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BASICS OF CHEST X-RAY INTERPRETATION:

AN INTRODUCTION TO THE PRINCIPLES OF CHEST X-RAY


INTERPRETATION
By Barbara Ritter, EdD, FNP, CNS with assistance from Leslie Muma, RN, MSN, NP
SECTION 1: VIEWS OF THE CHEST
Standard Frontal Chest Radiora!h
Standard Lateral Chest Radiora!h
Portable Chest "#Ray
$ther %iews
P& obli'ue (iews
decubitus (iews
cross#table lateral
lordotic (iews
e)!iratory (iews
Buc*y films
tomora!hy
Densities
SECTION 2A: INTERPRETATION
S*eletal Structures
Soft +issues
mediastinum
Dia!hram
,eart and -reat %essels
Luns
SECTION 2B: ASSESSMENT
./ S*eletal Structures
../ Soft +issues
Basics of Chest X-ray Interpretation
.../ Dia!hram
.%/ ,eart and -reat %essels
SECTION 3: RADIOLOGIC SIGNS OF CARDIAC DISEASE
Pro0ections
+echnical Factors
E)tracardiac Structures
C,F
Chamber Enlarement
Enlarement of L&
Enlarement of L%
Enlarement of Riht Side
Myocardial Dysfunction
Myocardial .schemia
%al(ular Dysfunction
Poor E)ercise Ca!acity
&rrhythmias
SECTION 4: RADIOLOGIC SIGNS OF PULMONARY DISEASE
Structures
Pulmonary Nodules
&l(eolar Lun Disease
.nterstitial Lun Disease
1erley2s Lines
(iral !neumonia
dru#induced !neumonia
!ulmonary edema
DD" of .nterstitial Lun Disease
GLOSSARY
CHEST RADIOLOGY ARTICLES
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Basics of Chest X-ray Interpretation
Sec!"# O#e
VIEWS OF THE CHEST:
STANDARD FRONTAL CHEST RADIOGRAPH 4Roentenoram5 6 u!riht7 P& or
!osterior #anterior 4film in front of !atient, beam behind at a distance of si) feet7 !atient usually
u!riht7 distance of beam determines manification and clarity or shar!ness
Place the films on the (iew bo) as thouh you were facin the !atient with his left on
your riht side8
&n &P film, ta*en from the same distance 49:5 enlares the shadow of the heart which is
far anterior in the chest and ma*es the !osterior ribs a!!ear more hori;ontal8
.n a su!ine film, the dia!hram will be hiher and the lun (olumes less than in a
standin !atient8
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Basics of Chest X-ray Interpretation

STANDARD LATERAL CHEST RADIOGRAPH 6 left side of the chest aainst filmholder
4cassette57 beam from riht at a distance of si) feet7 lesion located behind the left side of the heart
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Basics of Chest X-ray Interpretation
or in the base of the lun are often in(isible on the P& (iew because the heart or dia!hram
shadow hides it7 the left lateral will enerally show such lesions7 the left lateral is thus the
customary lateral (iew as it is the best view to visualize lesions in the left thorax8 &lso, the heart
is less manified when it is closer to the film8
-ood for (iewin area behind heart 4retrosternal airs!ace 6 between the heart and
sternum58
Mar*ed with a >R> or >L> accordin to whether the riht or the left side of the !atient was
aainst the film 6 left lateral or riht lateral8
To visualize a lesion in the left thorax, it is better to get a left lateral view.
To visualize a lesion in the right thorax, it is better to get a right lateral view8
& fundamental rule of roentenora!hy 6 Try to get the lesion as close to the film as
possible8
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Basics of Chest X-ray Interpretation
PORTABLE CHEST X-RAYS 6 are &P (iews 4anterior#!osterior57 !referably u!riht but may
be su!ine, de!endin on !atient:s condition7 ta*en with beam at distance of <9 inches#blurrin
and manification
OTHER VIEWS:
Posteroanterior Oblique Views 6 !atient at =?@ anle to cassette and beam8
+he tracheal bifurcation is best seen in an obli'ue (iew8
.n bilateral in(ol(ement of the luns 4as by lym!homa in(ol(ement of the lower luns5,
an obli'ue (iew a(oids the su!erim!osition of a lateral (iew8
Sometimes used in studyin the heart or hila of the luns7 also in detailed study of the
ribs8
+he o!timum deree of obli'uity de!ends on the site of the lesion bein studied and the
information desired 6 it may ha(e to be determined by fluorosco!y8
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Basics of Chest X-ray Interpretation
Ahen we:re too tired to thin* of whether we need a riht or a left obli'ue we 0ust ta*e
both obli'ues8
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Basics of Chest X-ray Interpretation
Left Anterior Oblique 6 Left &nterolateral Chest Ne)t to Cassette
Right Anterior Oblique 6 Riht &nterolateral Chest Ne)t to Cassette
Decubitus Views 6 >decubitus> actually means >lyin down7> made with the !atient lyin on his
side and the )#ray beam hori;ontal 4!arallel5 to the floor8 Es!ecially ood to confirm air#fluid
le(els in the lun8
CrossTable Lateral !"orizontal# Views 6 made with !atient !rone or su!ine and the beam
hori;ontal to the floor8
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Basics of Chest X-ray Interpretation
Lor$otic Views 6 formerly made in the u!riht &P !osition with the !atient leanin bac*ward at
an anle of D <E@ from the (ertical which was (ery aw*ward7 now made with the !atient facin
the film as for an u!riht P& (iew but the tube is ele(ated and anled downward =?@8
Pro0ects the lun a!ices of the luns below the cla(icles and causes the ribs to !ro0ect
more hori;ontally8
Es!ecially ood for (iewin the a!ices of the luns, lesions that are !artially obscured by
ribs, or the riht middle lobe or linula of the left lun8
%x&irator' Views 6 on e)!iration the luns >cloud u!> and the heart a!!ears larer8
.f the air on one side cannot be readily e)!elled, the lun on the obstructed side remains
e)!anded and radiolucent on e)!iration8
Fseful in detectin unilateral obstructi(e em!hysema 4as from a unilateral obstruction of
a bronchus58
& !neumothora) always a!!ears larer on e)!iration than on ins!iration8
Since the thora) is smaller on e)!iration, the unchaned (olume of !leural air s!reads out
in the smaller thoracic s!ace8
$ccasionally a small !neumothora) is only (isible on e)!iration8
(uc)' *il+s 6 made with a mo(in rid between the !atient and the film which absorbs e)cess,
scattered radiation8
Scattered radiation !roduces a ha;y, unshar! imae, or fo, and detracts from film clarity8
Fsed to delineate a thic* !ulmonary or !leural lesion, bony structures, or to more clearly
see structures in an obese !atient8
Buc*y techni'ue also used whene(er the abdomen, s!ine, mediastinum, !el(is, or hea(y
lon bones are studied8
T"$"%&'()* +L'$!#'%&'()*,
&n a!!aratus mo(es the tube and film synchronously in o!!osite directions7 the
ad0ustable fulcrum is set to the !lane of the lesion to be studied7 blurs structures in the
!lanes abo(e and below the le(el bein studied8
Es!ecially hel!ful in e(aluatin !ulmonary nodules, demonstratin ca(ities, and de!ictin
bronchial obstruction8
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Basics of Chest X-ray Interpretation
.f you can:t thin* of the e)act name for a (iew, be descri!ti(e or draw a !icture 4i8e8, >-et
me a cross#table (iew with the !atient lyin on his riht side facin the tube8>5 or consult
with the radioloist8
+here are all sorts of inenious !ro0ections and fascinatin s!ecial !rocedures in the
armamentarium of the radioloist8
DENSITIES &ir H fat H li(er H blood H muscle H bone H barium H lead8
A!& 6 least dense7 most trans!arent or radiolucent7 unobstructed beam or air#filled
densities a!!ear blac*
Luns, astric bubble, trachea, I bifurcation of bronchi
F' 6 breasts
F-.!/ 6 most of what you see7 (essels, heart, dia!hram, soft tissues, mediastinal
structures
M!#e&'- 6 most dense 4or radio!a'ue5 of body structures7 mostly CaJJ7 bones 4marrow
