interpretasi rontgen dada atau foto thoraks

INTERPRESTASIRONTGENDADAEriYanuarAkhmadB.S.,S.Kep.,Ns.,M.N.Sc(I.C)

GambaranRontgenDada

TujuanPembelajaran

• LimaOpasiti Radiografi• AspekTeknisRontgenDada• Interprestasi RontgenDada

Lima Opasiti Radiografi

Aspek Teknis

TheNormalCXR

StandardCXRbiasadiambil:• PA– minimalmagnificationoftheheart

• Patientstanding• Fullinspiration

01Inillpatients,theCXRisusuallytaken:• AP– magnifiescardiacshadow• Oftensupine– diaphragmshigher,lungvolumeslower,pathologyoftenobscured

02

KualitasFilm

PAorAPview.

Upright/ErectorSupine

Breath:InspirationorExpiration

X-raypenetration:Under- orOver-

Rotation

PA

AP

Effectofprojectiononapparentheartsize

X-raytube

PA

AP

Effectofprojectiononapparentheartsize

X-raytube

PAvsAP

PAview• Scapulaisseeninperipheryofthorax

• Claviclesprojectoverlungfields• Posteriorribsaredistinct• Positionofmarkers

APview• Scapulaeareoverlungfields• Claviclesareabovetheapexoflungfields

• Anteriorribsaredistinct• Positionofmarkers

Inspirationvs Expiration

Inspiration- 500mlsairinpleuralspace,2500mlsinlung=17%pneumothorax

Expiration- 500mlsairinpleuralspace,1500mlsinlung=25%pneumothorax• Pleurallinedisplacedfurtherinferiorly

ExpiratoryCXR

• Makesapneumothoraxappearrelatively largerthanonaninspiratoryfilm

• PTxmayonly visibleonexpirationfilm• Whenyouseetheword‘expiration’onaCXRyouarealmostcertainlylookingforapneumothorax(especiallyinanexam!)

• Expiratoryfilmisalsousefulinkidswhenlookingforairtrappingduetoanobstructingforeignbody– lungonobstructedsideremainsexpanded

PenetrationWithcorrectexposureyoushouldbarelyseethe

intervertebral discthroughtheheart

• Ifyouseethemveryclearlythefilmisoverpenetrated

• Ifyoudonotseethemitisunderpenetrated

Penetration

Rotation

NotCentered

PitfallstoChestX-rayInterpretation

• Poorinspiration• Overorunderpenetration• Rotation• Forgettingthepathofthex-raybeam

NormalCXRAnatomy

NormalPACXR

AssessingforRotation

Spinousprocessshouldbeequidistantfrommedialendsofbothclavicles

Trachea

Leftmainbronchus

Rightmainbronchus

CarinalAngle(40-75degrees)

Rightpulmonaryartery

Leftpulmonaryartery

AorticArch

DescendingAorta

AortopulmonaryWindow

RightHeartBorder=Rightatrium

LeftHeartBorder=LeftVentricle

LeftAtrium

CardiothoracicRatio(<50%)

AnteriorRibs- fullinspiration

1

2

3

4

5

6

Gastricairbubble

STEPINTERPRESTASIRONTGENDADA

• Details• RIPEImage(Aspek Teknis)

• Rotation– medialclavicleendsequidistantfromspinousprocess

• Inspiration– 5-6anteriorribsinMCLor8-10posteriorribsabovediaphragm,poorinspiration?,hyperexpanded?

• Picture– straightvsoblique,entirelungfields,scapulaeoutsidelungfields,angulation(ie ’tilt’inverticalplane)

• Exposure(Penetration)– IVdiscspaces,spinousprocessesto~T4,L)hemidiaphragm visiblethroughcardiacshadow.

• SoftTissuesandBones• Ribs,sternum,spine,clavicles– symmetry,fractures,dislocations,lyticlesions,density

• Softtissues– lookingforsymmetry,swelling,lossoftissueplanes,subcutaneousair,masses

• Breastshadows• Calcification– greatvessels,carotids

• Airwaydan Mediastinum• Trachea– centralorslightlytorightlungascrossesaorticarch

• Paratracheal/mediastinalmassesoradenopathy• Carina&RMB/LMB• Mediastinalwidth<8cmonPAfilm• Aorticknob• Hilum– T6-7IVdisclevel,lefthilumisusuallyhigher(2cm)andsquarerthantheV-shapedrighthilum.

