Lateral Chest Radiographs Research Articles

Lead Dislodgment of a Permanent Pacemaker Due to Removal of a Temporary Pacing Electrode

A 63-year-old male received a transvenous temporary pacemaker for bradyarrhythmia following mitral valve replacement and tricuspid valve annuloplasty. A transvenous permanent pacemaker was implanted the following day due to persistence of the bradyarrythmia and pacemaker dependency of the patient. Later the same day during removal of the temporary pacing electrode the permanent pacing lead was dislodged and had to be operatively repositioned. To avoid this complication, the position of pacemaker leads should be checked postoperatively with a frontal and lateral chest radiograph, and fluoroscopy should be used during removal of a temporary lead.

Chest Radiographs Fail to Detect Right Ventricular Enlargement and Right Atrial Enlargement in Patients With a Pure Restrictive Ventilatory Impairment

The validity of measurements of the cardiac silhouette on chest radiographs for the evaluation of right ventricular enlargement and right atrial enlargement in patients with a pure restrictive ventilatory impairment was investigated in 19 patients. The forced vital capacity (FVC) percent predicted in these patients was 59 +/- 12 percent (mean +/- SD) (range, 29 to 79 percent). Right ventricular enlargement, by two-dimensional echocardiography, was defined as a right ventricular area > 20.4 cm2 and right atrial enlargement was defined as a right atrial area > 15.3 cm2. Chest radiographic measurements in the posteroanterior (PA) projection included distance from the midline to the farthest point of the right border of the cardiac silhouette, transverse cardiac diameter, and cardiothoracic ratio. Measurements in the lateral projection included the lateral horizontal transverse diameter, ventral portion of the lateral broad diameter, and obliteration of the retrosternal space. Neither the right ventricular area nor the right atrial area correlated with any of these radiographic measurements. There were no differences in these chest radiographic measurements among patients with normal right ventricular and right atrial dimensions, patients with right ventricular enlargement, and patients with right atrial enlargement. We conclude, therefore, that PA and lateral chest radiographs do not reliably detect right ventricular enlargement or right atrial enlargement in patients with a pure restrictive ventilatory impairment.

330 THE VALUE OF THE LATERAL CHEST RADIOGRAPH IN THE DIAGNOSIS OF PULMONARY TUBERCULOSIS IN CHILDREN

The aim of the study was to assess the value of the lateral chest radiograph in children being investigated for tuberculosis (TB). Material and Methods: In a prospective study of 449 children the chest radiographs (PA and lateral) were assessed. The children were drawn from 2 groups. Firstly, those with symptomatic disease and secondly, asymptomatic children in contact with an adult with active pulmonary TB. Results: In 13% of the children with proven TB and 19% of children with probable TB (WHO criteria) the hilar glands were visible on the lateral chest radiograph only. Hilar glands were present only on the lateral chest radiograph in 11% of asymptomatic children in contact with an adult with active TB. Conclusion: These data suggest that lateral chest radiographs are essential in the evaluation of children suspected of having PTB and in children in contact with an adult with active disease.

Partial obliteration or blurring of the descending aortic contours: A pitfall on plain chest radiographs

We report the cause and clinical significance of partial obliteration or blurring of the descending aortic contour on the frontal chest radiographs of patients without pathology in the vicinity of the descending aorta. Among 112 cases, 26 cases (23.2%) showed obliteration or blurring of the contour (positive group). On the corresponding computed tomograph of the positive group, two dominant causes were shown. One was contact between the descending aorta and the left hilar or lower lobe vessels. The second was the adjacent pleura being obliquely orientated to the anteroposterior (A-P) axis. In the latter group, on the lateral chest radiographs, a flattened thorax with a smaller A-P diameter was seen. Identification of left hilar or lower lobe vessels on a frontal chest radiograph or a diminished A-P diameter of the thorax on a lateral radiograph is useful in differentiating these circumstances from true thoracic pathology.

Pulmonary strongyloidiasis: an unusual opportunistic pneumonia in a patient with AIDS.

