Table Of ContentTHE
CHEST
X-RAY
A SURVIVAL GUIDE
Gerald de Lacey, MA, MB, B Chir, FRCR
Consultant Radiologist
Radiology Red Dot Courses, London and www.radiology-courses.com
Simon Morley, MA, BM, BCh, MRCP, FRCR
Consultant Radiologist and Honorary Senior Lecturer
University College Hospitals, London
Laurence Berman, MB, BS, FRCP, FRCR
Lecturer and Honorary Consultant Radiologist
University of Cambridge and Addenbrooke’s Hospital, Cambridge
Philadelphia • Edinburgh • London • New York • Oxford • St Louis • Sydney • Toronto • 2008
Prelims-X4626.indd Sec1:380-Sec1:381 10/26/07 12:06:10 PM
SAUNDERS
ELSEVIER
An imprint of Elsevier Limited
© 2008, Elsevier Limited. All rights reserved.
The right of Gerald de Lacey to be identified as author of this work has been asserted in accordance
with the Copyright, Designs and Patents Act 1988
No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any
form or by any means, electronic, mechanical, photocopying, recording or otherwise, without the
prior permission of the Publishers. Permissions may be sought directly from Elsevier’’s Health Sciences
Rights Department, 1600 John F. Kennedy Boulevard, Suite 1800, Philadelphia, PA 19103-2899,
USA: phone: ((cid:2)1) 215 239 3804; fax: ((cid:2)1) 215 239 3805; or, e-mail: [email protected].
You may also complete your request on-line via the Elsevier homepage (http://www.elsevier.com),
by selecting ‘Support and contact’and then ‘Copyright and permission’.
First published 2008
Reprinted 2008 (twice)
ISBN: 978-0-7020-3046-8
British Library Cataloguing in Publication Data
A catalogue record for this book is available from the British Library
Library of Congress Cataloging in Publication Data
A catalog record for this book is available from the Library of Congress
Notice
Knowledge and best practice in this field are constantly changing. As new research and experience
broaden our knowledge, changes in practice, treatment and drug therapy may become necessary or
appropriate. Readers are advised to check the most current information provided (i) on procedures
featured or (ii) by the manufacturer of each product to be administered, to verify the recommended
dose or formula, the method and duration of administration, and contraindications. It is the responsibility
of the practitioner, relying on their own experience and knowledge of the patient, to make diagnoses, to
determine dosages and the best treatment for each individual patient, and to take all appropriate safety
precautions. To the fullest extent of the law, neither the Publisher nor the Editors/Authors assumes any
liability for any injury and/or damage to persons or property arising out or related to any use of the material
contained in this book. It is the responsibility of the treating practitioner, relying on independent expertise
and knowledge of the patient, to determine the best treatment and method of application for the patient
The Publisher
Printed in Spain
08 09 10 10 9 8 7 6 5 4 3
The
Publisher’s
policy is to use
paper manufactured
from sustainable forests
PREFACE
Despite the continuing development and increasing sophistication of computed
tomography (CT) and magnetic resonance imaging (MRI), the chest x-ray
(CXR) is still the most frequently requested radiology investigation in a general
hospital. Swiftly, inexpensively, and with a high degree of accuracy the CXR
enables the physician to detect or rule out numerous disorders, diseases
and abnormalities. It will also help to exclude several serious therapeutic
complications. A normal CXR will time and again provide valuable clinical
reassurance. The CXR remains the most appropriate examination in many
circumstances — it is a bedrock imaging test.
Yet there is an important caveat. Accurate CXR interpretation requires a
sound understanding of basic principles. The increasing reliance on CT and
MRI has caused these essential competencies to become neglected. They are in
danger of being lost altogether. The aim of this book is to assist in reversing this
trend, by providing a convenient and informative white coat pocket guide to
complement the numerous excellent bench reference volumes.
The structure of this book derives from the Radiology Red Dot teaching
course “The CXR: A Survival Course“ (www.radiology-courses.com), and from
the regular questions and concerns of its participants. Part A concentrates on
the core knowledge — describing normal and abnormal thoracic anatomy, CXR
appearances occuring with several common conditions, and also CXR (cid:196) ndings
in the intensive care and neonatal intensive care units. Part B focuses on speci(cid:196) c
clinical problems — including those CXR appearances about which our students
most frequently seek guidance.
