TEKNIK MEMBACA RONTGEN

THORAX
Study Club UPD
 Langkah 1 :
Pastikan identitas klien (nama, umur,
tanggal foto maupun no. registrasi)
 Langkah 2 :
Pastikan adanya marker (penanda) R
untuk kanan & L untuk kiri
Langkah 3 :
• Tentukan posisi foto apakah PA
(Posterior-Anterior) atau AP (Anterior-
Posterior).
– PA : jika tulang skapula tergeser ke samping
& klavikula mendatar membentuk huruf T
– AP : jika tulang skapula ditengah menutupi
paru & klavikula tidak mendatar
membentuk huruf V
Langkah 4 :
• Pastikan apakah foto layak baca
dengan cara:
• Rotasi foto :
– Prosesus spinosus dari vertebra torakal
bagian atas berada ditengah ujung
medial dari klavikula.
– Ukur jarak klavikula ke jarak tengah
vertebra, jika jarak ujung klavikula kanan
dan kiri sama maka rotasi negatif.
• Penetrasi foto :
– Vertebra torakal bawah terlihat, hitung
ruas vebtebra torakal sampai 3.
Umumya semakin kebawah semakin
tidak jelas.
• Inspirasi cukup :
– Titik tengah diafragma kanan di costae
VI di bagian anterior.
Langkah 5 :
• Setelah foto layak baca maka mulailah
membaca foto toraks.
• Perhatikan foto toraks secara sistematis
untuk memastikan bahwa semua daerah
dada tercakup.
• Untuk membaca foto toraks dapat
dimulai dari bagian perifer-sentralnya
dulu ataupun sebaliknya.
1. Jaringan Lunak :
• Perhatikan bagian tepi foto, apakah ada massa
tumor, kalsifikasi. Gambaran normalnya
jaringan lunak terlihat kulit dan lemak
subkutan
2. Tulang :
• Perhatikan costae, vertebrae, klavikula dan
skapula untuk mengetahui adanya fraktur atau
dislokasi maupun deposit sekunder. Keadaan
normal, tulang-tulang costae kanan & kiri
simetris, trabekulasi tampak baik,bentuk
tulang tampak normal,jumlah tulang normal,
dan tak ada osteolitik maupun osteoblastik.
3. Trakea :
• Berada pada garis tengah dengan bifurkasio
setinggi T6. Trakea mengalami deviasi sedikit
ke kanan setinggi tonjolan aorta.
• Nilai adanya lesi massa dan pergeseran
mediastinum oleh trakea dan bayangan
jantung.
4. Diafragma :
• Diafragma kanan biasanya lebih tinggi
dibandingkan sisi kiri, walau kadang-kadang
dapat terjadi sebaliknya.
• Sudut konstrofrenikus harus terlihat jelas,
lancip, dan dalam. Sudut yang tumpul
mungkin mengindikasikan adanya efusi pleura
atau penebalan pleural lama. Permukaan
bagian atas harus tegas: ketegasan yang buruk
sering menunjukkan adanya kelainan paru
basal. Pendataran diafragma menunjukkan
adanya hiperinflasi dan penyakit jalan napas
obstruksi kronis.
5. Hilus :
• Secara dominan disebabkan oleh arteri
pulmonalis, hilus kiri lebih kecil dan sedikit
lebih tinggi dibandingkan hilus kanan.
• Merupakan tempat yang paling sering untuk
limfadenopati dan karsinoma bronkus: cari
peningkatan densitas dan ketidakteraturan
seperti pembesaran bayangan hilus.
6. Lapang Paru :
• Arteri intrapulmonalis menyebar dari hilus
pulmonal dan semakin mengecil menuju
perifer memberikan sebagian besar gambaran
paru, dengan komponen yang lebih kecil dari
vena pulmonalis.
• Paru kanan dibagi menjadi tiga lobus: lobus
atas, lobus tengah yang kecil, dan lobus
bawah. Paru kiri memiliki dua lobus, bagian
atas (termasuk lingula) dan bagian bawah.
• Lakukan pemindaian pada kedua paru, dimulai
dari bagian apeks dan terus ke bawah.
• Bandingkan penampakan setiap zona dengan
sisi lainnya. (Paru dapat dibagi kira-kira
menjadi tiga zona: atas, tengah, dan bawah.)
• Satu-satunya bayangan yang terlihat secara
normal, selain fisura, pastilah berasal dari
vaskular, sehingga konsentrasilah untuk
mencari bayangan homogen pada tiap area
atau lesi massa.
• Mungkin lebih mudah untuk menjelaskan
suatu opasitas di dalam suatu zona dan
kemudian menentukan lobus paru.
7. Jantung :
• Atrium kanan terlihat sedikit di sebelah kanan
tulang belakang torakal. Batas inferior
dibentuk oleh ventrikel kanan dan batas kiri
oleh ventrikel kiri.
• Perhatikan ukuran dan bentuk jantung.
Pembesaran ruang jantung tertentu sering
sulit diidentifikasi: perhatikan dan berikan
tanggapan pada ukuran jantung secara
keseluruhan, dapat dihitung dengan CTR
untuk kardiomegali.