A 26-year-old man who was seropositive for HIV had had increasing dyspnea on exertion, vomiting, abdominal pain and cramps, and anorexia for approximately 1 week. The patient had a history of gastrointestinal strongyloidiasis previously diagnosed on the basis of the results of stool culture. He had been treated with a 2-day regimen of thiabendazole and was feeling well until 1 week before his present illness. He had no history of pneumonia. Tnimethopnim and sulfamethoxazole as prophylaxis for Pneumocystis pneumonia had been prescribed 8 months earlier. However, the patient said that he had not been taking the drug according to the recommended schedule. On admission, the physical examination revealed bilateral raies and tachycardia. Body temperature was 37.9#{176}C. Anteropostenior and lateral chest radiographs showed diffuse interstitial disease, with a predominantly reticulonodular pattern, consistent with opportunistic infection (Fig. 1A). Well-defined, small, noncavitany nodules 2-5 mm in diameter were scattered throughout the lungs, with the most severe involvement at the base of the left lung. Results of laboratory studies indicated peripheral eosinophilia. An ECG revealed sinus tachycardia without evidence of penicarditis or penicandial effusion. The patient was treated empirically for P caninll pneumonia with antituberculous medication in addition to IV pentamidine and IV methylprednisolone sodium succinate. He continued to have a lowgrade fever and remained markedly short of breath. All blood and urine cultures were negative for yeast and bacteria. Stool examination and bronchoalveolar lavage showed the presence of abundant rhabdoid larvae (Fig. 1B). The sputum was also positive for S. stercoralis larvae. All cultures, including culture of a transbronchial biopsy specimen, were negative for P carinii, acid-fast bacilli, and other opportunistic organisms. The patient received oral thiabendazole (1250 mg twice daily) for 2 weeks, and he gradually felt less dyspneic. A chest radiograph obtained 5 days after he started thiabendazole therapy showed significant clearing of the lung disease

Computed tomography in the early detection of asbestosis.

Computed tomography (CT; both conventional (CCT) and high resolution (HRCT)) scans of the thorax were evaluated to detect early asbestosis in 61 subjects exposed to asbestos dust in Québec for an average of 22(3) years and in five controls. The study was limited to consecutive cases with chest radiographs of the International Labour Organisation categories 0 or 1 determined independently. All subjects had a standard high kilovoltage posteroanterior and lateral chest radiograph, a set of 10-15 1 cm collimation CCT scans and a set of three to five 2 mm collimation HRCT scans in the upper, middle, and lower lung fields. Five experienced readers independently read each chest radiograph and sets of CT scans. On the basis of three to five readers agreeing for small opacities of the lung parenchyma, 12/46 (26%) negative chest radiographs were positive on CT scans, but 6/18 (33%) positive chest radiographs were negative on CT scan. On the basis of four to five readers agreeing on a chest radiograph, 36/66 (54%) subjects were normal (group A), 17/66 (26%) were indeterminate (group B), and 13/66 (20%) were abnormal (group C). By the combined readings of CCT and HRCT, 4/31 (13%) asbestos exposed subjects of group A were abnormal (p < 0.001), 6/17 (35%) of group B were abnormal, and in group C, 1/13 (8%) was normal, 2/13 were indeterminate, and 10/13 (77%) were abnormal. Separate readings of CCT and HRCT on distinct films in 14 subjects showed that all cases of asbestosis were abnormal on both CCT and HRCT. Inter-reader analyses by kappa statistics showed significantly better agreement for the readings of CT than the chest radiographs (p < 0.001), and for the reading of CCT than HRCT (p < 0.01). Thus CT scans of the thorax identifies significantly more irregular opacities consistent with the diagnosis of asbestosis than the chest radiograph (20 cases on CT scans v 13 on chest radiographs when four to five readers agreed, 13% of asbestos exposed subjects with normal chest radiographs or 21% of asbestos exposed subjects with normal or near normal chest radiographs. It decreased the number of indeterminate cases significantly from 17 on chest radiographs to 13 on CT scans. All cases of asbestosis detected only on CT scans were similarly seen on CCT and HRCT and did not have significant changes in lung function. The CT scans significantly reduced the inter-reader variability, despite the absence of ILO type reference films for these scans.

Measurement of scatter fractions in erect posteroanterior and lateral chest radiography.