is aerated5, aortic calcifications such as the aortic *nob, I calcification of the coronary
arteries, old ranulomas7 bullets, safety !ins, etc8
Structures which are !er!endicular to the !lane of the film a!!ear as they were much
more dense as the shadows re!resent the sum of the densities inter!osed between the
beam source and the film8 Learn to thin* in terms of those !arts that are relativel' &arallel
to the fil+ and those that are roughl' &er&en$icular to it. Thin) about it three
$i+ensionall'8
Thic)ness as well as co+&osition determine radiodensity8 +he shadow cast by a thic* mass
of soft tissues will a!!roach that of bone8
Sec!"# T0"
A1 PROCEDURE FOR INTERPRETATION OF CHEST FILMS
De2e-"( ' 3*3e$'!c '((&"'c) '#/ .3e ! c"#3!3e#-*1
4Fsually e)ternal#internal85
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Basics of Chest X-ray Interpretation
I1 LABEL 6 Read the label on e(ery film to (erify the !atient:s name, ae, and se)8
II1 ORIENTATION 6 .dentify the !atient:s riht side, his !osition, and determine if he is
rotated8
Symmetrical s!acin of the cla(icles and other structures on either side of the sternum7
cla(icles es!8 will show whether or not !atient is straiht or rotated8 Symmetry of the cla(icles
and ribs i(es you assurance that no rotation is !resent8 E(en sliht rotation is undesirable in a
chest film as the heart and mediastinum are then radiora!hy obli'uely and their shadows a!!ear
enlared and distorted8
III1 4UALITY 6 .n a film of ood technical 'uality in a !atient without ross cardiomealy,
you should be able to see the outlines of the (ertebral bodies within the heart shadow7 notice
linearity of s!ine 6 is it straihtI
IV1 INTERPRETATION/ the followin should be identified/
A1 S5ELETAL STRUCTURES 6 what you see of the bones is incidental as the techni'ue
used for chest films has been desined for study of the luns8 &lways com!are for symmetry8
11 Sc'(.-'e 6 P& and lateral7 are there two of eachI
Aith hands on hi!s, !alms out, and elbows forward the sca!ulae are rotated to the sides to
!re(ent their su!erim!osition u!on the u!!er lun fields8 +herefore only their medial marins are
seen8
21 H.$e&! '#/ S)".-/e& 6"!#3 6 P& and lateral8
Little of the shoulder irdle and humerus will be seen in films of broad#chested
indi(iduals8
Coracoid is seen throuh the s!ine of the sca!ula because they su!erim!ose8
,ead of humerus and the acromium are also seen additi(ely8
&re fractures or abnormal calcifications 4dense white shadows5 seenI
31 C-'2!c-e3 6 P&7 symmetrical s!acin on either side of sternum only if there is no rotation of
the chest8 +urned e(en a few derees, the cla(icles will e)hibit a remar*able deree of
asymmetry8
41 R!73 6 count on every film to le(el of dia!hram8
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Basics of Chest X-ray Interpretation
.dentify the first rib carefully by findin its anterior 0unction with the manubrium and
followin this rib bac*ward to the s!ine8 +hen count down the !osterior ribs8
Bein at the oriin of the first rib at its 0unction with the first thoracic (ertebra and trace
each rib as far anteriorly as you can to the beinnin of the radiolucent 4and hence
in(isible5 costal cartilae8
.nters!aces are useful in identifyin the location of a !recise shadow and are named for
the !osterior rib abo(e the inters!ace unless the anterior rib is s!ecified as the mar*er8
Number of ribs hel!s you determine how much luns are inflated L G or more ribs M
ood inflation8
+rans(erse cardiac shadow smallest 6 used for measurement8
Luns better filled with air7 therefore relati(ely minor disease is seen better8
KE or more ribs M I hy!erinflated
E)!iratory film 6 see H G ribs8
Dia!hram hiher7 lun bases less well seen7 trans(erse diameter of heart is larer8
Minimal !neumothora) can be seen better8 &lso, obstructi(e em!hysema8
Com!are both sides for symmetry,
Note width of the intercostal s!aces8 &re they e'ualI
&re they continuous or is there a fractureI
Beam only >sees> what is !arallel to it7 anterior ribs are more !er!endicular and thus not
seen (ery well8
81 S(!#e 6 notice linearity 6 is it straihtI
S!ine and sternum are su!erim!osed u!on each other and u!on the dense shadows of the
mediastinal structures in the P& (iew8
Scoliosis may mas* marin of R&7 don:t mista*e for R& with mediastinal shift8
B1 SOFT TISSUES 6 Symmetry of Density8
11 C)e3 0'-- 4outside of lun fields58
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Basics of Chest X-ray Interpretation
21 Nec98
31 Me/!'3!#.$1
MEDIASTINAL STRUCTURES
.dentify trachea 6 is it midline, not shiftedI
.dentify bifurcation and !osition8
Should not be able to follow airways any further out as they are (ery thin walled7 if (isible
4air bronchoram sin5 # II !ulmonary edema8
41 B&e'33 6 symmetrical in si;e, sha!e, !osition7 ni!!les may !ossibly be (isible8
Be sure to chec* whether there are two breasts8
+he lun field under a missin breast will a!!ear a little dar*er than the other lun field8
C1 DIAPHRAGM
11 D!::e&e#ce !# )e Le2e- ": )e He$!/!'()&'%$3
Riht hemidia!hram is normally a bit hiher8
.m!aired mobility of dia!hram 6 may be from !aralysis of either !hrenic ner(e,
disease in abdomen such as a subdia!hramatic abscess, !leurisy, !ulmonary
infarction, etc8
21 N"&$'- P"3!!"#
Distance from astric bubble 4if it is (isible5 to dia!hram should be (ery small8
31 S)'(e ": )e D!'()&'%$1
41 I/e#!:!c'!"# ": Le: '#/ R!%) D!'()&'%$3 6 lateral film8
81 C"3"()&e#!c A#%-e3
Should be shar! and clear8
No fluid density should be (isible8
;1 C'&/!"()&e#!c '#%-e 3)".-/ 7e :'!&-* c-e'&1
<1 I#:e&!"& 2e#' c'2' '//3 !3 "0# -!-e 3)'/"01
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Basics of Chest X-ray Interpretation
D1 He'& '#/ G&e' Ve33e-3
S!=e ": He'& 6 measure at widest !oint7 com!are to si;e of thora)7 should be no more than KN3
the width of the thora)8 Fsin any handy !iece of !a!er, determine the width of the heart8 +hen
decide whether this width e)ceeds the distance from the mid!oint 4s!ine5 to the inside of the rib
cae 4half the transthoracic diameter58 Still more sim!ly, you can measure from the midline to the
riht heart border and see whether that distance will fit into the !iece of lun field to the left side
of the heart8
&ssessment of the cardio(ascular anatomy includes assessment of heart and chamber si;e as well
as the !osition and si;e of the reat (essels8
K M riht brachioce!halic (essels
3 M ascendin aorta and su!erim!osed S%C
< M riht atrium 4R&5
= M inferior (ena ca(a 4.%C5
? M left brachioce!halic (essels
9 M aortic *nobNarch
B M !ulmonary trun*
C M left atrial a!!endae 4L&5
G M left (entricle 4L%5
N"e: Normally conca(e slo!e between arcs 9 and G is often called the >cardiac waistline8>

K=
Basics of Chest X-ray Interpretation
VISIBLE STRUCTURES:
K8 Left &trial Border 6 P& and lateral (iews8
38 Left %entricular Border 6 P& and lateral8
<8 Riht %entricular Border 6 P& and lateral 6 anterior structures and border is not
normally (isuali;ed8
=8 .nferior %ena Ca(a8
?8 Riht &trial Border 6 P&8
K8 Scoliosis, if !resent, may mas* border of the riht atrium8
98 Su!erior %ena Ca(a 6 P&8
B8 &scendin &orta 6 P& and lateral8
C8 &ortic 1nob 6 !osition, calcification8
G8 Main Pulmonary &rtery 6 lateral8
KE8 Relati(e !osition of left and riht main branches of !ulmonary arteries 6 in relation
to left and riht main bronchi8
KK8 Eso!haus 6 P& and lateral8
K38 Note cardiac si;e 6 normal is KN3 or less of the thoracic width on a P& film8
E1 L.#%3
VISIBLE STRUCTURES:
K8 +rachea and carina 6 P& and lateral8
38 Ma0or bronchi 6 P& and lateral8
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Basics of Chest X-ray Interpretation