• Checkvessels,calcification.

• Breathing• Lungfields• Pleura

• Circulationsystem• Heartposition• Aorticstripe

• Diaphragm• Hemidiaphragm levels– RightLunghigherthanLeftLung(~2.5cm/1intercostalspace)

• Diaphragmshape/contour• Cardiophrenic andcostophrenic angles– clearandsharpGastricbubble/colonicair

• Subdiaphragmatic air(pneumoperitoneum)

• Extras• ETT,CVPline,NGtube,PAcatheters,ECGelectrodes,PICCline,chesttube

• PPM,AIDC,metalwork

D- Details

Patientname,age/DOB,sex

Typeoffilm– PAorAP,erectorsupine,correctL/Rmarker,inspiratory/expiratoryseries

Dateandtimeofstudy

RIPEImages

Rotation– medialclavicleendsequidistantfromspinousprocess

Inspiration– 5-6anteriorribsinMCLor8-10posteriorribsabovediaphragm,poorinspiration?,hyperexpanded?

Picture– straightvsoblique,entirelungfields,scapulaeoutsidelungfields,angulation(ie ’tilt’inverticalplane)

Exposure(Penetration)– IVdiscspaces,spinousprocessesto~T4,L)hemidiaphragmvisiblethroughcardiacshadow.

AssessingforRotation

Spinousprocessshouldbeequidistantfrommedialendsofbothclavicles

AnteriorRibs- fullinspiration

1

2

3

4

5

6

S– Softtissuesandbones

Ribs,sternum,spine,clavicles–symmetry,fractures,dislocations,lyticlesions,density

Softtissues– lookingforsymmetry,swelling,lossoftissueplanes,subcutaneousair,masses

Breastshadows

Calcification– greatvessels,carotids

A– Airway&mediastinum

Trachea– centralorslightlytorightlungascrossesaorticarch

Paratracheal/mediastinalmassesoradenopathy

Carina&RMB/LMB

Mediastinalwidth<8cmonPAfilm

Aorticknob

Hilum– T6-7IVdisclevel,lefthilumisusuallyhigher(2cm)andsquarerthantheV-shapedrighthilum.

Checkvessels,calcification.

Trachea

Leftmainbronchus

Rightmainbronchus

CarinalAngle(40-75degrees)

LeftmastectomyBewareofremainingnipplemimickinganodule!

B– Breathing

• Lungfields• Vascularity– to~2cmofpleuralsurface(~3cminapices),vesselsinbases>apices

• Pneumothorax– don’tforgetapices• Lungfieldoutlines– abnormalopacity/lucency,atelectasis,collapse,consolidation,bullae

• HorizontalfissureonRightLung• Pulmonaryinfiltrates– interstitialvsalveolarpattern

• Coinlesions• Cavitary lesions

B– Breathing

• Pleura• Pleuralreflections• Pleuralthickening

Anatomy

Lobes• Right upper lobe:

• Right middle lobe:

• Right lower lobe:

• Left lower lobe:

• Left upper lobe with Lingula:

Lingula:

Leftupperlobe- upperdivision:

Pulmonaryoedema- cardiomegaly

NormalCTR

Tensionpneumothorax

LULcollapse-tracheadisplacedtoleftlefthilumelevatedlefthemidiaphragmelevated

C–Circulation

Heartposition–⅔toleft,⅓toright

Heartsize– measurecardiothoracicratioonPAfilm(normal<0.5)

Heartborders– R)borderisR)atrium,L)borderisL)ventricle&atrium

Heartshape

Aorticstripe

CardiothoracicRatio(<50%)

RightHeartBorder=Rightatrium

LeftHeartBorder=LeftVentricle

LeftAtrium

AorticArch

DescendingAorta

AortopulmonaryWindow

Leftatrialenlargementinmitralstenosis-doublerightheartborder,splayedcarina

Sternotomywiresandaorticvalvereplacement

D–Diaphragm

Hemidiaphragmlevels– RightLunghigherthanLeftLung(~2.5cm/1intercostalspace)

Diaphragmshape/contour

Cardiophrenicandcostophrenicangles–clearandsharp

Gastricbubble/colonicair

Subdiaphragmaticair(pneumoperitoneum)

DiaphragmaMale

??

E– Extras

ETT,CVPline,NGtube,PAcatheters,ECG

electrodes,PICCline,chesttube

PPM,AIDC,metalwork

PosisiNGTnormal

TERIMAKASIH