Chest X-Ray in Clinical Practice

Thechestradiograph(chestX-ray)isthemostcommonly- questedexamination,anditisprobablythehardestplain?lm tointerpretcorrectly. Accurateinterpretationcangreatly- ?uence patient management in the acute setting. It is, h- ever,oftenperformedoutofhoursandtheinterpretationis undertakenbyrelativelyjuniormembersofstaffwithno- mediateseniorsupportorradiologicalinput. Despitethe- creasingavailabilityofmorecomplexradiologicalinvesti- tions,thechestX-raycontinuestoberequestedasa?rst-line investigationandthisislikelytocontinue. The structure of this book derives from many teaching sessions that have been given to junior doctors and me- calstudents. Theauthorshavefoundthat,ingeneral,tea- ingregardingchestX-rayinterpretationhadlackedaformal structuredapproach,andjuniordoctorsandmedicalstudents foundinterpretingachestX-raydif?cult. Givingthemastr- turedapproachallowedthemtofeeltheycouldtackleint- pretationwithmorecon?dence. Weaimtoprovideaportablehandbookforjuniordoctors. The structure is based upon those lectures that the authors havegiven. Thebookitselfisintendedtobeeasilyaccessible andtohelpthiswehaveincludedtablescontainingthekey teachingpoints,toalloweasyreference. Wehaveincluded- tensiveexamplesofcommonpathologies. Thisbookis,h- ever,notanexhaustiveworkofreference. WehaveincludedbasicinformationonhowachestX-ray isperformedandhowsuchperformancefactorscanaffectthe qualityoftheimage. Weconsidertheimplicationsofrad- tiondoseandgivedetailsofbasicnormalanatomy. Wethen explainwhynormalstructuresappearastheydoonthechest vii viii Preface X-ray. Theabilitytointerpretthenormaliskeytointerpr- ingtheabnormalandweexplainwhyabnormalitiescreatethe imagingfeaturestheydo. Using a structured logical approach, we focus on both anatomical abnormality and more generalized patterns of lungdisease. Our ultimate aim is to equip the reader with a con?dent, simplebutlogicalapproachtochestX-rayinterpretation. R. Joarder N. Crundwell Acknowledgments We would like to acknowledge Christina Worley for all her hardworkinpreparingthemanuscript. We would also like to acknowledge the following for their valuable contribution to this book: Steve Page, DCR, MSc, Conquest Hospital, St Leonards-On-Sea, East Sussex, UK,andAndrewDeveling,DipMDI,ConquestHospital,St Leonards-On-Sea,EastSussex,UK ix Contents Preface. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vii Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ix PartI 1 ChestRadiography . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 1. 1. RadiographicTechnique . . . . . . . . . . . . . . . . . . . . 4 1. 1. 1. Postero-anterior(PA). . . . . . . . . . . . . . . . 4 1. 1. 2. Antero-posterior. . . . . . . . . . . . . . . . . . . . 6 1. 1. 3. Lateral . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 1. 1. 4. Obliques. . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 1. 1. 5. PenetratedPostero-anterior . . . . . . . . . . 12 1. 1. 6. Inspiration/ExpirationPostero-anterior 12 1. 1. 7. ApicalLordotic . . . . . . . . . . . . . . . . . . . . . 12 1. 2. KeyPoints. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 2 The Normal Chest X-ray: An Approach toInterpretation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 2. 1. UnderstandingNormalAnatomy . . . . . . . . . . . . 17 2. 2. ReviewAreas. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22 2. 3. Pseudo-abnormalitiesonaNormalFilm. . . . . . 24 2. 4. KeyPoints. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27 PartII 3 TheMediastinumandHilarRegions . . . . . . . . . . . . . 31 3. 1. MiddleMediastinumandHilarRegions. . . . . . 34 xi xii Contents 3. 1. 1. CardiacAbnormality. . . . . . . . . . . . . . . . .