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Chest x rays made easy

In the fourth of a five part series, Elizabeth Dick compares collapse and consolidation of the lung and looks at pleural effusions
The basics of looking at a chest x ray (recap):
First look at the mediastinal contoursrun your eye down the left side of the patient and then up the right. The trachea should be central. The aortic arch is the first structure on the left, followed by the left pulmonary artery; notice how you can trace the pulmonary artery branches fanning out through the lung. Two thirds of the heart lies on the left side of the chest, with one third on the right. The heart should take up no more than half of the thoracic cavity. The left border of the heart is made up by the left atrium and left ventricle. The right border is made up by the right atrium alone. Above the right heart border lies the edge of the superior vena cava. The pulmonary arteries and main bronchi arise at the left and right hila. Enlarged lymph nodes can also occur here, as can primary tumours. Now look at the lungs. Apart from the pulmonary vessels (arteries and veins), they should be black (because they are full of air). Scan both lungs, starting at the apices and working down, comparing left with right at the same level, just as you would when listening to the chest with your stethoscope. The lungs extend behind the heart, so look here too. Force your eye to look at the periphery of the lungsyou should not see many lung markings here; if you do then there may be disease of the air spaces or interstitium. Dont forget to look for a pneumothorax. Make sure you can see the surface of the hemidiaphragms curving downwards, and that the costophrenic and cardiophrenic angles are not bluntedsuggesting an effusion. Check there is no free air under the hemidiaphragm. Lateral films: if the area anterior or superior to the heart is opacified, suspect disease in the anterior mediastinum or upper lobes respectively. If the area posterior to the heart is opacified suspect collapse or consolidation in the lower lobes.
Normal R Upper lobe Frontal view L Upper lobe Post Oblique fissure Vertebrae Ant Horizontal fissure Middle lobe Lower lobe R Lung Post Upper lobe Ant Oblique fissure Lower lobe L Lung Lateral view

Horizontal fissure

Fig 1 Where the lobes of the lung normally lie

Abnormality: lobar collapse

Collapse of a lobe is caused by proximal obstructionfor example, by a neoplasm, mucus plug, such as in a postoperative patient, or foreign body, such as in a child. Always mention that you are looking for the cause of the collapse. When the lobe is not aerated it will lose much of its volume and collapse to a predictable location depending on whether it is an upper, middle, or lower lobe. Figure 1 shows the normal site of the lobes of the lung; figures 2 to 5 and their accompanying line diagrams show where the lobes collapse to. The collapsed lobe itself can be very difficult to seethere may simply be a little extra shadowing on the film. A collapsed lobe is a cause of volume loss; the other cause is a pneumothorax. The signs that should alert you to a collapse are due to the loss of lung volume: The mediastinum may be shifted towards the side of collapse The hilum is pulled up or down from where it normally lies The horizontal fissure will also be pulled up (in a right upper lobe collapse) or down (right lower lobe collapse) The remaining (non-collapsed) lung on the side of the collapse has to expand to fill the hemithorax, thus spreading its contained vessels; therefore the abnormal side will

Fig 2 Right upper lobe collapse. Increased shadowing in the right upper zone with a clear linear border of the horizontal fissure which has been pulled up (arrowhead). Note the remaining right lung is blacker than the opposite side. In addition the hilum is pulled up. There is a mass arising from the right hilum (arrow); this is the obstructing bronchial carcinoma which is causing the collapse
R Upper lobe collapse Collapsed R upper lobe Horizontal fissure pulled up Residual R middle and lower lobe expands to compensate so R side blacker than L side Look for proximal obstruction eg a carcinona

Frontal view

seem blacker with fewer lung markings than the opposite normal side The proximal obstruction may be

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Fig 4a Antero-posterior chest radiograph. Right middle lobe collapse. The right middle lobe lies adjacent to the right heart border, so the right heart outline is lost. Fig 3a Antero-posterior chest radiograph, left upper lobe collapse

Fig 5a Antero-posterior chest radiograph. Left lower lobe collapse. The lower lobes collapse posteriorly and inferiorly so that the contour of the hemidiaphragm is lost. The collapsed left lower lobe may form a sail shape behind the heart border on the Antero-posterior film (arrow)

