5分钟看懂如何阅读胸片
2017/9/20 医学界临床药学频道

     做CT偶然发现肺部结节，这个会不会是肺癌？发现可疑肺癌结节要怎么办？

     作者丨潘战和

     来源丨肿瘤专科医生(微信号：zlzkys)

    

     今天就推送一篇我们独家译制的中英文对照版视频哦~连字幕的中英文对照文字版都有!Mark一下好好学吧!

     字幕翻译、制作丨@___Raeeeee

     来源丨医学界影像诊断与介入频道

     英文视频来源丨放射科那点事儿

     写在前面：翻译可能有不足之处，请大家多多讨论、指正!

     ----视频时长4分41秒----

     中文字幕文字版

     系统阅读胸片的实用方法，以及一些基础解剖知识，这会帮助你避免漏掉关键的异常表现。

     首先，快速确认病人的信息，以及胸片的方位：是后前位(从前面看)还是前后位(从后面看)？

     有用的信息常常会在图像上标明。在评价图像质量方面，看看在图像上能否找到自己所需要的所有信息。

     然后检查以下三个方面：RIP。

     R即是否有转位。棘突应该位于两侧锁骨近胸骨端的中点处。

     I 即吸气。从前面看，应该能看到5-7根肋骨。

     P 即透射程度。即此处X线穿透人体的程度。在心脏后面，这里的脊柱是可见的吗？

     为了更好的读片，我们将运用ABCDE法 则。如果图像上有明显的异常区域，请首先标注出来。但记住之后要系统地观察图像，以确保你没有遗漏。

     A 气道，肺，胸膜。从气管开始，然后向下走行。气管含气，所以比周围显得更暗(低密度)。检查气管是否位置居中，或是偏向一侧。气管可以被塌陷的肺牵拉至一侧，或者由于一侧张力性气胸被推移到另一侧。描述胸片时，肺叶被分成了上，中，下三个区域。 请注意这和解剖上的肺叶并不是相对应的。轮流观察双侧的肺区，检查是否对称。每一个区域都要和对侧相对比。有没有哪个区域看起来太亮(密度高)了或者太暗(密度低)了？如果有的话，判断哪一侧是异常的。确保你能看见肺纹理一直走行直到胸壁的边缘(细小的灰色纹理)。如果你看见肺的边缘围绕着暗区，那就要怀疑可能有气胸。注意，正常的胸片是看不见胸膜的。

     B，骨。观察肋骨，锁骨，肱骨上段以及胸椎。检查有无骨折或癌症转移性病灶的征象。观察肩关节以明确有无关节炎或脱位的表现。

     C，循环。心脏与纵隔。观察心脏与纵隔的大小，形状与边界。心脏的测量，用心胸比。在后前位胸片上，心脏占据胸腔的比值小于50%。心胸比大于50%，胸片上显示出异常，这提示着心脏增大。

     构成纵隔左缘的结构有主动脉结，肺动脉流出道，左心耳以及左心室。右缘包括了上腔静脉，右心房。

     以及下腔静脉。正常情况下，这些边缘都是界限分明的。如果边缘模糊，则提示可能有肺的塌陷或肺实变。

     D，横膈。两侧的胸膜都呈现光滑的圆顶状，与肺的暗区之间有一条锐利的白色线条，界限清晰。

     正常情况下，右侧横膈比左侧稍高，约高1-3厘米，原因是其下有肝脏。肋膈角是指横膈和肋骨交界处。

     心隔角是心脏与横膈交界处。这些角都应该是界限清晰的。常常还能看到左侧横膈下有胃泡。

     E，其他征象与回顾检查区域。检查有无医疗介入器械。比如，监护设备的电线和插管。他们的位置是否正确？如果上述胸片未见异常，那么注意以下回顾检查区域。肺尖部、肺门区。这是主要的细支气管和主要的肺血管。左侧肺门会比右侧稍高，或者一样高。双侧肺门在大小和密度上都应该是对称的。

     检查心脏的后方。检查软组织。最后检查膈下。

     综上，这是史密斯先生的后前位胸片。图像质量良好。在对影像进行检查的过程中，未见明显异常。

     拟做进一步临床检查。

     英文字版文字版

     The systematic approaches useful when starting to interpret chest X-rays along with some basic knowledge of anatomy. This will help to make sure you don’t miss any key abnormalities.

