ANATOMY: LE 3 | TRANS 9

RADIOLOGY OF THE CHEST

DR. ERWIN YAP | 11/22/19

● How often should a regular CXR be done?

OUTLINE
→ Once or twice a year, depending on the case U
I. Introduction to VI. Systematic Approach ● Why should a CXR be done [Mayo Clinic]?
Radiography A. Airway → Often among the first procedures a patient has to undergo if
A. Brief Overview B. Bones & Soft tissues we suspect a heart or lung disease
B. Review of Respiratory C. Cardiac Shadow → Can also be used to check how the patient is responding to
System D. Diaphragm treatment
C. Indications E. Effusions → Can reveal many things inside the body, including the ff.:
II. Spectrum of F. Fields (Lung fields) ▪ The condition of the lungs – CXRs can detect cancer,
Radiodensities G. Gastric bubble infection or air collecting in the space around a lung
III. Other Medical Imaging H. Hila (pneumothorax)
Techniques I. Instruments
▪ Heart-related lung problems – CXRs can show
IV. Normal Radiologic J. Mediastinum
changes or problems in the lungs that stem from heart
Anatomy of the Chest VII. Quiz
problems
V. Proper Radiographic VIII. References
▪ The size and outline of the heart
Techniques IX. Appendices
A. X-ray Projections ▪ Blood vessels – Because the outlines of the large
B. Special Techniques vessels near the heart (aorta and pulmonary arteries and
veins) are visible in CXRs, they may reveal aortic
SUMMARY OF ABBREVIATIONS aneurysms, other blood vessel problems or congenital
CXR Chest X-ray heart disease
MRI Magnetic Resonance Imaging ▪ Calcium deposits
CT Scan Computed Tomography Scan ▪ Fractures
▪ Postoperative changes – CXRs are useful for
Remember Lecturer Book Previous Trans monitoring the patient’s recovery after surgery in the
G U & chest
Practice How to Read a Chest X-ray Result: ▪ Pacemaker, defibrillator or catheter – CXRs are
usually taken after placement of such medical devices to
make sure everything is positioned correctly
READING CXR RESULTS [South Sudan Medical Journal]
• Check the patient details
® First name, surname, sex, date, etc.
§ Name, age and date are always on the left upper or
left lower corner U
• Check the orientation, position, and side description
® Left, right, erect, AP, PA, supine, prone (terms will be
South Sudan Medical Journal discussed in the succeeding parts of the transcript)
• Check additional information
LEARNING OBJECTIVES
® Inspiration, expiration, etc.
Identify anatomic structures as seen in the radiographs • Check for rotation
To be able to familiarize the different radiograph views ® Measure the distance from the medial end of each
To be able to differentiate the normal chest radiograph clavicle to the spinous process of the vertebra at the
from the abnormal same level, which should be equal
To compare and contrast the advantages and • Check for adequacy of inspiration
disadvantages of the different imaging modalities ® You should barely see the thoracic vertebrae behind the
To select the ideal imaging modality to evaluate a particular heart
structure • Check exposure
I. INTRODUCTION TO RADIOGRAPHY ® You need to be able to identify both costophrenic angles
and lung apices
A. BRIEF OVERVIEW
● Comparing CXR with the gross anatomy of the chest B. REVIEW OF RESPIRATORY SYSTEM
→ It is important that we know what is expected to be seen on
a CXR with an understanding of the gross anatomy U
● Why is CXR more used than other modalities?
→ CXR is usually the most accessible modality U
● Common misconception in Radiology:
→ Patients might develop cancer from a single CXR U
▪ Lead gowns, gloves, and other Personal Protective
Equipment (PPE) protect the lab technician from harmful
exposure to x-rays
▪ In CXR procedures, the patient will be inside a lead
cubicle that blocks radiation
− Furthermore, x-ray beams travel in a straight line and
do not go after humans U Figure 1. Cricoid and Tracheal Cartilage on CT [Dr. Yap’s PPT]
(Dr. Yap said that we must familiarize with the diagram above G)
LE 3 TRANS 9 TG: Bugante, Cabang, Caburnay, Cadet TH: Bermejo, Dee VPAA: Bermejo (09494741543) and Cobol (09157374720) Page 1 of 13
● Respiratory System
→ Starts with the oronasal cavity à trachea à bronchi à lungs
(bronchi enter the root/hilum) bronchioles à alveoli
→ Trachea
▪ C-shaped rings of hyaline cartilage
▪ Bounded posteriorly by the trachealis muscle
− Flat/concave posteriorly
▪ “Windpipe” that provides a pathway for air to enter the
lungs
→ Cricoid Cartilage
▪ Complete ring, unlike the trachea
▪ Thich posteriorly
▪ Do not confuse this with the trachea in a CT Scan (see
the ff. image) U
Figure 4. Radiodensities of Certain Structural Components [Dr. Yap’s PPT]