The English author C.C. Colton identi(cid:196) ed three dif(cid:196) culties in authorship:
to write anything worth publishing, to (cid:196) nd honest people to publish it, and to
get sensible people to read it. In attending to these we added our own fourth
requirement…to (cid:196) nd an outstanding medical illustrator. Explanatory drawings
were always crucial to achieving our main goal — to describe and explain how
assessment of the CXR depends upon an informed and organised analytical
approach. Happily, we found that exceptional illustrator, Philip Wilson.
Finally, a couple of quick notes about our use of language. We use the word
“physician” to include all medical doctors (rather than just those covered by the
parochial British usage of the word). Our choice of pronoun (he or she) occurs
randomly and arbitrarily throughout the book.
Whether you are a senior doctor, a doctor in training, or a medical student
learning the fundamental and important aspects of our craft, we hope that you
will have as much enjoyment reading and using this book as we had creating it.
Gerald de Lacey,
Simon Morley,
Laurence Berman,
July 2007
vi
Prelims-X4626.indd Sec1:384-Sec1:385 10/26/07 12:06:12 PM
PREFACE AND ACKNOWLEDGEMENTS vii
ACKNOWLEDGEMENTS
We owe debts of gratitude to so many individuals. Our priority was to utilise
a large number of exquisitely precise drawings within an overall structure and
design layout that would assist in explaining the basic concepts that underpin
accurate analysis of the plain CXR. To achieve this we needed to assemble a
team that included a skilled medical illustrator and a (cid:196) rst class designer / editor.
These were our principle objectives before we set about making the (cid:196) rst
keystrokes. We had worked with Claire Gilman previously and her design
skills, imagination, and superb professionalism have proved to be more than
invaluable — they have been priceless. We sought and found a wonderfully
skilful medical artist, Philip Wilson, who created 250 (cid:196) gurative and realistic
artworks of the very highest quality. Michael Houston and Cheryl Brant of
Elsevier completed the team and with predictable expertise guided the project
through to completion.
We could not have completed this Survival Guide without the help of
Pam Golden who typed numerous drafts and revisions. Others who helped us
included Floss (Tracey Wilson) who carried out supplementary typing. Dr Denis
Remedios, Dr Emily Tam and Jeremy Weldon of Northwick Park Hospital, Julian
Evans and Dr Nick Screaton of the University of Cambridge, and Dr Tracey
Kilborn of Red Cross Children’s Hospital, Cape Town, South Africa, assisted
us with material for illustration. Professor Colin Morley (Professor of Neonatal
Medicine, Royal Womens’ and Royal Childrens’ Hospitals, Melbourne, Victoria,
Australia) provided practical and constructive advice when reviewing important
parts of the manuscript.
It would be very wrong to write a book on the plain CXR without
acknowledging the in(cid:197) uence of numerous internationally renowned masters
and past masters. We have appropriated and utilised their original observations
and explanations time and time again. There are too many of these experts
for us to list. Nevertheless, two maestros must be mentioned. Firstly, Professor
Peter Armstrong, recently of St Bartholomew’s Hospital, London, and previously
radiologist at the University of Virginia Medical School. Peter is the principal
faculty member on our advanced plain CXR course held in London. Every
year we learn something new from his clear and logical analyses. He will
surely forgive us for adapting several of his descriptions in order to explain
and illustrate various anatomical concepts — particularly around the hilum of
the lung. Another renowned expert, Dr Benjamin Felson, through his writings
and enduring teachings had long ago stimulated our interest in the diagnostic
subtleties underpinning CXR analysis. Dr Felson, once a radiologist at the
University of Cincinnati College of Medicine, was the acknowledged pioneer
in developing the scienti(cid:196) c approach to CXR assessment. His enduring legacy
remains an academic and clinical treasure chest. Dr Felson’s numerous and
exquisitely perceptive observations retain a relevance and a freshness which
remain fully appropriate to 21st century medicine and modern day medical
imaging. We owe all these individuals a very great debt. Thank you.
Prelims-X4626.indd Sec1:384-Sec1:385 10/26/07 12:06:12 PM
REFERENCE: NORMAL CXR
A normal CXR
Below are representations
indicating the positions of
the three lobes of the right
lung and the two lobes of
the left lung. The dotted
lines represent the lung
(cid:196) ssures which separate
the lobes.
RUL = right upper lobe
ML = middle lobe
RLL = right lower lobe
LUL = left upper lobe
LLL = left lower lobe
RUL LUL
RLL LLL
ML
viii
Prelims-X4626.indd Sec1:386-Sec1:387 10/26/07 12:06:13 PM