<8 Pleura8
=8 Left 6 u!!er and lower lobe re!resentation 6 P& and lateral8
Minor fissure on left 6 between ribs 9 and C8 $nly one fissure8
Linula 4tonue#sha!ed5 6 area ad0acent to L%7 not a se!arate lobe8
?8 Riht 6 u!!er, middle, and lower lobe re!resentation 6 P& and lateral8
$bli'ue or ma0or fissure 6 +< # +KE8
98 Differences in density, u!!er and lower lun fields8
.n a P& film the !eri!heral (asculature is normally seen out to the lateral one inch of
the films and is more clearly delineated in the lower lobes than the a!ices8
F!riht 6 most of !erfusion oes to lower luns so you should see it all the way out8
O P&P#re(ersal of blood flow with enhancement of a!ical (ascularity8
$lder smo*er and (asculature not (isible all the way out M I em!hysema8
Pouner !erson and not (isible all the way out M I !neumothora)8
P#e.$")"&'> ? '7". )e "#-* )!#% )' c'# 7e /!'%#"3e/ 0!) '73"-.e
ce&'!#* 0!) CXR8
B8 Peri!heral (asculature 6 follow it out as far as you can see it8
,ilum 4!l8 M hila58
Position 6 hiher or lower8
Symmetry
o Lun fields 6 symmetry re/ amount of density8
@1 S!-)".ee S!%#
+wo densities that are ali*e with marins ad0acent to each other 6 borders will be
mas*ed8
.f marin is obliterated, whate(er is mas*ed and it has to be in the same !lane8
Mas*in of R& 6 would be from R middle lobe8
Mas*in of !osterior dia!hram 6 would be from R lower lobe8
Mas*in of L% 6 would be from L u!!er lobe 4anterior58
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Basics of Chest X-ray Interpretation
Mas*in of descendin aorta 6 would be from L lower lobe8
Mas*in of .%C and S%C 6 would be from R lower and middle lobes8
.f you can see heart 6 comes from !osterior8
G8 A!& B&"#c)"%&'$ S!%# 6 >butterfly> distribution of the abnormal densities or an
anatomic distribution of abnormal densities restricted to lobar or sublobar !ortions of the
lun8
+em!orally ra!id 4rec*oned in days5 chanes in the a!!earance of the lun infiltrate8
.ndicati(e of al(eolar disease8
See airways out !ast bifurcation8
&ir#filled airway su!erim!osed on air#filled densities8
Demonstration of the air#filled bronchus as a radiolucent >tube> is de!endent on its
close association with al(eoli that are fluid#filled rather than air#filled8
+wo contrastin densities ma*e it (isible8
&irways $1, surround tissues not $18
KE8 5e&-e*A3 L!#e3
1erley:s B Lines 6 short, thin hori;ontal lines at the !eri!hery of the lun near the
costo!hrenic anles7 formed by thic*enin of the interlobular se!ta 3@ to fibrosis 4e88,
!neumoconiosis5, fluid accumulation, or distended lym!hatics#(enules 1erley:s & Lines
6 lon, linear densities, more centrally located in the u!!er !ortions of the luns near the
hila7 may be seen in interstitial lun disease and C,F7 re!resent swollen lym!hatic
channels8
F1 I'&"%e#!c3
K8 EC- leads
38 Endotracheal tube 6 !ositionin
<8 C%P and P& lines
B: ASSESSMENT OF CHEST FILMS
I1 S9e-e'- S&.c.&e3
KB
Basics of Chest X-ray Interpretation
&8 Sca!ulae
B8 ,umeri
C8 Cla(icles 6 symmetrical s!acin on either side of sternum
D8 Ribs
II1 S": T!33.e3 6 symmetry of density8
&8 Chest wall
B8 Nec*
C8 Mediastinum
+rachea 6 is it midline, not shifted8
.dentify bifurcation and !osition8
Should not be able to follow airways any further out as they are (ery thin walled7 if
(isible 4air bronchoram sin5 # II !ulmonary edema8
D8 Breasts 6 symmetrical in si;e, sha!e, !osition7 ni!!les may I be (isible8
III1 D!'()&'%$
&8 Difference in the le(el of the hemidia!hrams8
B8 Normal !osition8
C8 Sha!e of the dia!hram8
D8 .dentification of left and riht dia!hrams 6 lateral8
E8 Costo!hrenic anles8
IV1 He'& '#/ G&e' Ve33e-3 6 &ssessment of the cardio(ascular anatomy includes assessment
of heart and chamber si;e as well as the !osition and si;e of the reat (essels8
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Basics of Chest X-ray Interpretation
&8 Left atrial border 6 P& and lateral8
B8 Left (entricular border 6 P& and lateral8
C8 Riht (entricular border 6 P& and lateral 6 anterior structures and border is not
normally (isuali;ed8
D8 .nferior (ena ca(a8
E8 Riht atrial border 6 P&8
Scoliosis, if !resent, may mas* border of R&8
F8 Su!erior (ena ca(a 6 P&8
-8 &scendin aorta 6 P& and lateral8
,8 &ortic *nob 6 !osition, calcification8
,y!ertension can cause a flat, almost absent aortic arch8

.8 Main !ulmonary artery 6 lateral8
KG
Basics of Chest X-ray Interpretation
Q8 Relati(e !osition of L and R main branches of !ulmonary arteries 6 in relation to L R
R main bronchi
18 Eso!haus 6 P& and lateral
3E
Basics of Chest X-ray Interpretation
L8 C'&/!'c S!=e 6 normal is KN3 or less of the thoracic width on a P& film8
Simulation of cardiac enlarement 6 P& films made in e)!iration 4hih
dia!hram#heart tilted u!ward brinin a!e) closer to the lateral chest wall J less
flare of ribs which alters the a!!arent cardiothoracic ratio57 also any abdominal
distention 4late !renancy, ascites, intestinal obstruction5 !roduces similar results7
dia!hram also li*ely to be hiher in su!ine (iews7 !ortable chest films and other
&P (iews !lace heart farther away from the film8
Rotation of the !atient !roduces a!!earance of widenin of the heart and
mediastinal shadows8
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Basics of Chest X-ray Interpretation
Deformity of the thoracic cae 6 se(ere scoliosis7 de!ressed sternum 4!ectus
e)ca(atum5 usually dis!laces heart to the left J riht heart border not (isible8
Difference between heart (olumes in systole and diastole usually not enouh to
affect rouh estimate of the cardiothoracic ratio in adults8
Simulation of dece!ti(ely small heart 6 o(erdistention of the luns for any reason
4dys!neic !atient with low dia!hram or em!hysematous !atient5 com!resses the
heart and mediastinal structures from both sides and narrows their P& shadow8
Mediastinal disease, !ulmonary disease, or any density 4consolidation, effusions,
true mediastinal shift5 may render the dimensions of the heart unobtainable8
Sec!"# 3
RADIOLOGIC SIGNS OF CARDIAC DISEASE:
PRO6ECTIONS
P"3e&"'#e&!"& P&"Bec!"#
+he u!!er riht border is formed by the S%C and the lower cardiac border is formed by the R&8
+he left border has three well#defined sements/ +he u!!ermost is formed by the aortic arch, the
main !ulmonary artery lies immediately below the aortic *nob, and the lower left cardiac border
is formed by the L% and the a!e)8 +he L& a!!endae lies between the !ulmonary artery sement
and the L% and is usually not seen as a se!arate bule8
L'e&'- P&"Bec!"#
R% is the most anterior cardiac chamber and is in direct contact with the lower sternum8
+here should be a clear s!ace 4lun tissue5 between the sternum, the R% outflow tract, and the
root of the !ulmonary artery, but !ectus e)ca(atum as well as R% enlarement can im!ine
on this s!ace8
+he !osterior cardiac border is made u! of the L& abo(e and the L% below8
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Basics of Chest X-ray Interpretation
K M riht brachioce!halic (essels
3 M ascendin aorta and su!erim!osed S%C
< M riht atrium 4R&5
= M inferior (ena ca(a 4.%C5
? M left brachioce!halic (essels
9 M aortic arch
B M !ulmonary trun*
C M left atrial a!!endae 4L&5
G M left (entricle 4L%5
Tec)#!c'- F'c"&3
+he heart a!!ears larer on &P than P& (iews8
Film durin e)!iration 6 simulates !ulmonary edema and the heart a!!ears larer8
$ne should chec* side mar*ers for de)trocardia8
$ne should chec* the cla(icles for anulation8
$(er!enetrated films may miss heart failure8
E>&'c'&/!'c S&.c.&e3
Rib notchin indicates coarctation of the aorta8 Rib notchin M saucered erosions of the