     First of all, have a quick check to confirm the identity of the patient and comment on the orientation of the film. Is it PA or AP? Often, useful information may be written on the image. In terms of image quality, ask yourself if you can see everything you need in the picture. Then check three aspects usually in acronymic RIP.

     R is rotation. The spinous process should be at the midpoint between the medial ends of the clavicles.

     I is the inspiration. There should be 5 to 7 ribs visible anteriorly.

     P is penetration. The degree to which X-rays here pass through the body. Is this spine visible behind the heart?

     We’ll be using the ABCDE approach to chest X-ray interpretation. If there is a clear area of abnormality. Don’t hesitate to highlight it first. But remember to go through systematically afterwards to check you haven’t missed anything.

     A, airway, lungs and pleura. Start with the trachea, and your way down. The trachea contains air so it’s blacker than the surroundings. Check if it is centrally positioned or deviated to one side. The trachea can be pulled towards the side of collapse or pushed away from the side of tension pneumothorax. When describing a chest X-ray, the lobes are divided into upper, middle and lower zones. Note this did not correlate with the lung lobes. Look at each of the lung zones in turn for symmetry. Compare each zone with the opposite side. Do any areas look too black or too white? If so, decide which is the abnormal side. Make sure you can see lung markings go all the way to the edge of the chest wall. If you could see the lung edge with the black area surrounding it, suspect it’s pneumothorax. Note the pleura are not visible in healthy people.

     B, bones. Look at the ribs, clavicles, proximal end of the humerus and the thoracic spine. Check for evidence of fractures or metastatic deposits. Examine the shoulder joints for signs of arthritis or dislocation.

     C, circulation. Heart and mediastinum. Look at the size, shape and border of the heart and mediastinum. Heart size is assessed using the cardiothoracic ratio. In the PA film, the heart occupies less than 50% of the width of the thorax. A cardiothoracic ratio of greater than 50% in a PA view is abnormal and indicates cardiomegaly. Structures making up the left border of the mediastinum include the aortic knuckle, pulmonary outflow tract, left atrial appendage, and left ventricle. On the right side, the border includes the superior vena cava (SVC), the right atrium, and the inferior vena cava (IVC). These borders should be well defined.

     A blurred edge could indicate collapse or consolidation of the lung.

     D, diaphragm. Each side of the diaphragm should appear as a dome with a sharp white edge against the adjacent black lung. The right hemi-diaphragm is normally higher than the left, right about 1-3 centimeters due to the liver underneath. The costophrenic angles are the areas where the diaphragm meets the ribs actually. The cardio-phrenic angle is where the heart meets the diaphragm. These angles should be clearly defined. Often, you would see the gastric air bubble under the left hemi-diaphragm.

     E, extra features and review areas. Look for evidence of medical intervention. For example, monitoring equipment, lines and tubes. Are they correctly positioned? If the chest X-ray appears normal so far, pay attention to the review areas. The lung apexes, the hilum regions. These are the major of bronchi and major pulmonary vessels. The left hilum is higher than the right, or the same level. They should be symmetrically in size and density. Look behind the heart. Check the soft tissues. Finally review under the diaphragm.

     In summary, this is a PA chest X-ray of Mr. Smith. The film is technically adequate.On review of the film there were no obvious abnormalities. I would now like to view the patient clinically.

     (本视频字幕及中英文文字版字幕均为医学界影像诊断与介入频道原创，转载需经授权并标明作者、来源)

    

    

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