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Chest Radiographs


CHEST X RAY A Chest X-ray (CXR) is normally taken erect and PA X(posterior anterior) at a distance of 5 or 6 feet (150 or 200cm).






Chest Radiography : Basics Principles A Structure is rendered visible on a radiograph by the juxtaposition two different densities .

.Silhouette Sign Loss of expected interface normally created by the juxtaposition of two structures of different densities No boundary can be seen between two structures of similar densities.

.ERECT FILMS Erect position is the most ideal technique for chest x ray because It reproduces the normal state of the lungs & mediastinum. making it easy to recognise a pneumothorax. producing a level at the base with a curved line (meniscus). Fluid runs downwards. mediastinum. pneumothorax. The diaphragms are lower showing more of the lung bases and the heart size can be accurately assessed. Air rises to the apical region.

POSTERIOR ± ANTERIOR VIEW The film is taken PA because: It is easier to clear the scapulae from the lung fields by moving the shoulders forward There is less magnification of the heart because the heart is lying adjacent to the film When the patient is too sick to stand unaided or unable to keep still the X-ray is taken supine. X- .


This may help to show bronchial obstruction with air trapping (e. inhaled foreign body in a child): LATERAL FILM: A lateral film should never be part of a standard chest examination especially for medical purposes or for follow up of a known lesion.g. The PA film should be examined. . If there is an abnormality.EXPIRATORY FILM: This is taken when the patient has breathed out. a lateral film may then be useful for further assessment & localisation of abnormalities seen or suspected on the PA film.

LORDOTIC VIEWS They can be obtained to better visualize structures in the thoracic apex obscured by overlying bony structures. The patient will have to lie on either the right or left side for two minutes and a shoot through x-ray is taken. x- .OBLIQUE VIEWS: These are helpful in assessing rib lesions & some pneumothoraces. DECUBITUS VIEW The decubitus view can be done to locate fluid in the chest cavity. pneumothoraces.

increased heart size ² Basilar infiltrates & interstitial spaces accentuated ² Increases venous return to the heart SemiSemi-upright position ² Enlarges normal structures ² Changes air-fluid levels air- Failure to hold breath ² Lung structures & diaphragm blurred Expiration film ² Basilar infiltrates & interstitial spaces accentuated ² Increased heart size .Poor Quality CXR Supine position ² Decreases lung volume.

Why order a CXR? SYMPTOMS: SYMPTOMS: Bad or persistent cough Chest pain Chest injury Coughing up blood Fever Shortness of breath .

Why order a CXR? Pleural effusion Pneumothorax Hemothorax Pulmonary embolus Trauma Monitoring chest drainage TB Lung cancer Chest pain (MI?) Hypertension Screening Pneumonia COPD Asthma .

The 12-Step Program 121: Name Pre-read 2: Date 3: Anatomical markings 4: What type of view(s) 5: Penetration 6: Inspiration Quality Control 7: Rotation 8: Angulation 9: Soft tissues / bony structures 10: 10: Mediastinum Findings 11: 11: Diaphragms 12: 12: Lung Fields } } } .

Quality Control 5. ± Should see pulmonary vessels nearly to the edges of the lungs . Penetration ± Should faintly see ribs through the heart ± Barely see the spine through the heart so that lesions behind or in front of the heart will not be missed.

Overpenetrated Film ‡ Lung fields darker than normal²may obscure subtle pathologies ‡ See spine well beyond the diaphragms ‡ Inadequate lung detail .

Underpenetrated Film ‡Hemidiaphragms are obscured ‡Pulmonary markings more prominent than they actually are .

.A body section view may be done in addition to a routine PA chest to outline the lower regions of the chest in very obsessed patients.

Quality Control 6. Inspiration 2 1 ± Should be able to count 9-10 posterior 9ribs ± Heart shadow should not be hidden by the diaphragm 3 4 5 6 7 8 9 10 .

the ³disease process´ at the lung bases has cleared 9 9-10 posterior ribs are showing .Poor inspiration can crowd lung markings producing pseudopseudo-airspace disease 8 About 8 posterior ribs are showing With better inspiration.