CASES
 Massive pleural effusion
• Complete ‘white-out’ of the right hemithorax
• Trachea is being pushed to the opposite side.
• A huge lung mass could also potentially have
this appearance.
• If the trachea were being pulled towards the
opacified side, the differential diagnosis
changes to pneumonectomy or complete
collapse of the lung, which could be caused by
an obstructing tumour in the right main
bronchus.
 Metastatic lung cancer
• This patient presented with advanced lung cancer.
• Opacification of the right hemithorax, which is due to
a combination of complete collapse of the right lung
and a large malignant pleural effusion. T
• he right lung had collapsed due to a large tumour
obstructing the right main bronchus (note the abrupt
cut-off in the bronchus, arrow).
• The resultant volume loss in the right hemithorax has
resulted in shift of the trachea to the right.
• There are multiple large metastases in the left lung.
 Tension pneumothorax
• Large right pneumothorax
• Hyperlucent right hemithorax
• Collapsed right lung
• Tracheal and mediastinal shift
• At the base of the right hemithorax is a small
pleural effusion, but with no ‘meniscus’ sign –
this is one of the hallmarks of pleural fluid in
the setting of a pneumothorax
Dramatic examples of tracheal shift
• On the left is a 25 year old man who
presented to ED with acute chest pain and
shortness of breath.
– Massive right-sided tension pneumothorax with
shift of the trachea (outlined by the dashed line)
to the left.
– The heart is also displaced to the left.
– Note the hyperlucency of the right hemithorax
and the absence of any lung markings on this side.
• The right-hand image also shows tracheal shift,
however this patient was in his 70s and had a
background of lung cancer.
• The tracheal displacement is due to a massive right
pleural effusion
• Opacifying almost the entire right hemithorax.
• This was a malignant pleural effusion caused by
pleural metastases.
• If you look carefully you will see multiple nodules
throughout the left lung, which were also
metastases, plus a small left pleural effusion.
• Normally, the trachea is located in the midline at the
level of the clavicles, often deviating slightly to the
right more inferiorly at the level of the aortic arch.
 As a reminder, the causes of tracheal
displacement include the following:

Causes of displacement AWAY from the side of

the pathology:
• Pneumothorax
• Pleural effusion
• Mediastinal neoplasm including lymphoma,
lymphadenopathy, thymic tumour, germ cell
tumour
• Retrosternal goitre
Causes of displacement TOWARDS the side of
the pathology:
• Apical lung fibrosis (for example, due to TB or
prior radiotherapy)
• Collapse of one or more lung segments, for
example due to bronchial obstruction by
tumour
• Previous pneumonectomy
• The boundaries of the anterior
mediastinum are the sternum anteriorly
and the great vessels and
brachiocephalic veins, pericardium and
ascending aorta posteriorly.
• It normally contains only the thymus,
lymph nodes, fat and some small vessels.
Anterior mediastinal masses may arise
from any of these structures.
• Masses in this region may be discovered as
incidental findings on imaging or the patient
may present with symptoms due to
compression of the airways or the superior
vena cava, or because of invasion of nerves
such as the vagus or recurrent laryngeal.
The classic differential diagnosis for an
anterior mediastinal mass is known as
the 5 ‘T’s:
• Thymic neoplasma
• Teratoma (and other germ cell tumours)
• Thyroid (goitre/neoplasm)
• Terrible lymphoma
• Thoracic aorta (aneurysm)
 Typical of metastatic disease
• You will note that there are multiple surgical
clips in the left supraclavicular region, outlined
by the yellow circle.
• The patient had a history of laryngeal
squamous cell carcinoma, treated surgically,
and had subsequently developed metastatic
lymphadenopathy in the left side of his neck,
for which a neck dissection was performed
(explaining the clips).
 Asbestos History
• This male patient, a smoker, presented with
haemoptysis. Chest X-ray shows a large mass
at the right hilum (yellow arrows).
• You will also notice that there is a calcified
pleural plaque adjacent to the medial aspect
of the right hemidiaphragm (orange arrow),
indicating previous asbestos exposure. Biopsy
of the hilar mass showed non-small cell lung
cancer.
Potential imaging findings in the chest in
patients with a history of asbestos exposure
include:
• Pleural plaques
• Diffuse pleural thickening
• Mesothelioma
• Interstitial lung disease (‘asbestosis’,
predominantly in the lung bases)
• Rounded atelectasis (focal fibrosis and volume
loss in a lung, often mass-like)
• Bronchogenic carcinoma
 Primer malignancy or metastatic
disease
• In this case, there are multiple subtle lung
nodules (arrows), which all represent
metastases from this patient’s rectal cancer.
• Other potential sites of metastatic disease
on a chest x-ray: pleura (beware the
unilateral pleural effusion),
hilar/mediastinal lymph nodes, bones
(ribs/clavicles/shoulders).
 Lymphadenopathy
• This patient had a history of renal cell
carcinoma.
• The CXR shows a large rounded lymph node
above the right hilum (arrow), which was
metastatic disease.
 Lung metastases
• There are multiple metastases in both lungs in
this patient.
