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Basic Radiology:
Chest X-Ray Fundamentals
J ohn Mabee, PhD, PA-C
Assistant Professor Clinical Family Medicine
Keck School of Medicine of USC
Division of Physician Assistant Studies
Primary Care Physician Assistant Program
October 4, 2012
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Underpenetrated
Exposure
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Overpenetrated
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Exposure
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Rotation
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T-spine disc spaces barely visible thru heart
Bronchovascular structures seen thru heart
Diaphragm: 8
th
-10
th
posterior or 5
th
-6
th
anterior rib
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http://www.med-ed.virginia.edu
PA
View
Sternum should be seen edge on
Spine darkens as you move caudally
Posteriorly, you should see 2 sets of ribs
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Lateral
View
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Key
Landmarks
Horizontal fissure
parallels 4
th
rib
Oblique fissures
parallel 5 - 6
th
ribs
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R Ribs
L Ribs
BASI CS
One approach to reading a CXR:
- A: Airways
- B: Bones
- C: Cardiomediastinal silhouette
- D: Diaphragm
- E: Everything else (plus lungs!)
Selected CXR Findings &
Case Demonstrations
Normal
A: Airways
B: Bones
C: Cardio-
mediastinal
silhouette
D: Diaphragm
E: Everything
else (+lungs)
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Emphysema
Bilateral diffuse
hyperinflation,
flattening of
diaphragms,
bullae
Narrowing of
the cardiac
silhouette
Emphysema
Dilated Airways
Emphysematous
subpleural
spaces
(Blebs)
A 66-year old man is seen in the office
for progressive shortness of breath for
the past 2 months. He smokes 2 packs
of cigarettes per day for the past 40
years. Physical examination shows
pursed lip breathing, and mild curvature
of the thoracic spine. Heart sounds are
distant, but without murmur or gallop.
Lung sounds are normal. Chest x-ray
study is shown.
Case 1
Case 1
En.wikipedia.orgwili/File:Emphysema2008.jpg
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Case 1
En.wikipedia.orgwili/File:Emphysema2008.jpg
- Hyperinflation
- Hyperlucency
- Flattening of
the diaphragm
- Narrowing of
the cardiac
silhouette
Dx:
Emphysema
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En.wikipedia.orgwiki/File:Cardiomegally.png
Normal: 50% of
thoracic diameter
Pulmonary Edema
Bat wing" pattern & air bronchograms
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Pulmonary Edema
Cephalization of pulmonary vessels, Kerley B
(septal) lines, peribronchial cuffing
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LVH & Pulmonary Edema
Alveolar
Edema
Library.med.utah.edu/WebPath/webpath.html
Library.med.utah.edu/WebPath/webpath.html
A 58-year old man is seen in the
emergency department because of
increasing dyspnea and orthopnea for
the past 2 days. Vital signs: pulse 98,
BP 132/84, respirations 22. Physical
examination shows bilateral scattered
rales, intermittent wheezes, and an S3.
Chest x-ray study is shown.
Case 2
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- Cardiomegaly
- Prominent
bilateral
pulmonary
vasculature
- Cephalization
of vessels
- Kerley B lines
Dx: Heart failure; pulmonary edema
Case 2
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Airspaces
filled with pus
(pneumonia)
or other fluid
(inflammation
, CA, blood)
Infiltrate
Usually no
loss of lung
volume
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Consolidation
Loss of the
silhouette or
lung/soft
tissue
interface
caused by a
mass or fluid
in the
normally air
filled lung
Silhouette Sign
RML
Bronchopneumonia vs.
Lobar Pneumonia
Bronchopneumonia Lobar Pneumonia
Inflammatory
infiltrate (pus)
in alveoli
consolidation of
airspaces
Bronchopneumonia Lobar Pneumonia
Pneumonia: Gross Pathology
Library.med.utah.edu/WebPath/webpath.html Library.med.utah.edu/WebPath/webpath.html
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A 35-year old man comes to the office
for evaluation of fever, and productive
cough for the past 4 days. Temperature
is 39.4 C (103 F). Physical examination
shows rales over the right lower
anterior chest. Chest x-ray study is
shown.
Case 3
Case 3
- + silhouette sign
- Focal area of
consolidation by
right heart
- Fluid in horizontal
fissure
Dx: RML pneumonia
Case 3
A 58-year old man is being evaluated in
the intensive care unit. Two days ago,
he was in a high speed car accident,
and was treated for a closed right tibia
and fibula fracture. Earlier today, he
was intubated because of increasing
dyspnea, tachypnea, and confusion.
Chest x-ray study is shown.
Case 4
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Case 4
- Diffuse
bilateral
infiltrates
- Appropriate
positioning of
ET tube
Dx: ARDS
Case 4
Mediastinum
Mediastinum: 8 cm
Aortic
Knob
Pulmonary
Artery
Aorto-
Pulmonary
Window
Mediastinal Mass
Note aorto-
pulmonary
window
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Aortic Dissection
Library.med.utah.edu/WebPath/webpath.html
A 68-year old man is seen in the
emergency department because of
sharp tearing chest pain radiating to the
upper back that began 1 hour ago. He is
lightheaded, and has nausea. Vital signs:
pulse 80, BP 200/110, respirations 18.
Physical examination shows grade II/VI
diastolic murmur over the aortic area,
and diminished pulses in both lower
extremities. Chest x-ray study is shown.
Case 5
Case 5
- Mediastinal
widening
- Tracheal
shift
Dx: Aortic
dissection
Case 5
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Pneumothorax
Violation of
pleural space
Loss of
vascular
markings at
lung periphery
If small, best
seen in apices
on expiratory
view
Hemopneumothorax
Air-fluid level with hemothorax
Hemothorax
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A 27-year old man is evaluated in the
emergency department for right-sided
chest pain, and shortness of breath.
During the primary survey, no breath
sounds are heard over the right chest
wall. Chest x-ray study is shown.
Case 6
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C
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- Hyperlucent
right hemithorax
- No lung
markings
- Ipsilateral lung
edge parallel to
chest wall
Dx: Pneumothorax
Case 6
Pleural Effusion
Fluid collection
in pleural space
blunting of
costophrenic
Minimum vol:
- 250 mL on
PA view
- 75 mL on
lateral view
www.yale.edu/imaging
Pleural Effusion
Lateral decubitus view fluid layering
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Empyema
Pus
Library.med.utah.edu/WebPath/webpath.html
A 28-year old man is seen in the office
because of fever, chills, and productive
cough for the past week. Over the past 2
days, he has developed left-sided chest
pain, and progressive shortness of
breath. Vital signs: pulse 110, BP 108/72,
respirations 28, and temperature 39.4 C
(103 F). Physical examination shows
decreased breath sounds over the left
lower 2/3s of the chest. Chest x-ray
study is shown.
Case 7
Case 7
- Opacification (white
out) of lower 2/3 of
left hemithorax
- Meniscus
- Deviation of trachea
& heart to right
- Elevation of right
horizontal fissure
Dx: Pleural effusion (empyema)
Case 7
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Atelectasis
Collapse or incomplete expansion of
lung or lung segment
Characteristics:
- opacity of airless lobe (+ volume loss)
- displacement of fissures, hilar &
cardiomediastinal structures toward
side of collapse
- elevation of ipsilateral hemidiaphragm
- lucency of aerated lung
- silhouette sign
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RUL
Radiopaedia.org
RML
Atelectasis
En.wikipedia.org
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RLL
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Radiopaedia.org
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