Rotation ± Medial ends of bilateral clavicles are equidistant from the midline or vertebral bodies .Quality Control 7.


If spinous process appears closer to the right clavicle (red arrow). the patient is rotated toward their own left side If spinous process appears closer to the left clavicle (red arrow). the patient is rotated toward their own right side .

Quality Control 8. Angulation


± Clavicle should lay over 3rd rib


Pitfall Due to Angulation

Apical lordotic

Same patient, not lordotic

A film which is apical lordotic (beam is angled up toward head) will have an unusually shaped heart and the usually sharp border of the left hemidiaphragm will be absent

Findings 9. Soft tissue and bony structures ± Check for Symmetry Deformities Fractures Masses Calcifications Lytic lesions

10. Mediastinum ± Check for Cardiomegaly Mediastinal and Hilar contours for increase densities or deformities .Findings 10.

Measurement of the cardiothoracic ratio. .

5cm in adult females. When the cardiothoracic ratio is used it should not exceed 50%. A+B = the transverse diameter of the heart. C= the transverse diameter of the thorax which is measured at the level of the diaphragms from the inner ribs A+B divided by C = the cardiothoracic ratio (CTR) .5cm in adult males and 14.Maximum transverse diameter of the heart on a normal PA film is not more than 15.

Diaphragms ± Check sharpness of borders ± Right is normally higher than left ± Check for free air. pleural effusions .Findings 11. gastric bubble. 11.



12.Findings L 12. The Lung Fields! ± To help you determine abnormalities and their location« Use silhouettes of other thoracic structures Use fissures .

Lung Anatomy Right Lung ± Superior lobe ± Middle lobe ± Inferior lobe Left Lung ± Superior lobe ± Inferior lobe .

the RUL is adjacent to the first three to five ribs. Anteriorly. Anteriorly. Posteriorly. the RUL extends inferiorly as far as the 4th right anterior rib . Posteriorly.Lung Anatomy on Chest X-ray XThe right upper lobe (RUL) occupies the upper 1/3 of the right lung.

being narrowest near the hilum . and appears triangular in shape.Lung Anatomy on Chest X-ray XThe right middle lobe is typically the smallest of the three.

and extends inferiorly to the diaphragm. separated from the others by the major fissure. RLL. Review of the lateral plain film surprisingly shows the superior extent of the RLL. Posteriorly. the RLL extend as far superiorly as the 6th thoracic vertebral body. . Posteriorly.Lung Anatomy on Chest X-ray XThe right lower lobe is the largest of all three lobes.

. The minor fissure separates the RUL from the RML.Lung Anatomy on Chest X-ray XThese lobes can be separated from one another by two fissures. Oriented obliquely. and thus represents the visceral pleural surfaces of both of these lobes. the major fissure extends posteriorly and superiorly approximately to the level of the fourth vertebral body.

the left upper .Lung Anatomy on Chest X-ray XThe lobar architecture of the left lung is slightly different than the right. there are only two lobes on the left. Because there is no defined left minor fissure.

Lung Anatomy on Chest X-ray XLeft lower lobes .

although often slightly more inferior in location. identical to that seen on the right side.Lung Anatomy on Chest X-ray XThese two lobes are separated by a major fissure. . The portion of the left lung that corresponds anatomically to the right middle lobe is incorporated into the left upper lobe.

Chest Radiographic Patterns of Diseases Air Space Opacity Interstitial Opacity Nodules and Masses Lymphadenopathy Cysts and Cavities Lung Volumes Pleural Diseases .

it is called consolidation . When the alveoli fill with fluid or other substances.AIR SPACE OPACITY /ALVEOLAR /ALVEOLAR SHADOWING The alveoli are filled with fluid or solid tissue and appear as small separate rounded 6mm opacities in the early stages. The vessels are obscured and there may be an air bronchogram and silhouette sign.

