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Chest X-Ray Anatomy Normal chest X-ray anatomy Chest X-Ray Anatomy Normal chest X-ray anatomy

Chest X-Ray Anatomy Normal chest X-ray anatomy - PowerPoint Presentation

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Chest X-Ray Anatomy Normal chest X-ray anatomy - PPT Presentation

Visible structures 1   Trachea 2   Hila 3   Lungs 4   Diaphragm 5   Heart 6   Aortic knuckle 7   Ribs 8   Scapulae 9   Breasts 10   Bowel gas Normal chest Xray anatomy ID: 999156

lung chest ray left chest lung left ray costophrenic normal lateral hemidiaphragm visible heart pulmonary structures soft diaphragm pleural

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1. Chest X-Ray Anatomy

2. Normal chest X-ray anatomyVisible structures1 - Trachea2 - Hila3 - Lungs4 - Diaphragm5 - Heart6 - Aortic knuckle7 - Ribs8 - Scapulae9 - Breasts10 - Bowel gas

3. Normal chest X-ray anatomyKey pointsSome anatomical structures in the chest should be assessed on every chest X-rayEach of these anatomical structures should be viewed using a systematic approachThere are also important structures that are obscured or become visible only when abnormal

4. Trachea and major bronchiNormal chest X-rayThe trachea and bronchi are visible - branching at the carinaThe trachea passes to the right of the aorta and so may be slightly off mid-line to the rightHighlight these structures by hovering the mouse over the image

5. Trachea and major bronchiKey pointsThe large airways contain air and are therefore less dense (blacker) than surrounding tissueThe trachea should be central

6. Hilar structuresNormal hilar positionBy convention the hilar points are the angle formed by the descending upper lobe veins, as they cross behind the lower lobe arteriesNot every normal patient has a very clear hilar point on both sides, but if they are present then they can be useful in determining the position of the hila

7. Hilar structuresPulmonary arteriesDeoxygenated blood (blue arrows) is pumped upwards out of the right ventricle (RV) via the main pulmonary artery (MPA)The MPA divides into left (LPA) and right (RPA) which each pass via the lung hila into the lung tissue to distribute blood for oxygenationOn the left the LPA hooks backwards over the left main bronchusOn the right the RPA lies in front of the right main bronchus

8. Hilar structuresKey pointsEach hilum contains major bronchi and pulmonary vesselsThere are also lymph nodes on each side (not visible unless abnormal)The left hilum is often higher than the rightIf a hilum is out of position, ask yourself if has been pushed or pulledAs well as position - check the size and density of the hila

9. Lung zonesLung zonesDividing the lungs into zones allows more careful attention to be paid to each smaller area. If this is not done it is easy to ignore important abnormalities.Note that the lower zones reach below the diaphragm. This is because the lungs pass behind the dome of the diaphragm into the posterior sulcus of each hemithorax. Normal lung markings can be seen below the well defined edges of the diaphragm.

10. Lung zonesKey pointsThe lungs are assessed and described by dividing them into upper, middle and lower zonesRefer to 'zones' not 'lobes'Compare left with rightCompare an area of abnormality with the rest of the lung on the same side

11. Pleura and pleural spacesNormal pleura and pleural spacesTrace round the entire edge of the lung where pleural abnormalities are more readily seenStart and end at the hilaIs there pleural thickening?Is there a pneumothorax? The lung markings should be visible to the chest wallIs there an effusion? The costophrenic angles and hemidiaphragms should be well defined

12. Pleura and pleural spacesKey pointsThe pleura and pleural spaces are only visible when abnormalLung markings should reach the thoracic wall

13. Lung lobes and fissures

14. Lung lobes and fissuresHorizontal fissureThe horizontal fissure separates the right upper lobe from the right middle lobe. It can be seen on normal chest X-rays as a thin line running roughly horizontally from the edge of the lung towards the right hilum.

15. Lung lobes and fissuresOblique fissuresThe oblique fissures overlie each other on a lateral view and are not always seen in entirety. If seen at all, the lower end is usually seen most clearly, as on this X-ray.