• She had a history of right mastectomy for
breast cancer (note the asymmetry of the
breasts)
• Metastases appear extremely dense. That’s
because they are made of bone – this turned
out to be metastatic osteosarcoma.
 Pneumothorax post central venous
line insertion
• In this example, attempted central line
insertion through the left internal jugular was
unsuccessful
 Intra-aortic balloon pump
• The tiny metallic density projected to the left
of the carina in this patient (arrow) represents
the radio-opaque marker of an IABP, and
indicates that we are dealing with a very sick
patient in cardiogenic shock.
• Note that this patient also has a ‘batwing’
pattern of pulmonary alveolar oedema.
 Endotracheal tube at carina
• In this example, the tip of the ETT (yellow
arrow) is too close to the carina (orange
arrow), and is at the origin of the right main
bronchus.
• In this position, there is a risk of
overventilation of the right lung and
underventilation of the left.
 Bronchiectasis
• a young patient with cystic fibrosis. On the CXR (a), you will notice that the lungs
are hyperinflated (note the depressed diaphragms and the obtuse costophrenic
angles). There is a Port-a-Cath in-situ (arrow). The most common scenarios to see
one of these venous access devices in our institution is in oncology patients
undergoing chemotherapy and in patients with cystic fibrosis.
• There are multiple cystic structures visible in the lungs, particularly in the mid and
upper zones. These are easier to identify on the magnified image (b), indicated by
the arrows. These represent grossly dilated bronchi. Corresponding coronal CT
chest image (c) depicts these dilated bronchi much more clearly. In addition, in the
right lung you can see one of the typical CT signs of bronchiectasis, known as a
‘signet ring’ sign – this is outlined by the circle and a magnified version of it is
shown on image (d). This appearance is caused by the dilated bronchus with its
accompanying pulmonary artery – the artery is the small soft tissue nodule lateral
to the bronchus and indicated by the arrow. Normally, the artery is around the
same diameter as the adjacent bronchus, hence this sign is useful when
diagnosing mild bronchiectasis on CT.
 Emphysema
• This smoker has hyperinflated lungs due to emphysema
• Note the increased number of ribs that you can count
anteriorly above the diaphragms – normally you should only
be able to count 6 or 7 ribs.
• You’ll also note that both lungs look abnormally dark, i.e.
lucent.
• The diaphragms are flattened, having been pushed down by
the hyperinflated lungs.
• The hila are enlarged due to due the dilated pulmonary
arteries, however immediately beyond the hila the vessels
rapidly become very small in calibre (so-called ‘pruning’).
 RML collapse
• The typical appearance of right middle lobe
collapse on a lateral CXR is the presence of a
wedge-shaped opacity projected over the heart
shadow, as shown here (arrow).
• The opacity is demarcated inferiorly by the
oblique fissure.
• The horizontal fissure forms the superior
boundary of the opacity, but when the lobe has
collapsed the fissure is pulled inferiorly and will
no longer be ‘horizontal’.
 Pulmonary fibrosis
• This CXR shows a ‘reticular’ (net-like) pattern
of increased interstitial lung markings in the
peripheries of both lungs, worst at the lung
bases.
 Cavitating lung cancer
• This patient has a large thick-walled cavitating
mass in the right lung.
• The differential diagnosis for this appearance
includes primary pulmonary tumours
(particularly squamous cell carcinoma),
metastases (again, particularly SCC), cavitating
pneumonia.
• CT-guided biopsy of the wall of this cavity
showed squamous cell carcinoma.
• This 40-year-old patient has a form of non-
cardiogenic pulmonary oedema (Interstitial
pulmonary edema)
• Note the normal heart size and the interstitial
(Kerley B) lines at the lung bases, better seen
on the magnified image (arrows).
• Remember also that another diagnosis to
consider when you see pulmonary oedema
with a normal size heart is an acute MI,
causing acute heart failure.
• This elderly man with a history of emphysema
– note the hyper inflated lungs – presented
with a cough.
• His chest x-ray shows a subtle rounded lesion
above the right hilum (arrows).
• CT-guided biopsy showed that this was a
carcinoma.
 Usual interstitial pneumonia (UIP)
• This 78-year-old woman presented with
progressive dyspnoea.
• The chest radiograph on the left shows how
difficult it can be to identify early interstitial lung
disease – it looks normal however the images
from the patient’s CT (performed in the prone
position) show subpleural, basal-predominant
reticular opacities.
• In more advanced stages of UIP, CT often shows
honeycombing, traction bronchiectasis (where
bronchi become dilated because they are being
pulled into areas of fibrosis), and volume loss.
• Patients with left atrial enlargement will often
have a ‘double right heart border’ sign on a
frontal CXR, while collapse of the left lower
lobe can sometimes result in a ‘double left
heart border’ sign.
• In this case, there is simply a double heart –
the patient’s heart-shaped plastic necklace is
projected over her left ventricle.
 Hydropneumothorax
• Another nice example of a right-sided
hydropneumothorax – the pleural line is
clearly visible (orange arrows), and the
pleural effusion is almost perfectly horizontal,
with no meniscus sign.
TERIMAKASIH