undersurface of the ribs where dilated intercostal arteries ha(e de(elo!ed as collateral
3<
Basics of Chest X-ray Interpretation
!athways8 Seldom !resent in children youner than KE8 $ther conditions such as
neurofibromatosis can also cause rib notchin8
Pectus e)ca(atum simulates cardiac enlarement by dis!lacin heart to the left8 Lateral
(iew shows de!ression of the sternum at the le(el of the heart8 S &P dimension of the
chest at heart le(el and the heart is dis!laced !osteriorly 4!osterior marin behind the
inferior (ena ca(a58
Straiht bac* is aNw mitral (al(e !rola!se and aortic insufficiency8
Riht#sided !leural effusion occurs with C,F8
P)*3!"-"%!c A#'-*3!3 ": )e P.-$"#'&* V'3c.-'.&e 6 a!!earance of the hilar and !ulmonary
(essels is an e)cellent indicator of the !hysioloic state of the heart8
Congestive Heart Failure
O si;e, sha!elessness of heart, J e(idence of !ulmonary (enous enorement 6 the
(essels are seen to e)tend farther than normal into the lun field8
Bronchi become >framed> in the interstitial fluid accumulatin around them and, when
seen end#on, a!!ear as white rins8 +his is often called >!eribronchial cuffin> and can be
obser(ed to decrease as the !atient im!ro(es8
Pleural effusion in cardiac failure may be bilateral or unilateral and is more fre'uent on
the riht8
Luns a!!ear ha;y and less radiolucent than normal because of retained water7 lattice
!attern8
1erley:s B lines a!!ear 6 short, hori;ontal white linear densities (ery close to the
!eri!heral marin of the lun7 ha(e been !ro(en to re!resent the thic*ened, edematous
interlobular se!ta7 also seen in lym!hanitic s!read of malinancies within the lun
!arenchyma and interstitial !ulmonary disease8
Ra!id accumulation of fluid s!ills o(er into the al(eoli and causes the de(elo!ment of
al(eolar 4air#s!ace5 (.-$"#'&* e/e$'8
P.-$"#'&* e/e$' -- the so#called >bat#win> a!!earance about both hila7 su!erim!osed
shadows of innumerable fluid#filled al(eoli may cause disa!!earance of the (essels of the hilum7
interstitial !ulmonary edema#blurrin of !ulmonary (asculature7 !erihilar ha;e7 may a!!ear
3=
Basics of Chest X-ray Interpretation
ra!idly after sudden L% failure or it may be su!erim!osed on the more radual C"R findins of
C,F8
Pulmonary edema can also occur in noncardiac conditions such as fluid o(erload, renal failure,
heroin o(erdose, and inhalation in0ury or burns8
C"R findins can la behind hemodynamic Ds but the followin !atterns can !redict !ulmonary
artery wede !ressure/
-rade E/ normal 6 P&AP H K3 mm ,8
-rade K/ !ulmonary (enous ,+N, !ulmonary (ascular redistribution to the a!ices 4(enous
mar*ins Tinto the u!!er lobes5, and loss of the riht hilar anle 6 P&AP K3#KG mm
,8
-rade 3/ interstitial edema 41erley:s B lines5, hilar ha;e or blurriness, !eribronchial
(ascular thic*enin 6 P&AP 3E#3? mm ,8
-rade </ enerali;ed or !erihilar al(eolar edema 6 P&AP U 3? mm ,8
D!3!#%.!3)!#% Be0ee# C'&/!'c H*(e&&"()*C D!-''!"#C '#/ Pe&!c'&/!'-
E::.3!"#:
Plain films may show (entricular enlarement but do not differentiate between
hy!ertro!hy and dilatation8
.f heart is decom!ensatin, it will tend to sha!elessness and e)tend to both the R and L in
the P&(iew, suestin either failure or !ericardial effusion8 & re(iew of the !atient:s old
films is !robably the best way to assess de(elo!ment of cardiac enlarement, in and out of
failure8
Sudden sha!eless Oin si;e should suest !ericardial effusion8
CHAMBER ENLARGEMENT
+he echocardioram is much more s!ecific for identifyin structural abnormalities and
chamber enlarement8 +he echocardioram also is (ery im!ortant for distinuishin
hy!ertro!hy from dilation and reconi;in !ericardial effusions8
3?
Basics of Chest X-ray Interpretation
AP V!e0 L'e&'- V!e0
&o Dil M &ortic Dilatation
&sc &o M &scendin &orta
L&E M Left &trial Enlarement
L%E M Left %entricular Enlarement
P& Dil M Pulmonary &rtery Dilatation
P& ,+N#Dil M Pulmonary &rtery Bulin due to
Pulmonary ,y!ertension
R%E M Riht %entricular Enlarement
E#-'&%e$e# ": )e Le: A&!.$
39
Basics of Chest X-ray Interpretation
C"R studies are most accurate in detectin enlarement of the L& com!ared to the other
< chambers8
L& M most !osterior of the cardiac chambers and lies in the midline below the carina of
the trachea and the mainstem bronchus8
L& has 3 distinct com!onents 6 a body and an a!!endae8
+he body of the L& is centrally !laced and does not form a border on the frontal (iew8
+he L& atrial a!!endae is to the left of the body, immediately beneath the !ulmonary
artery sement, and abo(e the L%8
+he most common findins are a double density of the riht cardiac shadow, bulin the
atrial a!!endae alon the middle of the left cardiac border on the frontal (iew, and a
!osterior bule of the u!!er cardiac border on the lateral (iew8
L& enlarement may e(entually e)tend it to the riht so that its marin is (isible alon the
riht heart border, abo(e the !rofile of the R& and o(erla!!in it 6 the >double shadow>
fre'uently referred to as a classic sin of L& enlarement8
Straihtenin of the L heart border may be a normal findin7 does not always sinify
increased L& si;e8
Fillin in of the normally conca(e waistline may be due to fullness that is either !osterior 4as in
L& dilatation5 or anterior 4as in any condition such as !oststenotic dilatation in !ulmonic stenosis,
or dilatation due to PD&58
3B
Basics of Chest X-ray Interpretation
L& enlarement in mitral disease cardiac enlarement 6 ele(ation of the L main
bronchus 0ust abo(e the L Cth rib, double shadow alon the R heart border, I straihtenin
of L heart border 4I due to sliht fullness of main !ulmonary artery58
E#-'&%e$e# ": )e Le: Ve#&!c-e
L% forms the a!e) of the heart on the frontal (iew8
Aith dilation, the cardiac a!e) is dis!laced downward toward the dia!hram and to the
left7 shadow of aortic arch may be flattened8
Aith hy!ertro!hy, the a!e) becomes rounded8
L% enlarement often aNw aortic stenosis and chronic ,+N both of which may cause
enlarement of the aorta8
Lateral film 6 rounded !osterior !ro0ection of L%7 border of heart is e)tended !osteriorly
and low aainst the dia!hram8
E#-'&%e$e# ": )e R!%) S!/e 6 more difficult to reconi;e8
R& forms the riht lateral cardiac border8 +he R% is normally an anterior midline chamber
located directly behind the sternum8
R& enlarement fills in the s!ace behind the sternum8
3C
Basics of Chest X-ray Interpretation
R% enlarement 6 enlares in cor !ulmonale and in !ulmonic stenosis7 C"R 4P&5 may
be dece!ti(ely normal or show dis!lacement of normal L% to the left8
Pulmonary artery often enlared concomitantly8
May also see L% and L& enlarement if Lateral film 6 fillin in of the lower !art of the anterior
clear s!ace J flat !osterior surface of the heart8 ,eart is not e)tended !osteriorly8
C)e3 X-R'* F!#/!#%3 0!) M*"c'&/!'- D*3:.#c!"#
& lare heart on C"R films su!!orts the d)8 of systolic myocardial dysfunction8
& lateral (iew is often hel!ful to chec* for riht#sided failure8 .f the s!ace behind the
sternum is filled in, riht#sided heart failure and R% dilation are !ossible8
Echocardiora!hy is most useful for identifyin enlarement of a s!ecific chamber and
se!aratin dilation from hy!ertro!hy8
O (ascular mar*ins in the u!!er lobes are 3@ to increased fillin !ressure of D K<#KC mm
,8
.nterstitial edema 41erley:s B lines5 suests a L% end#diastolic !ressure of KG#3? mm
,8
&l(eolar infiltrates 4!ulmonary edema5 are consistent with a L%EDP U 3? mm ,8
Bluntin of the marins is due to effusion8
C"R can hel! rule in or out other causes of dys!nea such as !ulmonary fibrosis or C$PD8
3G
Basics of Chest X-ray Interpretation
C)e3 X-R'* F!#/!#%3 0!) M*"c'&/!'- I3c)e$!'