16. Lung lobes and fissuresAccessory fissuresThe most common accessory fissure you will see on a chest X-ray is an azygos fissure. This occurs in approximately 1-2% of individuals.The azygos vein usually runs horizontally along the right side of the mediastinum. It hooks forwards over the right main bronchus, draining the azygos system into the superior vena cava.If there is an azygos fissure, the vein appears to run within the lung, but is actually surrounded by both parietal and visceral pleura. The azygos fissure therefore consists of four layers of pleura, two parietal layers and two visceral layers, which wrap around the vein giving the appearance of a tadpole.

17. Lung lobes and fissuresKey pointsThe left lung has two lobes and the right has threeEach lobe has its own pleural coveringThe horizontal fissure (right) is often seen on a normal frontal viewThe oblique fissures are often seen on a normal lateral view

18. Costophrenic recesses and anglesostophrenic recesses and angles - PA viewOn a PA view, the costophrenic recesses are seen on each side as the costophrenic anglesThe costophrenic angles are formed by the lateral chest wall and the dome of each hemidiaphragm

19. Costophrenic recesses and anglesCostophrenic recesses and angles - lateral viewOn a lateral view the costophrenic recesses are seen in the region of the anterior and posterior costophrenic angles formed by the chest wall and the dome of each hemidiaphragm.

20. Costophrenic recesses and anglesKey pointsThe costophrenic angles are limited views of the costophrenic recessOn a frontal view the costophrenic angles should be sharp

21. DiaphragmHemidiaphragmsThe right hemidiaphragm is slightly higher than the leftThe liver is located immediately inferior to the diaphragm on the rightThe stomach bubble can be seen below the left hemidiaphragmIf you look closely you can see lung markings below the diaphragm on both sidesMedially the hemidiaphragms form an angle with the heart - the cardiophrenic angles (asterisks)On both sides the contour of the hemidiaphragm should be seen passing medially as far as the spine

22. DiaphragmHemidiaphragms - lateral viewThe left and right hemidiaphragms are almost superimposed on a lateral view. Anteriorly the left hemidiaphragm blends with the heart and becomes indistinct.

23. DiaphragmKey pointsThe hemidiaphragms are domed structuresEach hemidiaphragm should be well definedThe left hemidiaphragm should be visible behind the heartThe hemidiaphragm contours do not represent the lowest part of the lungs

24. Heart size and contoursCardiothoracic ratio (CTR)Cardiac size is measured by drawing vertical parallel lines down the most lateral points on each side of the heart, and measuring between them.Thoracic width is measured by drawing vertical parallel lines down the inner aspect of the widest points of the rib cage, and measuring between them.The cardio-thoracic ratio can then be calculated.Here the CTR is approximately 15 : 33 (cm) and is therefore within the normal limit of 50%.

25. Heart size and contoursKey pointsThe heart size is assessed as the cardiothoracic ratio (CTR)A CTR of >50% is abnormal - PA view onlyThe left hemidiaphragm should be visible behind the heartThe hemidiaphragm contours do not represent the lowest part of the lungs

26. Heart size and contoursNormal cardiac contoursThe left heart contour (red line) consists of the left lateral border of the Left Ventricle (LV). The right heart contour is the right lateral border of the Right Atrium (RA).

27. Mediastinal contoursNormal aortic knuckleThe aortic knuckle (red line) represents the left lateral edge of the aorta as it arches backwards over the left main bronchus, and pulmonary vessels. The contour of the descending thoracic aorta (yellow line) can be seen in continuation from the aortic knuckle.Displacement or loss of definition of these lines can indicate disease, such as aneurysm or adjacent lung consolidation.

28. Mediastinal contoursAorto-pulmonary windowThe aorto-pulmonary window lies between the arch of the aorta and the pulmonary arteries. This is a potential space in the mediastinum where abnormal enlargement of lymph nodes can be seen on a chest X-ray.In this chest X-ray, which is entirely normal, the curved arrow points towards the aorto-pulmonary window between the Aortic Knuckle (AK) and the Left Pulmonary Artery (LPA).(AA) = Ascending Aorta(DA) = Descending Aorta

29. Mediastinal contoursRight para-tracheal stripeFrom the level of the clavicles to the azygos vein the right edge of the trachea is seen as a thin white stripe. This appearance is created by air of low density (blacker) lying either side of the comparatively dense (whiter) tracheal wall. If this stripe is thickened (normally less than 3mm) this may represent pathology such as a paratracheal mass or enlarged lymph node.The left side of the trachea is not so well defined because of the position of the aortic arch and great vessels.