Components Air bronchogram : air ± filled bronchus sorrounded by airless lung. Confluent opacity extending to pleural surfaces. Segmental distribution Blood (hemorrhage) .

hydrostatic or non ± cardiogenic Cells (tumor) Protein/fat: alveolar proteinosis and lipoid pneumonia Pus (pneumonia) .e.Water (edema) i.

. The bronchi in the upper lobes are visible as dark lines because the surrounding alveoli are filled with exudate due to pneumonia.Air bronchograms.


localised. .i. This leads to a non homogenous pattern of shadowing which may take many forms. The normally visualised blood vessels become ill defined or obscured and may be diffuse or localised.Interstitial opacity This is due to a disease in the interstitium .e. the tissue in which the blood vessels and bronchi lie within the lungs.

well ± defined nodules Lines i.Hallmarks : Small. interlobular septal thickening or fibrosis Reticulation .e. Idiopathic interstitial pneumonias Infections ( TB . Viruses) .

Edema Hemorrhage Non ± infectious inflammatory lesions e. scarcoidosis Tumor Normal interstitium Interstitial disease Reticulo nodular pattern .g.

alveolitis. .Close up of interstitial shadowing in a patient with fibrosing alveolitis. There is a nodular pattern super-imposed on a fine network of lines. superLoss of vessels.

discrete nearly circular opacity 2 ± 30 mm in diameter Mass: larger than 3cm .Nodules and Masses Nodule: any pulmonary lesion represented in a radiograph by a sharply defined.

Qualifies : Single or multiple Size Border definition Presence or absence of calcification Location .

Well Defined Calcifications Ill Defined Mass .

The solitary nodule .

Hilar prominence Specific patterns : 1. Particular station enlargement . Mediastinal widening 2.Lymphadenopathy Chronic abnormal enlargement of the lymph nodes Non ± specific presentations 1.

Right paratracheal lymphadenopathy .

Left Hilar Lymphadenopathy .

Cysts and Cavities Cyst: abnormal pulmonary parenchymal space. congenital or acquired . with a wall thickness greater than 1mm Epithelial lining often present . not containing lung tissues but filled with air and/or fluid.

.Cavity: Cavity: abnormal pulmonary parenchymal space . with a definitive wall greater than 1mm in thickness and comprised of inflammatory and / or neoplastic elements. It is caused by tissue necrosis. not containing lung but filled with air and / or fluid .

2.Cysts and cavities 1. 4. 3. Characterize: Wall thickness at the thickest portion Inner lining Presence/ absence of air/fluid level Number and location .

Benign Lung Cyst :PCP Pneumatocele Uniform Wall Thickness 1mm Smooth Inner lining .

Malignant Cavities: Squamous Cell Cavities Maximum Wall Thickness 16mm Irregular Inner Lining .

Pleural Effusion .

Right Side leural Effusion .

Fracture of posterior rib # .

cavitation Fibrosis Calcifications Consolidation Granuloma Hilar Lymphadenopathy (Tuberculoma) Tuberculoma) Miliary Shadowing Pericardial Effusion Pleural Manifestation of pulmonary tuberculosis effusion .

Pericardial effusion .

Linear/curved/wedge(apex-hilum) Linear/curved/wedge(apex-hilum) density with hilar/tracheal/mediahilar/tracheal/mediastinal/diaphragm stinal/diaphragm deviation with volume loss +/.compensatory +/ TB/ Radiation/ inflammation.inflation. Endobronchial± Endobronchial± mucus plug/ tumor. hyper.inflation. compression± ascites. . Scarring-Scarring-. Extrinsic compression± mass/ effusion/ ascites.Atelectasis - Collapse/ incomplete expansion.

Right upper and lower lobe atelectasis .

Right middle lobe pneumonia .

high mortality rate.nosocomial (Pseudomonas. immunocompromised host(bacterial. patchy opacities. immunocavitation. Interstitial . mechanical vent.multifocal. cavitation.can become confluent and/or patchy as disease progresses. fungal.starts perihilar .entire lobe consolidated and air bronchograms common Lobular .Type of pneumonia Lobar . Pneumocystic Carinii Pneumonia) Pneumonia) . debilitated. patchy. no air bronchograms Aspiration pneumonia Diffuse pulmonary infections .