Figure 2. Cricoid and Tracheal Cartilage on CT Scan [Dr. Yap’s PPT] Left – Cricoid
Cartilage; Right - Trachea
→ Bronchi
▪ Right Main Bronchus – wider, shorter and more vertical
than the left
▪ Left Main Bronchus – longer and smaller in diameter
→ Lobes (5)
▪ Right Lobes (divided by the oblique and horizontal
fissures):
− Superior Lobe
− Middle Lobe
− Inferior Lobe
▪ Left Lobes (divided by the oblique fissure only):
− Superior Lobe
− Inferior Lobe
→ Pleura
▪ Visceral pleura covered by parietal pleura (part of the
serous pericardium)
▪ Fibrous pericardium is separated from the serous
pericardium by the pleural space (space between the
lungs and chest wall)
C. INDICATIONS
● Evaluation of symptoms (e.g. difficulty of breathing, chest
pain and cough)
● Evaluation of physical signs (e.g. hypoxemia, abnormal Figure 5. Radiodensities [AccessPhysiotherapy]

pulmonary tests) Factors that Determine the Shadow Brightness of CXRs U

● Evaluation of placement of central lines, nasogastric tubes • Radiodensity
(NGT) and endotracheal (ET) tubes. ® Knowing the radiodensity of anatomical features is
● Others: necessary in imagining and analyzing a CXR
→ Annual Physical Exam § Air is less dense than bone, hence air allows the beams
→ School Enrolment to pass through more than in bones
II. SPECTRUM OF RADIODENSITIES • Radiolucent (Black)G: These structures allow beams to pass
through
• Radiopaque (White)G: Beams are blocked, hence film will
appear white
• Thickness of the Subject
® In the presence of more fat, x-ray beams would have more
difficulty passing through and coming out
Figure 3. Spectrum of Radiodensities [Dr. Yap’s PPT] • Duration of Exposure
® The longer the duration of exposure, the film will come out
darker (because there is more time for the beams to pass
through)