Scatter fractions (SFs) measured in patients undergoing erect posteroanterior (PA) and lateral chest radiography with a 12:1 antiscatter grid are reported. Modifications to the posterior beam-stop (PBS) technique allowed measurement of scatter in these patients, without altering the diagnostic image and without additional radiation exposure. The SF measurements are reported by anatomic location on 42 clinical chest images. Average SF values ranged from 0.27 to 0.90 on lateral radiographs and from 0.27 to 0.68 on PA radiographs. Scatter measurements with the 12:1 grid were found to be greater than estimates from previous PA chest phantom experiments. To the authors' knowledge, they were the first to measure radiation scatter with the PBS technique in patients undergoing PA and lateral chest radiography with the antiscatter grid.

Postaortic left innominate vein: Radiological assessment and pathogenesis

Postaortic left innominate vein (PALIV) is a rare venous anomaly and the findings on plain chest radiographs have not been well described. Plain chest radiographs, CT and MR of nine adults known to have PALIV were reviewed. They all showed a high aortic arch, including four with a right-sided aortic arch and one with a double aortic arch, in postero-anterior radiographs, and seven showed curved shadows in the left upper mediastinum. On all lateral chest radiographs (n = 5), the superior retrosternal region was opacified by the high aortic arch. CT or MR images confirmed the aortic arch and/or innominate artery to be in that part of the retrosternal space, normally occupied by the left innominate vein, in all cases. Association of a curved shadow in the superior mediastinum with a high aortic arch on plain chest radiographs is therefore suggestive of, though not diagnostic for, PALIV. This entity was well documented by CT or MR and the radiological findings were considered to imply that developmentally PALIV is secondary to a high position of the aortic arch.

Anterior Mediastinal Mass

(Chest 1993; 103:1577-78) A 41-year-old woman presented with a 3-month history ofright anterior chest pain. PA and lateral chest radiographs showed a smooth, well-defined 8cm anterior mediastinal mass. No contained calcification was present (Fig 1). Computed tomography (CT) of the thorax with bolus injection of contrast material revealed multiple punctate calcifications in the mass, which spanned the anterior and middle mediastinum (Fig 2, left). Pooling of the contrast occurred on the later scans (Fig 2, right). Further history revealed that the patient was a lifetime nonsmoker. There was flO history of dyspnea, hemoptysis, cough, voice change, difficulty in swallowing, fever, weight loss, or sensory or motor abnormalities in the upper extremities. Physical examination revealed normal vital signs. There was fl() clubbing, cyanosis, or edema. Examination of the neck revealed flO lymphadenopathy or thyroid enlargement. Excursion of the chest was normal. There were no rubs, crackles, or wheezes. Laboratory investigations revealed a hemoglobin level of 13.4 mmIL, a WBC count of 8.7 x 10”/L and a platelet count of 212,000/mm3. Oxygen saturation on room air was 97 percent. The patient was taken to the operating room, and the tumor was removed through a midline sternotomy without complication. Pathologic examination revealed

Multiple matched ventilation-perfusion defects in illicit drug use

A 21-YEAR-OLD BLACK WOMAN presented to the emergency room with a history of acute onset of shortness of breath and associated chest pain. The patient had been snorting heroin intranasally and smoking freebased cocaine 30 minutes before the onset of dyspnea. The dyspnea continued for 30 to 36 hours, prompting her to seek medical assistance at the emergency room. The patient gave no history of asthma or significant smoking of tobacco and denied any drug use. Physical examination showed a young black female in mild respiratory distress. There was no calf swelling or tenderness. A posterioranterior and lateral chest radiograph (Fig 1) demonstrated normal heart size and clear lung fields bilaterally. Although the patient denied use of oral contraceptives, pulmonary embolism was considered as a potential cause of these findings. A ventilation-perfusion lung imaging study was performed using aerosolized inhalation of 1.1 mCi of technetium-99m (99mTc) diethylenetriaminepentaacetic acid (DTPA) with images obtained from the anterior, posterior, and bilateral posterior oblique projections using a general purpose collimator. The perfusion study followed using an intravenous injection of 3.5 mCi of 99mTc microaggregated albumin (MAA), with images obtained in the same projections. The images demonstrated multiple, bilateral, matched, nonsegmental ventilation and perfu-

The efficacy of a single posteroanterior radiograph in the assessment of metastatic pulmonary melanoma.