30. Mediastinal contoursKey pointsThe mediastinum consists of potential spaces used to describe the location of disease processesThe middle mediastinum contains the heartImportant diseases change the appearance of the aortic knuckle, the aorto-pulmonary window and the right para-tracheal stripe

31. Soft tissuesBreast asymmetryHere the breasts are asymmetric. The underlying lung markings (white boxes) appear denser on the left than the right. This should not be mistaken for underlying lung disease.Breast asymmetry is very common, even to the extent that no breast tissue is visible on one side. It should not be assumed that the patient has had a mastectomy, unless this is known from the history.

32. Soft tissuesNipple markingsThe nipples are clearly seen on this chest X-ray, but care is needed whenever there is a chance that the markings may represent underlying lung nodules. If there is any doubt then a repeat chest X-ray should be performed, with metallic markers used to indicate the position of the nipples.

33. Soft tissuesPseudo-blunting of the costophrenic angleAt first glance the left costophrenic angle appears blunt. This is because the patient was in a rotated position when the X-ray was taken. This has resulted in a greater thickness of breast overlying the costophrenic angle on the left, compared to the right.If you are not careful you may be misled into thinking there is a pleural effusion or other pathology causing costophrenic angle blunting.

34. Soft tissuesSoft tissue fatThis close-up demonstrates a normal fat plane between layers of muscle. Fat is less dense than muscle and so appears blacker.Note that the edge of fat is smooth. Irregular areas of black within the soft tissues may represent air tracking in the subcutaneous layers (surgical emphesyma).

35. Soft tissuesKey pointsAssess the soft tissues on every chest X-rayThick soft tissue may obscure underlying structuresBlack within soft tissue may represent gas

36. BonesClavicles, spinous processes and ribsThe spinous processes of the vertebrae (posterior structures) should lie midway between the medial ends of the clavicles (anterior structures).If the spinous processes are not central, then the patient is rotated - positioned obliquely to the X-ray beam.The anterior and posterior ends of the 5th rib are also shown.

37. BonesClavicle, scapula, and humerusThe clavicle, scapula and humerus are often clearly seen on a chest X-ray. Occasionally you will see evidence of important disease such as metastases in these bones.Key1 - Clavicle2 - Acromioclavicular joint3 - Acromion process of scapula4 - Body of scapula5 - Glenoid fossa of scapula6 - Head of left humerus7 - Glenohumeral joint8 - Coracoid process of scapula

38. BonesRibsThe ribs play a role in assessing the adequacy of inspiration taken by the patient. The anterior end of approximately 5-7 ribs should be visible above the diaphragm in the mid-clavicular line. Less than this indicates an incomplete breath in, and more than 7 ribs or flattening of the diaphragm, suggests lung hyper-expansion.On this normal X-ray the anterior end of the 7th rib (asterisk) intersects the diaphragm at the mid-clavicular line.This chest X-ray also demonstrates the subcostal grooves (red highlights) on the underside of the ribs. These grooves contain the neurovascular bundles that accompany each rib. To avoid damaging the nerves or vessels, the superior edge of a rib is used as the landmark for needle insertion during procedures such as chest drain insertion.Note: The spine can be seen through the heart, indicating adequate X-ray penetration.

39. BonesKey pointsAssess the bones on every chest X-rayCheck for abnormalities of single bones and for diffuse bone diseaseThe bones are helpful in assessing the quality of the chest X-ray

40. Tutorial conclusionKey pointsSome anatomical structures in the chest should be assessed on every chest X-rayEach of these anatomical structures should be viewed using a systematic approachThere are also important structures that are obscured or become visible only when abnormal

41. ReferenceChest X-ray Anatomyhttps://www.radiologymasterclass.co.uk/tutorials/chest/chest_home_anatomy/chest_anatomy_start