ANATOMY Radiology of the Chest Page 2 of 13

 ® The shorter the duration of exposure, the whiter (opposite
concept of the above-mentioned)
® These can lead to false reults
III. OTHER MEDICAL IMAGING TECHNIQUES U
• CT Scan
® Gives a 3-D image of the lungs
® Gives a better view of the lung parenchyma as compared to
an MRI
• MRI
® In case a CT finding needs further confirmation, an MRI is
the next choice
§ MRI is better for viewing the soft tissues, in cases of
metastasis, etc.
• Ultrasound (Sonography)
® It is not good for imaging bones or any tissues that
contain air (like the lungs). Under some conditions,
ultrasound can image bones (such as in a fetus or in small
babies) or the lungs and lining around the lungs, when they
are filled or partially filled with fluid [NIBIB, 2016]
IV. NORMAL RADIOLOGIC ANATOMY OF THE CHEST
*Dr. Yap briefly flashed the normal anatomy prior to discussing the
techniques.
Figure 6. CXR with Anatomic Markings (PA View) [Dr. Yap’s PPT]
Figure 7. CXR with Anatomic Markings (Lateral View) [Dr. Yap’s PPT]
ANATOMY Radiology of the Chest
V. PROPER RADIOGRAPHIC TECHNIQUES
P.R.I.M. Penetration, Rotation, Inspiration, Motion
• Penetration
® Refers to the penetration of the x-ray beam to the structure
® In viewing the CXR, the bare minimum is to visualize the first
four thoracic vertebra
§ Too dark: over penetration [2022A Trans]
§ Too light: under penetration [2022A Trans]
• Rotation
® There should be no rotation as it could cause displacement
of reference structures from the midline
® Both clavicular heads should be equidistant to the midline
§ Oblique or slight rotation: might falsely cause the heart to
appear enlarged
• Inspiration
® Deep breath will cause the thoracic cavity to expand and
increase in volume, and the pulmonary vessels to expand
® For ambulatory (ability to walk or move around) patients,
if the subject fails to exhale properly, the diaphragms will be
elevated à vascular markings will go up and will appear
crowded à cannot rule out pneumonia or any other lung
pathology
® For non-ambulatory (cannot move) patients,
considerations as to the technique of inspiration are given
as they would likely have difficulty of breathing
• Motion
® Just as in taking photographs, we would not want our
subjects to be moving
§ Movement increases the likelihood of creating blurs in
the film
A. X-RAY PROJECTIONS
*X-ray Projections are described by the patient’s relation to the
beam U
Posteroanterior (PA) View
Figure 8. Posteroanterior X-ray Projection [Dr. Yap’s PPT]
● Standard Frontal Chest Radiograph (Roentgenogram)
→ Patient usually upright (for ambulatory patients)
→ X-rays traversed the patient from posterior (P) to anterior
(A)
→ Film cassette in front of patient, beam behind at a distance
of 6 ft.
→ Distance of beam determines magnification and clarity of
sharpness
Page 3 of 13
 ▪ Structures that are nearer to the beam appear more ● Film cassette behind the patient, beam is in front
magnified in the x-ray film U ● Unlike the PA view, the scapulae are not retracted and may
→ Radiographs are viewed with a standard orientation that is obstruct the lung fields because of the patient’s position
independent of the radiographic projection & ● This view may cause magnification of cardiac shadow
▪ For most of the body, radiographs are viewed as if the → Heart appears bigger because it is farther from the cassette
patient is facing you (i.e. patient’s right to the viewer’s left) and the beam hits it first
→ Radiolucent structure at the midline extending from the
neck up to the superior mediastinum is the trachea
▪ Trachea contains air which makes it appear radiolucent
(black)
→ The esophagus, which is also found at the midline, does not
usually appear because it doesn’t always contain air and is
collapsed
→ Patient’s position : Refer to Fig. 8
▪ Patient is upright facing the image receptor, the superior
aspect of the receptor is 5 cm above the shoulder joints
▪ Chin is raised so it would be out of the image field
▪ Hands are placed on the posterior aspect of the hips, with
the elbows slightly flexed anteriorly
− This is to retract the scapulae so they wouldn’t obstruct
the lung fields U
▪ Shoulders are depressed to move the clavicles below the
lung apices

Figure 11. X-ray taken in AP view [Dr. Yap’s PPT]

Lateral View

Figure 9. Normal CXR Taken in PA View [Dr. Yap’s PPT]