Posteroanterior (PA) and lateral chest radiographs are performed as part of the routine staging and follow-up investigation of patients with malignant melanoma. We have assessed the contribution of the lateral chest radiograph in the follow-up of 227 consecutive patients with proven malignant melanoma. In only once case was an abnormality evident on the lateral radiograph which was not previously detected on the PA films. Our department, as a result of this study, has discontinued the routine use of lateral chest radiography in the follow-up of patients with malignant melanoma.

Effects of Bronchial Artery Embolization on the Plain Chest Radiograph

The bronchial circulation may influence pulmonary edema. This study evaluates possible effects of bronchoesophageal artery embolization on the plain film manifestations of hydrostatic pulmonary edema in sheep. Anteroposterior and lateral chest radiographs were obtained during the induction of pulmonary edema both before and after embolization of the bronchoesophageal artery in six adult sheep. Interstitial lines and perivascular, segmental bronchial, proximal bronchial, carinal, tracheal, and parenchymal edema were evaluated. Only parenchymal edema was graded consistently. Though edema increased with left atrial pressure before embolization (P < .001), there was no similar change afterward. The embolized animals tended to be more edematous by the first film. Rather than any protective effect, bronchoesophageal artery embolization may increase edema. This model may be inappropriate for further investigation of the bronchial circulation in the development of human pulmonary edema.

Predictive equations for total lung capacity and residual volume calculated from radiographs in a random sample of the Michigan population.

Published predicted values for total lung capacity and residual volume are often based on a small number of subjects and derive from different populations from predicted spirometric values. Equations from the only two large studies gave smaller predicted values for total lung capacity than the smaller studies. A large number of subjects have been studied from a population which has already provided predicted values for spirometry and transfer factor for carbon monoxide. Total lung capacity was measured from standard posteroanterior and lateral chest radiographs and forced vital capacity by spirometry in a population sample of 771 subjects. Prediction equations were developed for total lung capacity (TLC), residual volume (RV) and RV/TLC in two groups--normal and total. Subjects with signs or symptoms of cardiopulmonary disease were combined with the normal subjects and equations for all subjects were also modelled. Prediction equations for TLC and RV in non-smoking normal men and women were square root transformations which included height and weight but not age. They included a coefficient for duration of smoking in current smokers. The predictive equation for RV/TLC included weight, age, age and duration of smoking for current smokers and ex-smokers of both sexes. For the total population the equations took the same form but the height coefficients and constants were slightly different. These population based prediction equations for TLC, RV and RV/TLC provide reference standards in a population that has provided reference standards for spirometry and single breath transfer factor for carbon monoxide.

Structural change of the thorax in chronic obstructive pulmonary disease.

This study examines structural changes of the thorax in hyperinflated subjects with chronic obstructive pulmonary disease (COPD). Age-matched normal subjects were used for comparison. Thoracic dimensions were determined using anteroposterior and lateral chest radiographs performed at total lung capacity, functional residual capacity, and residual volume. Rib cage dimensions (lateral diameter, rib angle, anteroposterior diameter) and diaphragm position were determined at each lung volume. There were no significant differences in rib cage dimension between the COPD and normal subjects for all lung volumes. In contrast, the diaphragm was significantly lower in the COPD subjects. The change of rib cage dimensions in the COPD subjects (for a similar volume change) was not different from that in normal subjects, whereas the change of diaphragm position in the COPD subjects (for a similar volume change) was reduced. In conclusion, the primary structural change of the thorax in COPD with chronic hyperinflation is confined to the diaphragm, with no appreciable structural change in the rib cage.

Obliteration of the descending aortic interface in pectus excavatum: correlation with clockwise rotation of the heart.

Obliteration of the descending aortic interface is a new radiographic finding in pectus excavatum. Seventy frontal and lateral chest radiographs and 33 computed tomographic (CT) scans of patients with pectus excavatum were retrospectively reviewed to evaluate the frequency, possible cause, and clinical significance of this finding, which was detected in 21 of 70 cases (30%) of pectus excavatum. No significant relationship was found between this finding and the extent of the thoracic deformity. In patients with this finding, the left inferior pulmonary vein (PV) entered the left atrium at an acute angle to the sagittal plane, as demonstrated at CT, and this angle was significantly smaller than that in patients without this finding. The PV angle also significantly correlated with the cardiac rotation angle. In pectus excavatum, partial obliteration of the descending aortic interface can be mistaken for adjacent disease.

