

Kriteria gambar yang tampak antara lain (A) Vena kava superior, (B) Aorta ascenden, (C) arteri pulmonari utama, (D) Vena pulmonari kiri, (E) arteri pulmonari kiri, (F) aorta descenden, (G) Vertebra thorakal VI-thorakal VII, (H) Vena azygos, (I) oesofagus, (J) arteri pulmonari kanan.

Kriteria Gambar yang tampak adalah (A) Vena kava inferior, (B) atrium kanan, (C) Katup trikuspidalis, (D) perikardium, (E) ventrikel kanan, (F) septum interventrikular, (G) ventrikel kiri, (H) atrium kiri, (I) aorta descenden, (J) vertebra thorakal IX-thorakal X, (K) Oesofagus, (L) hemidiafragma kanan.