Fig 3b Lateral. Left upper lobe collapse. Increased shadowing in the left upper and mid zone with a blurred lower border. The left heart border is also lost, because the lung collapses adjacent to it. On the lateral view the upper lobe can be seen to have collapsed anteriorly and lies anterior to the oblique fissure (arrow)
L Upper lobe collapse Frontal view Lateral view Upper zone Upper lobe veil-like collapses shadowing anteriorly with no and clear superiorly lower border Oblique fissure

Fig 4b Lateral, same patient. The right middle lobe collapses anteriorly in a wedge shape over the heart. The upper border of the wedge is the horizontal fissure (arrowhead), the lower border is the oblique fissure (arrow)
R Middle lobe collapse Frontal view Lateral view

Fig 5b On the lateral film there is extra shadowing posteriorly over the vertebrae due to the collapsed lobe (arrow)

L Lower lobe collapse Frontal view Horizontal fissure R Middle lobe R Middle lobe lies against heart border making it indistinct Oblique fissure L Lower lobe shadowing behind heart with loss of clarity of medial hemi-diaphragm L Lower lobe collapses posteriorly and inferiorly L Hilum pulled down Lateral view

Hilum pulled up

visiblefor example, a large carcinoma arising from the right upper lobe.

Abnormality: confluent opacification of the hemithorax

There are four main causes of confluent opacification of a hemithoraxconsolidation (fig 6) (that is, material within the air-spacessee November studentBMJ ) and pleural effusion that is, material within the pleural space, which could be

serous fluid, blood, or pus (fig 7). Complete collapse of one lung with the mediastinum shifting over the the abnormal side can also cause a white out on the abnormal side (fig 8). Finally, after a pneumonectomy the mediastinum shifts to the empty hemithorax and the residual pleural space fills with fluid and fibrotic material leaving the patient with a complete white out on the side that has been operated on ( fig 9 ) . Consolidation and pleural effusion are

the two most common, and it can be difficult to distinguish between themof course, they can coexist. The key features of an effusion are: If the patient is erect there should be a fluid level and meniscus visible If the effusion is large the mediastinum will be shifted to the opposite side. Compare this with pure consolidation in which there is

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Fig 7 Right pleural effusion. There is opacification of the lower right hemithorax with a fluid level, and the mediastinum is pushed to the left side

Fig 6a Left lower lobe consolidation. There is opacification of the left lower zone with loss of the hemidiaphragm, indicating the consolidation abuts the diaphragmthat is, is within the lower lobe. A key feature is that there is no loss of volume. There is no mediastinal shift and no fluid level

collapse of the lung is accompanied by a pleural effusion the loss of volume (caused by the collapse) may be balanced out by the increase in volume of the hemithorax (caused by the effusion) and therefore it may seem as if the volume of the hemithorax overall is equivalent to the opposite side. As we discussed in November the key feature of consolidation is an air bronchogram. In infective causes of consolidation the process may affect a lobe (lobar pneumonia in a distribution according the normal anatomy shown in fig 1) or spread in a more patchy distribution (bronchopneumonia). Now test yourself with our web quiz at studentbmj.com.

Fig 8 Complete collapse of the right lung. A proximal right main bronchus carcinoma has obstructed the distal right bronchus and caused complete collapse of the right lung with the trachea and mediastinum pulled to the right side by the loss of volume on the right. There is also a rightsided pleural effusion, best seen superiorly. However, the loss of volume due to the right lung collapse is greater than the increase in rightsided volume due to the pleural effusion so that overall the mediastinum is pulled over to the right

Fig 6b On the lateral film, air bronchograms can be seen within the consolidation which occupies the posterior lower hemithoraxthat is, the normal anatomical site of the left lower lobe

no change in volume of the hemithorax and therefore no mediastinal shift. There is one caveat to bear in mind, which is that if

Next month: we will look at lung nodules and masses. I would like to thank Dr Anju Sahdev, Dr Brian Holloway, and Dr Robert Dick for contributing some of the films which are illustrated.
Elizabeth Dick, specialist registrar in radiology, North Thames Deanery

Fig 9 Left pneumonectomy. The left lung contained a carcinoid tumour and was removed. There is left sided loss of volume with shift of the mediastinum and chest wall (ribs) and left hemidiaphragm towards the empty left hemithorax. The residual space in the left hemithorax fills with fluid and fibrotic tissue a few weeks after pneumonectomy

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