S!ecial )#ray imain 4fluorosco!y or C+5 can demonstrate coronary artery calcification,
but this is an uncertain mar*er8 .t has not had the test characteristics that were oriinally
antici!ated because calcification of the arterial walls is not necessarily aNw luminal
occlusion, !articularly in older indi(iduals8
C)e3 X-R'* F!#/!#%3 0!) V'-2.-'& D*3:.#c!"#
Sins of C,F and chamber enlarement can be detected usin chest )#ray studies8
%al(ular calcification can sometimes be seen8
C)e3 X-R'* F!#/!#%3 0!) P""& E>e&c!3e C'('c!*
Sins of !ulmonary disease can suest a noncardiac limitation to e)ercise and a lare
heart could suest cardiac disease8
Sins of C,F can offer the !ossibility of a cardiac cause for a chane in e)ercise ca!acity8
C)e3 X-R'* F!#/!#%3 0!) A&&)*)$!'3
Films are of little use in the dianosis of arrhythmias8 ,owe(er, findin !roblems that are
often aNw arrhythmias, such as cardiac enlarement and lun disease, should alter one to
the !ossibility of arrhythmias8
+he straiht bac* syndrome or !ectus e)ca(atum was thouht to be aNw with mitral (al(e
!rola!se and arrhythmias8
<E
Basics of Chest X-ray Interpretation
Sec!"# 4
RADIOLOGIC SIGNS OF PULMONARY DISEASE:
STRUCTURES
K8 +rachea and carina 6 P& and lateral
38 Ma0or bronchi 6 P& and lateral
<8 Pleura
=8 Left 6 u!!er and lower lobe re!resentation 6 P& and lateral
?8 Riht 6 u!!er, middle, and lower lobe re!resentation 6 P& and lateral
98 Differences in density, u!!er and lower lun fields 6 reason
B8 Peri!heral (asculature 6 in a P& film the !eri!heral (asculature is normally seen out to
the lateral one inch of the films and is more clearly delineated in the lower lobes than the
a!ices
C8 Silhouette sin
G8 &ir bronchoram sin
<K
Basics of Chest X-ray Interpretation
1D1 S"-!'&* P.-$"#'&* N"/.-e3
Aell#circumscribed, a!!ro)imately round lesion that is H =#9 cm8 in diameter on
C"R8
By definition, it is com!letely surrounded by aerated lun8
&1& a >coin lesion8>
Pulmonary masses are U =#9 cm8 in diameter8
Calcification of the lesion, absence of a history of tobacco use, and ae H <? years are
im!ortant factors that stronly correlate with benin nodules8
Noncalcified lesions can be benin or malinant8
E(en benin calcification does not e)clude the !resence of coincidental malinancy in
ad0acent tissue or the subse'uent deeneration of a !re(iously benin !rocess into a
malinant lesion8
Close obser(ation with serial C"Rs e(ery 9 mo8 for at least 3 years is !rudent8
Ca(itatin lesions, lesions with multilobulated or s!iculated contours, and lesions with
shay or e)tremely irreular borders tend to be malinant8
Benin nodules tend to row at either (ery slow or (ery ra!id rates8
.n contrast, malinant !rocesses row at steady, !redictable, e)!onential rates8
+he rowth of a nodule is con(entionally defined as the doublin time 4time re'uired
for its (olume to double5 and corres!onds to an increase in diameter by a factor of
K8398
.n eneral, doublin times U K9 months or H K month are associated with benin
!rocesses8
.f a nodule has not increased in si;e o(er a 3#year !eriod, the !robability that it is
benin is U GGV8

SIX COMMON PATTERNS OF CALCIFICATION IN SOLITARY PULMONARY
NODULES
<3
Basics of Chest X-ray Interpretation
&da!ted from/ Aebb, A8 R8 4KGGE58 Radioloic e(aluation of the solitary !ulmonary nodule8
A+erican ,ournal of Ra$iolog', 184, BEK#BEC8
From left to riht/ diffuse, central, !o!corn, laminar, sti!!led, eccentric8
+he first four are almost always benin7 the latter two may be benin or malinant8
RADIOLOGIC SIGNS OF ALVEOLAR LUNG DISEASE
H*(e&3e#3!!2!* P#e.$"#!!3 +E>&!#3!c A--e&%!c A-2e"-!!3,
Perihilar ha;iness and !eri!heral al(eolar infiltrates8
Chronic disease 6 abnormalities indistinuishable from fibrosin al(eolitis are
commonly found 6 reticulonodular !arenchymal infiltrates, dense fibrotic areas, and
decreased lun (olumes8
,ilar adeno!athy is not found8
S!%#3ES*$("$3 ": Ac.e E>("3.&e 6 fe(er, chills, anore)ia, shortness of breath, dry couh7
tachy!nea, !yre)ia, tachycardia, dry basilar ins!iratory rales without rhonchi7 occasionally,
cyanosis or restlessness indicatin hy!o)emia8
S!%#3ES*$("$3 ": C)&"#!c E>("3.&e 6 shortness of breath, mild fe(er, weiht loss, fatiue,
malaise, dry couh, dys!nea on e)ertion, tachy!nea7 abo(e sins J I cor !ulmonale 4nec* (ein
distention, he!ato0uular refle), he!atomealy, an*le edema, ascites, loud P3, increased R%
acti(ity with a !arasternal lift and !arasternal S= allo!58
RADIOLOGIC SIGNS OF INTERSTITIAL LUNG DISEASE
Re!c.-'& 6 lun !arenchyma re!laced by many thin#walled cysts 4lesions less than KE mm
in diameter5, hence the term >honeycomb> lun, these microcysts may be barely !erce!tible,
round or o(al, i(in the lun the radioloic a!!earance of a fine networ*8
Seen in disseminated interstitial diseases such as eosino!hilic ranuloma of the lun,
scleroderma, !neumoconiosis 4diseases caused by inhalation of oranic or inoranic matter5,
idio!athic !ulmonary fibrosis, sarcoidosis, and other, less common disorders8
<<
Basics of Chest X-ray Interpretation
M!-!'&*C N"/.-'& 6 numerous discrete, tiny 4H ? mm5, uniform densities7 e(enly distributed
throuhout the luns7 'uite uniform in si;e8
Seen in miliary tuberculosis, other funal diseases 4histo!lasmosis5, !neumoconiosis,
histiocytosis " 4early stae5, !ulmonary hemosiderosis 4late stae5 and !rimary amyloidosis8
Re!c.-"#"/.-'& 6 mi)ture of the two !re(iously described !atterns8
May !redominate in one or another !ortion of the lun in the diseases described8
5e&-e*A3 L!#e3 6 most commonly encountered in C,F and interstitial !ulmonary edema7
may be 'uite transient in these conditions8
May re!resent a constant, irre(ersible findin in other interstitial disease, es!8 !neumoconiosis,
lym!hatic s!read of neo!lasm, lym!hatic mitral (al(e disease, and C$PD8
5e&-e* B L!#e3 6 usually H 3 cm in lenth and about K mm in thic*ness8
Not confined to the marins of the lun8
&ttributed to increased tissue andNor fluid accumulation in interlobular se!ta7 also referred to
as se!tal lines8
5e&-e* A L!#e3 6 usually D = cm in lenth, relati(ely straiht, linear densities8
+end to be oriented !er!endicular to the nearest !leural surface8
&ttributed to increased tissue andNor fluid accumulation in communicatin lym!hatics
between (eins and bronchi8
E>'%%e&'e/ B&"#c)"2'3c.-'& M'&9!#%3 6 ill#re!uted sin7 lac*s s!ecificity in terms of
!atholoic correlation8
May refer to a lac* of cris!ness of the marins of structures initially i(in rise to the linear
densities within aerated lun8 Caused by e)cessi(e tissue or fluid dis!lacin air#filled lun from
the interstitial structures8
o .nability to detect radioloic sins of al(eolar consolidation on abnormal C"Rs such
as the air bronchoram sin8
o Ma0ority of interstitial diseases are chronic8 Princi!al e)ce!tions are (iral !neumonia,
dru#induced !neumonia, and !ulmonary edema8
<=
Basics of Chest X-ray Interpretation
V!&'- P#e.$"#!'