319. 可動絞り挿入型胸部濃度補償フィルタの側面撮影における有用性(X 線装置-7 補償フィルタ)

319. 可動絞り挿入型胸部濃度補償フィルタの側面撮影における有用性(X 線装置-7 補償フィルタ)

319. 可動絞り挿入型胸部濃度補償フィルタの側面撮影における有用性(第 48 回総会学術大会一般研究発表予稿)

319. 可動絞り挿入型胸部濃度補償フィルタの側面撮影における有用性(第 48 回総会学術大会一般研究発表予稿)

Imaging Techniques in the Evaluation of Pulmonary Parenchymal Neoplasms

Conventional PA and lateral chest radiographs continue to be the initial examination of choice to evaluate patients who are suspected of having a pulmonary parenchymal neoplasm. A lung lesion can be characterized as probably benign or malignant based on its radiographic appearance (size, shape, margins, presence of calcification, cavitation or air bronchograms, growth rate). A spiculated or lobulated lesion greater than 3 cm in size that is noncalcified is highly suspicious for malignancy. A lung lesion less than 3 cm in size with smooth borders that appears noncalcified on conventional radiographs should be examined by CT, including densitometry to detect calcification or fat, which indicates benignity. In patients with known lung cancer, CT can help to stage the tumor by indicating hilar or mediastinal involvement, or distant metastases. Currently, MR imaging has a limited role, but can be used as a "problem solving" modality for selected cases in evaluating pulmonary parenchymal neoplasms.

Usefulness of empiric chest radiography and urinalysis testing in adults with acute sickle cell pain crisis

To determine the usefulness of obtaining routine chest radiographs and urinalyses on adults presenting to the emergency department in acute sickle cell pain crisis. The hypothesis tested is that in some adult sickle cell patients, sickle cell pain crises are precipitated or accompanied by acute infection that may be clinically occult and that routine screening for pulmonary or urinary tract infection would identify some of these precipitating illnesses. Prospective clinical study. A university hospital ED. All patients more than 14 years old with S-S, S-C, or S-beta-thalassemia sickle hemoglobinopathies who presented to the ED with acute nontraumatic painful complaints during a six-month period. All patients underwent posteroanterior and lateral chest radiography, routine urinalysis, and CBC count with reticulocyte count. A standard questionnaire for localizing symptoms of systemic, pulmonary, and urinary tract infection was completed for each patient. Urine cultures were ordered on all patients with voiding symptoms, flank pain, and/or more than 5 WBCs or RBCs per high-power field on urinalysis. Physical examination for evidence of pulmonary and urinary tract infection was carefully performed and recorded for subsequent analysis. Seventy-one patients with 134 ED presentations were studied over a six-month period. Eight diagnoses of acute pneumonia were made. Four of these patients complained of chest pain (50% vs 48% overall) and three had shortness of breath (38% vs 21%). None of these patients complained of fever or symptoms of upper respiratory illness. Ten diagnoses of urinary tract infection were made. Four of these patients complained of dysuria and frequency; three complained of flank pain. Eleven of the 18 infections (61.1%) did not have a typical history for or suggestive physical or laboratory findings of bacterial infection. In sickle cell disease patients with pain crisis, routine chest radiography and urinalysis may be clinically useful and cost effective in the early diagnosis of crisis-related infection.

Advanced multiple beam equalization radiography (AMBER) in the detection of diffuse lung disease

To evaluate the effects of scanning equalization radiography (SER) on the detection of diffuse lung disease a clinical comparison between an Advanced Multiple Beam Equalization Radiography (AMBER) unit and conventional chest radiography was performed. Even though the overall detection of focal pulmonary lesions with the AMBER unit has been shown to be significantly higher than with conventional radiography because of the improved demonstration of the costophrenic and retrocardiac regions, the utility of AMBER in the demonstration of diffuse lung disease has not been established. Twenty-one patients with diffuse lung disease (fibrosing alveolitis or sarcoidosis) and six patients with no pulmonary disease had high kVp frontal and lateral chest radiographs on both an AMBER unit and a conventional chest stand. The pooled results of five observers using Receiver Operating Characteristic (ROC) analysis indicate that there is a slight improvement but no statistically significant difference in observer performance between AMBER (Area under the ROC curve AZ = 0.934) and conventional radiography (AZ = 0.868) in the task of detecting diffuse lung disease.