.Major differentiating factors between atelectasis and pneumonia Atelectasis Pneumonia Volume Loss Associated Ipsilateral Shift Linear. Wedge-Shaped WedgeApex at Hilum normal or increased volume no shift/ contralateral shift air space process not centered at hilum Air bronchograms can occur in both.

Dextrocardia .

Aortic Aneurysm .

Putting It Into Practice

Case 1

A single. This finding is most typical of squamous cell carcinoma (SCC). 3cm relatively thin-walled cavity is noted in the left thin- midlung. One-third of SCC masses show cavitation One- .

Case 2 .


Notice over inflation on unaffected lung .LUL Atelectasis: Loss of heart borders/silhouetting.

Case 3 .


Right Middle and Left Upper Lobe Pneumonia .

Case 4 .


Cavitation:cystic changes in the area of consolidation due to

the bacterial destruction of lung tissue. Notice air fluid level.


Case 5


Tuberculosis .

Case 6 .


In addition the upper lobes will become hyperlucent due to destruction of the lung tissue.COPD: increase in heart diameter. flattening of the diaphragm. . and increase in the size of the retrosternal air space.

Chronic emphysema effect on the lungs .

Case 7 .


however. . reveals a classic pleural effusion in the right pleura. Further analysis.Pseudotumor: fluid has filled the minor fissure creating a Pseudotumor: density that resembles a tumor (arrow). Note the right lateral gutter is blunted and the right diaphram is obscurred. obscurred. Recall that fluid and soft tissue are indistinguishable on plain film.

Case 8 .


Pneumonia:a large pneumonia consolidation in the right lower lobe. Knowledge of lobar and segmental anatomy is important in identifying the location of the infection .

Case 9 .


CHF:a great deal of accentuated interstitial markings. Curly lines. and an enlarged heart. . Normally indistinct upper lobe vessels are prominent but are also masked by interstitial edema.

24 hours after diuretic therapy .

Case 10 .


Chest wall lesion: arising off the chest wall and not the lung .

Case 11 .


Fluid drained via thoracentesis .Pleural effusion: Note loss of left hemidiaphragm.

Case 12 .


Lung Mass .

Case 13 .


Small Pneumothorax: LUL .

Case 15

Right Middle Lobe Pneumothorax: complete lobar collapse Pneumothorax:

Post chest tube insertion and re-expansion re- .

Case 16 .


Metastatic Lung Cancer: multiple nodules seen .

Case 17 .


Right upper lower lobe pulmonary nodule .

Case 18 .


Tuberculosis .

Case 19 .


Perihilar mass: Hodgkin¶s disease .

Case 20 .


Widened Mediastinum: Aortic Dissection .

Case 21 .


Pulmonary artery stenosis with cardiomegally likely secondary to stenosis. .

PA view: RML consolidation and loss of right heart silhouette Lateral View: RML wedge shaped consolidation RML pneumonia .

bordered by minor fissure inferiorly Patchy LLL infiltrate that obscures the left hemidiaphragm. right and left heart borders obscured RUL and LLL pneumonia .RUL infiltrate / consolidation.

Multiple bilateral cavitary lesions with air-fluid levels c/w pulmonary abscesses Tuberculosis .

RML consolidation that appears wedge shaped on lateral view RML pneumonia .

RLL infiltrate / consolidation RLL pneumonia .

Patient BIBA to ER s/p airplane crash. Widened mediastinum Concern for aortic injury .

Obscuring of the right and left heart borders. infiltrate at the bases Bilateral aspiration pneumonia .

Diffuse bilateral fluffy interstitial infiltrates Pneumocystis carinii pneumonia .

LUL pneumonia .

Left lung opacity Later diagnosed as lung cancer .

Cardiomegaly. increased pulmonary vascular markings. fluid in the horizontal fissure CHF .

Kerley B lines .

The End Thank you .