Patchy al(eolar consolidation usually7 rarely a !redominance of interstitial abnormalities8
D&.%-I#/.ce/ P#e.$"#!'
o Nitrofurantoin#.nduced Pneumonia
o .nterstitial lun chanes, !rinci!ally a basal reticular infiltrate8
o Presents acutely with chills, fe(er, 'uite se(ere dys!nea, and non!roducti(e couh
within hours or days of the initiation of nitrofurantoin thera!y8
o Li*ely to ha(e moderate !eri!heral eosino!hilia8
<?
Basics of Chest X-ray Interpretation
P.-$"#'&* E/e$'
o Mi)ed al(eolar and interstitial edema8
o &!ical redistribution of blood flow 6 results in increased si;e of u!!er lun
(asculature and bac*round (eilin of the !ulmonary !arenchyma initially8
o Sub!leural edema, !eribronchial cuffin, bronchiolar cuffin, hilar ha;iness, ha;iness
of (essel detail, reticular !attern, and basilar se!tal lines8
o 1erley B lines are !resent at the !eri!hery of the lun bases and may be 'uite
!rominent 6 re!resent thic*ened interlobular se!ta8
o Fsually, enlarement of the heart 4if cardioenic in oriin5 and redistribution of the
!ulmonary (asculature 4a!!ears es!8 enored in the u!!er lun ;ones58
I/!"(')!c P.-$"#'&* F!7&"3!3 4,amman#Rich disease5Reticular !attern 4honeycombin58
Most common >etioloy> of disseminated !ulmonary fibrosis8
D!::e&e#!'- D!'%#"3!3 ": I#e&3!!'- L.#% D!3e'3e
P#e.$"c"#!"3!3 P&!$'&* L.#% D!3e'3e3
Silicosis
Sarcoidosis
&sbestosis
,istiocytosis "
Coal Aor*er:s !neumoconiosis
Lym!haniomyomatosis
Berylliosis
Lym!hanitic carcinomatosis
$ranic dusts 4!ieons, tur*ey, duc*, chic*en, humidifier5 Li!oidosis
Em!hysema
D&.%3
Cystic fibrosis
Chemothera!eutic aents 4busulfan, bleomycin, methotre)ate5
&ntibiotics 4nitrofurantoin, sulfonamides, .N,5
<9
Basics of Chest X-ray Interpretation
A-2e"-'& F!--!#% D!3e'3e
Diffuse al(eolar bleedin 4-ood!asture:s &miodarone syndrome, lu!us, mitral stenosis,
Penicillamine idio!athic !ulmonary hemosiderosis5
Lu!us#li*e reactions 4hydrala;ine, !rocainamide5
&l(eolar !roteinosis
Radiation
&l(eolar cell carcinoma
Eosino!hilic !neumonia
C"##ec!2e T!33.e D!3e'3e
Li!id !neumonia
Systemic lu!us erythematosus
Rheumatoid arthritis
I#:ec!".3 D!3e'3e3
Scleroderma
Miliary tuberculosis
Polymyositis
Some funal and (iral infections
O)e& C'&/!"2'3c.-'& D!3e'3e3
.dio!athic !ulmonary fibrosis
.nterstitial !ulmonary edema
Bronchiolitis obliterans orani;in
Pulmonary hemosiderosis 3@ to mitral !neumonia stenosis
Lym!hocytic interstitial !neumonia
&myloidosis
P.-$"#'&* S'&c"!/"3!3 6 lym!hadeno!athy always !recedes or !resents concurrently with
!ulmonary chanes of the disease8
W ,ilar and !aratracheal adeno!athy8
.ntrathoracic lym!hadeno!athy 4B?V5
Diffuse !arenchymal disease 4?EV5
<B
Basics of Chest X-ray Interpretation
E)clusi(ely hilar lym!hadeno!athy initially 4<<V5
Pulmonary disease without hilar lym!h node enlarement 43?V5
Lun in(ol(ement (aries from a miliary nodular !attern, to a reticulonodular !attern, to a !urely
reticular !attern 4honeycombin58
$ccasionally !atients e)hibit m)8 lare ranulomas simulatin metastatic neo!lasm8
Li*ely that a miliary nodular form !recedes the reticular !attern8
Proression to mar*ed !ulmonary fibrosis of bullous em!hysema with disablin functional
im!airment, de(elo!ment of cor !ulmonale, and death occurs in a small V of cases8
Ma0ority of !atients remain relati(ely asym!tomatic8
Sc-e&"/e&$'
-reat ma0ority of !atients with abnormal !ulmonary function studies do not e)hibit radioloically
discernible !ulmonary chanes8
II Relati(ely fine networ* of reticular infiltrates 4honeycombin57 enerally restricted to the
lower lun ;ones8
Radioloic demonstration of abnormalities of eso!haus, duodenum, small bowel, or terminal
!halanes more li*ely to be seen8
Recurrent or chronic as!iration of inested material may be underlyin cause of !ulmonary
fibrosis8
H!3!"c*"3!3 X 6 includes Letterer#Siwe disease, ,and#SchXller#Christian disease, and
eosino!hilic ranuloma8 $nly eosino!hilic ranuloma occurs in adults8
Coarse, reticular interstitial !attern8
.ndi(idual cysts com!risin the coarse reticular or honeycomb !attern are enerally less than ?
mm in reatest dimension, althouh lare cysts of u! to 9 cm in diameter ha(e been re!orted8
Pneumothora) M relati(ely fre'uent com!lication8
3N< deny dys!nea7 3N< ha(e dry couh7 systemic sym!toms M lassitude, weiht loss, and less
commonly, fe(er may !redominate in KN<8
Diabetes insi!idus may be and associated disorder8
Systemic form 6 I in(ol(ement of bone, li(er, CNS, *idneys, and alimentary tract8
P#e.$"#!'
<C
Basics of Chest X-ray Interpretation
IATROGENIC RADIOLOGIC SIGNS
&8 EC- leads
B8 Endotracheal tube 6 !ositionin
C8 C%P and P& lines
<G
Basics of Chest X-ray Interpretation
GLOSSARY
A!& 7&"#c)"%&'$ 6 Surroundin consolidation will sometimes allow more !eri!heral bronchi
to be seen as tubular or branchin lucencies8 Normally only the trachea, mainstem bronchi, and
occasionally the oriins of the lobar bronchi, are (isible on C"Rs as air#filled tubular structures8
%isuali;ation of the more !eri!heral bronchi with air in them is usually not !ossible8
A-2e"-'& +c"#3"-!/'!2e, /e#3!!e3 6 &n abnormal density caused by the colla!se or, more
often, the fillin of air s!aces with abnormal material 4blood, !us, water, !rotein, or cells58
&l(eolar densities characteristically ha(e irreular, ha;y marins e)ce!t where they are bounded
by a !leural surface8 4&lso referred to as >acinar !attern>85 Semental distribution and air
bronchorams are also characteristic of this !attern8
Ae-ec'3!3 6 Colla!se and (olume loss are synonymous terms8 %ery small areas of atelectasis
often !roduce a linear shadow, which is often, but not always, hori;ontal8 +his is referred to as
>!late#li*e>, >linear>, or >subsemental> atelectasis8 Lobar and total lun atelectasis also occur8
+hese larer (arieties of atelectasis are usually associated with increased density in the in(ol(ed
!ortion of lun so that there is, in fact, consolidation !resent as well8 +o dianose atelectasis,
there must be a s!ecific e(idence of (olume loss such as dis!lacement of a fissure, the
mediastinum, or a hilum8 Ele(ation of the hemidia!hram and decreased s!ace between ribs can
also be sins of atelectasis8
B-e7 6 & small, thin#walled, air#containin structure8 +his term is fre'uently reser(ed for such
small areas which are fre'uently intra!leural8 +his term may be used synonymously with >bulla>
but often is reser(ed for smaller air s!aces8
B&"#c)!ec'3!3 6 Dilatation of a bronchus or bronchi, usually secretin lare amounts of
offensi(e !us8 Dilatation may be in an isolated sement or s!read throuhout the bronchi8
B.--' 6 See >bleb> or >ca(ity8> +hese abnormal air s!aces may or may not be associated with
diffuse !ulmonary em!hysema8
C'3e".3 6 cheese#li*e8
C'2!* 6 &nother form of air s!ace in the lun8 +his term is usually reser(ed for those which are
the result of tissue necrosis, unli*e bullae8 +hic*ness and irreularity of the walls often the
distinuishin feature se!aratin ca(ities from bullae or blebs8
=E
Basics of Chest X-ray Interpretation
C"#3"-!/'!"# 6 Fillin of !ulmonary air s!ace with some abnormal material8 May also be
referred to as >al(eolar disease8>
De#3!* 6 & nons!ecific term that can be used to describe any area of whiteness on the chest
film8Normal structures such as the heart as well as abnormalities in the luns may be called
densities8 +his term is often used when the nature or cause of an abnormal shadow is not *nown8
.t is a useful term in that situation, since other terms 4e88, >mass> or >infiltrate>5 fre'uently im!ly
more s!ecific entities which may or may not be !resent8
E>&'-(-e.&'- 6 &nythin that is outside both the !arietal and the (isceral !leura but that
im!ines on the luns8 +he heart is the most ob(ious e)am!le8 Since normal or abnormal
structures in this location are se!arated by two layers of !leura from the lun, the marins of
these densities are characteristically shar! and smoothly ta!erin8
H!-.$ +(-e.&'- ? )!-'1, 6 >lun root7> medusa#li*e tanle of arteries and (eins on either side of
the heart shadow8 .rreular medial shadow in each lun where the bronchi and !ulmonary arteries
enter8 $ther structures in these areas, !articularly lym!h nodes, are normally so small as to be
ina!!arent8 +he normal hilar shadow is almost entirely com!osed of the central !ulmonary
arteries8 R hilar (essels seem to e)tend out farther than those on the L because a !art of the L
hilum is obscured by the shadow of the more !rominent L side of the heart8 +he L hilum on a
normal C"R is a little hiher than the R one because of the slihtly hiher ta*e#off of the L
!ulmonary artery8
I#e&$!#'e "& $!>e/ -.#% /!3e'3e 6 +his cateory of diffuse lun disease is fre'uently used
when the radiora!hic criteria to desinate a s!ecific !attern 4consolidati(e, interstitial, etc85 may
not be !resent, or when there may be elements of se(eral ty!es of diffuse lun disease in the same
!atient8
I#:!-&'e 6 & !oorly defined abnormal !ulmonary density or any such density shar!ly bounded
by !leura and fissures8 +his is a confusin term, since it may be used to indicate any abnormal
lun density or, by others, as a synonym for consolidation8 Synonymous with >fluid density8>
I#e&3!!'- 6 +he !ortion of the !ulmonary !arenchyma that consists of the actual lun tissue as
o!!osed to the air s!aces8 .ncludes al(eolar walls, se!ta, broncho(ascular structures, and !leura8
.n(ol(ement of this tissue is a fre'uent form of diffuse lun disease8
5e&-e*A3 -!#e3 6 most commonly encountered in C,F and interstitial !ulmonary edema7 may be
'uite transient in these conditions7 may re!resent a constant, irre(ersible findin in other
=K
Basics of Chest X-ray Interpretation
interstitial disease, es!8 !neumoconiosis, lym!hatic s!read of neo!lasm, lym!hatic mitral (al(e
disease, and C$PD8
5e&-e* B +3e('-, -!#e3 6 usually H 3 cm in lenth and about K mm in thic*ness7 not confined to
the marins of the lun7 attributed to Otissue andNor fluid accumulation in interlobular se!ta7
thic*enin of interlobular se!ta for any reason may allow them to be seen as narrow, straiht
shadows, es!ecially at the !eri!hery of the bases7 another form of interstitial abnormality8
5e&-e* A -!#e3 6 Fsually D = cm in lenth, relati(ely straiht, linear densities7 tend to be
oriented !er!endicular to the nearest !leural surface7 attributed to Otissue andNor fluid
accumulation in communicatin lym!hatics between (eins and bronchi8
9V( 6 Pea* *ilo(oltae7 the !ea* (oltae across the radiora!hic tube8 &n increase in this factor
allows increased tissue !enetration by hiher enery roentens8
L!#%.-' 6 4tonue#sha!ed5 area of left lun ad0acent to the left (entricle not a se!arate lobe8
L.ce#c* 6 &n increase in blac*ness of an area on the radiora!h8 .n the lun, it may im!ly that
air is bein tra!!ed, that lun tissue has been destroyed, or that there is decreased blood su!!ly8
&rtifacts, chanes in !osition, and soft tissue abnormalities can also cause areas of lucency8
$!--!'$(e&eE3ec"#/3 +$A3, 6 +his is the amount of current throuh the radiora!hic tube8 +he
amount of current and the lenth of time durin which the current flows control the 'uantity of )#
rays enerated8 .ncreasin the m& causes an increase in !atient e)!osure to ioni;in radiation and
!roduces more )#rays to create an imae on the film8
M'33 6 & solid#a!!earin, reasonably well#defined soft tissue density usually larer than < or =
cm in diameter8
Me/!'3!#'- 6 Referrin to the structures or a lesion between the luns8 Fnless the luns are
actually in(aded by a mediastinal lesion, the lesion:s )#ray shadow will be e)tra#!leural and,
therefore, usually will ha(e shar! demarcation from the lun8
M!-!'&* 6 & form of diffuse lun disease consistin of countless (ery tiny nodular densities8
N"/.-e 6 & well#defined, more or less round density in the lun7 smaller than a mass8 No riid
si;e distinction between a >mass> and >nodule> is !ossible8
O('c!* 6 Synonym for >density8>
=3
Basics of Chest X-ray Interpretation
P-e.&'- 6 Refers to an abnormality arisin in the !leura or !leural s!ace8 Most commonly this is
free of loculated fluid8
P#e.$")"&'> 6 Free air in the !leural s!ace7 may be modified by the followin descri!ti(e
terms> hydro#, !yo#, hemo#, chylo#, tension8
P.-$"#'&* e/e$' 6 defined radiora!hically as diffuse, bilateral consolidation by fluid: other
materials can fill air s!aces bilaterally and i(e the same radiora!hic !attern8
Re!c.-'& 6 & fine branchin !attern with lines radiatin in all directions7 one of the sins of the
interstitial !attern8
Se%$e#'- 6 Limited to s!ecific broncho!ulmonary sements or lobes8 Semental distribution
of disease usually indicated bronchial or (ascular in(ol(ement and is most common in
consolidation8
Se('- -!#e3 6 see 1erley B lines8
S!-)".ee 3!%# 6 Normally an interface is seen between areas of different density as between
shadows of the heart and lun8 Loss of air on the !ulmonary side, usually because of
consolidation, may cause obliteration or >silhouettin> of this normal interface8 +his sin is
useful in locali;in an abnormality or confirmin the !resence of abnormality8 $ccasionally the
silhouette sin will be the only definite indication of consolidation ne)t to the heart or dia!hram8
=<
Basics of Chest X-ray Interpretation
CHEST RADIOLOGY ARTICLES
Baumstar*, &8, Swensson, R8 -8, ,essel, S8 Q8, et al8 4KGC=58 E(aluatin the radiora!hic
assessment of !ulmonary (enous hy!ertension in chronic heart disease8 &merican Qournal of
Radioloy, K=3, CBB8
Cha**o, S8, Aos*a, D8, Martine;, ,8, et al8 4KGGK58 Clinical, radiora!hic, hemodynamic
correlations in chronic conesti(e heart failure/ Conflictin results may lead to ina!!ro!riate
care8 &merican Qournal of Medicine, GE, <?<8
Chen, Q8 +8 +8, Beliar, %8 S8, Morris, Q8 Q8, et al8 4KG9C58 Correlation of roenten findins with
hemodynamic data in !ure mitral stenosis8 &merican Qournal of Roentenoloy, KE3, 3CE8
Ciarroa, Q8 E8, .sselbacher, E8 M8, DeSanctis, R8 A8, R Eale, 18 &8 4KGG<58 Dianostic imain
in the e(aluation of sus!ected aortic dissection/ $ld standard and new directions8 New Enland
Qournal of Medicine, <3C, <?#=<8
Crystal, R8 -8, Bitterman, P8 B8, Rennard, S8 .8, et al8 4KGC=58 .nterstitial lun disease of un*nown
cause8 Disorders characteri;ed by chronic inflammation of the lower res!iratory tract/ Parts K and
38 New Enland Qournal of Medicine, <KE, K?=8
Friedman, B8 Q8, et al8 4KGC?58 Com!arison of manetic resonance imain and echocardiora!hy
in determination of cardiac dimensions in normal sub0ects8 Qournal of the &merican Collee of
Cardioloy, ?, K<9G8
-oodman, L8 R8 Radioloy of asbestos disease8 4KGC<58 Qournal of the &merican Medical
&ssociation, 39G, =9?8
-yssenho(en, E8 Q8, et al8 4KGC958 +ranseso!haeal two#dimensional echocardiora!hy/ .ts role in
sol(in clinical !roblems8 Qournal of the &merican Collee of Cardioloy, C, GB?8
,au!t, M8, Moore, -8 A8, R ,utchins, -8 M8 +he lun in systemic lu!us erythematosus8 4KGCK58
&merican Qournal of Medicine, BK, BGK8
,unninha*e, -8 A8, R Fauci, &8 S8 4KGBG58 Pulmonary in(ol(ement in the collaen (ascular
diseases8 &merican Re(iew of Res!iratory Disease, KKG, =BK8
Qay, S8 Q8, Qohannson, A8 -8, R Pierce, &8 18 4KGB?58 +he radiora!hic resolution of Stre!tococcus
!neumoniae !neumonia8 New Enland Medicine 3G<, BGC8
1houri, N8 F8, Me;iane, M8 &8, Yerhouni, E8 &8, et al8 4KGCB58 +he solitary !ulmonary nodule/
&ssessment, dianosis, and manaement8 Chest, GK, K3C#K<<8
==
Basics of Chest X-ray Interpretation
Lillinton, -8 &8 4May K?, KGG<58 Manaement of the solitary !ulmonary nodule8 ,os!ital
Practice, =K#=C8
Meaney, Q8 F8 M8, Ae, Q8 -8, Chene(ert, +8 L8, et al8 4KGGB58 Dianosis of !ulmonary embolus
with manetic resonance aniora!hy8 New Enland Qournal of Medicine, <<9, 43E5, K=33#K=3B
Mehlman, D8 Q8, R Resne*o(, L8 4KGBC58 & uide to the radiora!hic identification of !rosthetic
heart (al(es8 Circulation, ?B, 9K<8
Nienaber, C8 &8, (on 1odolistch, P8, Nicolas, %8, et al8 4KGG<58 +he dianosis of thoracic aortic
dissection by nonin(asi(e imain !rocedures8 New Enland Qournal of Medicine, <3C, K#G8
$:1eefe, M8 E8, -ood, C8 &8, R McDonald, Q8 R8 Calcification in solitary nodules of the lun8
&merican Qournal of Radioloy, BB, KE3<#KE<<8
Pratt, P8 C8 4KGCB58 Role of con(entional chest radiora!hy in dianosis and e)clusion of
em!hysema8 &merican Qournal of Medicine, C3, GGC8
Ritchie, Q8 .8, et al8 4KGG?58 -uidelines for clinical use of cardiac radionuclide imain8 & re!ort of
the &merican ,eart &ssociationN&merican Collee of Cardioloy +as* Force8 Circulation, GK 4=5,
K3BC#K<E<8
Rosenow ..., E8 C8 4KGGC58 .nter!retin chest films/ +ric*s of the trade8 Consultant, <C 4<5, ??<#
?9B8
Scha!iro, R8 L8, R Musallam, Q8 Q8 4KGBB58 & radioloic a!!roach to disorders in(ol(in the
interstitium of the lun8 ,eart R Lun, 9 4=5, 9<?#9=<8
Seward, Q8 B8 4KGG358 +ranseso!haeal echocardiora!hy/ &CC Position Statement8 Qournal of the
&merican Collee of Cardioloy, 3E, ?E98
Shuford, A8 ,8 4KGG358 Detection of cardiac chamber enlarement with the chest roentenoram8
,eart Disease and Stro*e, 3, <=K#<=B8
Stein, P8 D8, et al8 4KGG358 Relation of !lain chest radiora!hic findins to !ulmonary arterial
!ressure and arterial blood o)yen le(els in !atients with acute !ulmonary embolism8 &merican
Qournal of Cardioloy, 9G, <G=8
+a0i*, &8 Q8, et al8 4KGBC58 +wo#dimensional real#time ultrasonic imain of the heart and reat
(essels8 Mayo Clinic Proceedins, ?<, 3BK8
+a!son, %8 R8 4KGGB58 Pulmonary embolus # New dianostic a!!roaches8New Enland Qournal of
Medicine, <<9 43E5, K==G#K=?K8
=?
Basics of Chest X-ray Interpretation
Z +heodore, Q8, R Robin, E8 D8 4KGB?58 Pathoenesis of neuroenic !ulmonary edema8 Lancet, 3,
B=G8
Z Aebb, A8 R8 4KGGE58 Radioloic e(aluation of the solitary !ulmonary nodule8 &merican Qournal
of Radioloy, K?=, BEK#BEC8
Ainterhauer, R8 ,8, Belic, N8, R Moores, 18 D8 4KGB<58 Clinical inter!retation of bilateral hilar
adeno!athy8 &nnals of .nternal Medicine, BC, 9?8
Aoodrin, Q8 ,8 4KGGE58 Lun cancer8 Radioloy Clinics of North &merica, 3C, =CG8
Yelefs*y, M8 N8 4KGBB58 & sim!lified a!!roach to readin )#rays of the heart8 Modern Medicine,
$ctober <E, <<#<98
=9