Anteroposterior (AP) View

Figure 12. Chest Radiograph Procedure (PA view [A] vs. Lateral view [B])
● Left or right side of the chest against the film cassette
→ Heart is less magnified when it is closer to the film
→ Beam from right at a distance of 6 ft.
● Good for viewing area behind the sternum (retrosternal) and
behind the heart (retrocardiac)
→ Marked with a “R” or “L” according to whether the right or
left side of the patients was against the film
▪ Left lateral or right lateral
▪ To visualize a lesion in the left thorax, it is better to get a
left lateral view
● The image is viewed from the same direction that the beam was
projected &
● Radiolucent structures : Anterior is on the left, posterior is on
Figure 10. Anteroposterior (AP) X-ray Projection
the right
● Usually taken in a supine position or a sitting position (for → Trachea (anterior)
patients who are non-ambulatory) → Esophagus (posterior)
● X-rays traversed the patient from anterior (A) to posterior (P)
ANATOMY Radiology of the Chest Page 4 of 13
 → Tracheo-esophageal strike: the linear opacity between
trachea and esophagus
Figure 13. X-ray Taken in PA (left) and Left Lateral (right) Views
Figure 14. X-ray Taken in Right Lateral View (yellow arrows: right
diaphragm which continues beyond the cardiac shadow; red arrows: left
diaphragm which stops abruptly at cardiac shadow; green arrows: right ribs
which appear more magnified; blue arrows: left ribs) [Dr. Yap’s PPT]
B. SPECIAL TECHNIQUES
Lateral Decubitus Radiograph
● Detect small effusions
→ Effusions: escape of fluid in the pleural cavity
● Characterize free-flowing effusions
● Detect small pneumothorax
→ Pneumothorax: entry of air into the pleural cavity resulting
from a penetrating wound of the parietal pleura
● Patient is asked to lie on the suspected side of effusion (left
or right) for 10-15 minutes before the image is taken
● This radiograph is an additional view requested to confirm the
physician’s suspicion of an effusion because in a CXR, fluid
usually goes to the base of the lungs due to gravity in upright
position
ANATOMY Radiology of the Chest
Figure 15. Lateral Decubitus Radiograph (red arrows: layer of fluid on the
dependent portion – effusion) [Dr. Yap’s PPT]
Expiratory Radiograph
● Detects focal or diffuse air trapping
● Detects small pneumothorax
● Visceral pleural line can be observed
● When pneumothorax is suspected, both inspiratory and
expiratory radiograph are taken (see figure below)
→ In an inspiratory radiograph, the lungs are filled with air
and are closer to the thoracic wall due to lung expansion
▪ This makes pneumothorax less obvious
→ In an expiratory radiograph, the pleura is pushed further
away from the chest wall and pneumothorax becomes more
obvious while taking up a larger percentage of the thoracic
cavity
▪ This makes it easier to detect pneumothorax
Figure 16. Inspiratory (L) vs. Radiograph (R): Pneumothorax is detected on the
right lung [Dr. Yap’s PPT]
Apical Lordotic View
● Visualization of the lung apices
● Used when there are suspicious densities found in the apices
of the lungs that are obstructed by the clavicles and/or 1st ribs
in normal CXRs (e.g. in cases of tuberculosis)
● Patients are asked to lean back (approximately 30 degrees)
such that x-ray beams would strike the chest horizontally
→ This makes the ribs appear more horizontal and the lung
apices more visible
Page 5 of 13
 Figure 18. Anatomical Structure in PA View with Emphasis on the Airway (red:
tracheal shadow; green: left main bronchus; blue: right main bronchus) [Dr. Yap’s
Figure 17. Apical Lordotic View Procedure [Dr. Yap’s PPT]
PPT]
● Tracheal Shadow
→ Should be straight-looking and located in the midline
(lucency) U
→ Pushed towards the side of the lesion in cases of collapse,
effusion or presence of mass
● Right and Left Main Bronchi
→ Presence of breast shadows in females
→ Inferior lung zones are sometimes obscured by breasts’
shadows in females
→ There is absence of breast shadows in mastectomy
patients
→ Presence of nodule in the lung indicates metastasis in
cancer patients
Evaluating the airway is most important especially for patients
who are intubated. If the tube appears to have inserted more to
the right main bronchus (too far into the trachea beyond the
carina), this may require re-positioning of the endotracheal tube.
U
Figure 18. Apical Lordotic View (ribs appear more horizontal; lung apices are B. BONES AND SOFT TISSUES
more visible) [Dr. Yap’s PPT]

VI. SYSTEMATIC APPROACH

MNEMONICS FOR THE SYSTEMATIC APPROACH G
A – Airway
B – Bones & soft tissues
C – Cardiac Shadow/Silhouette (Mediastinum)
D – Diaphragm (& Gastric Bubble)
E – Effusions
F – Fields (Lung fields)
G – Gastric bubble
H – Hila
I – Instruments

A. AIRWAY

Figure 19. Anatomical Structure in PA View with Emphasis on the Bones

(orange: ribs; green: clavicle) [Dr. Yap’s PPT]

ANATOMY Radiology of the Chest Page 6 of 13

● Ribs
→ Anterior: oblique orientation
→ Posterior: horizontal orientation
● Clavicular Heads
→ Should be equidistant U
What to specifically look for when evaluating the bones G
→ Presence of fractures (i.e. overlapping of structures,
break in continuity of bone)
→ Presence of foreign bodies
→ Symmetry
→ Bone demineralization
→ Metastatic lesions
→ Edema
C. CARDIAC SILHOUETTE (MEDIASTINUM)

Figure 22. Radiographical Surfaces of the Heart [Dr. Yap’s PPT]

Figure 20. Radiograph of the Mediastinum in PA View [Dr. Yap’s PPT]

The right ventricle is not visible in a normal PA view because it
is located anteroinferiorly U

Figure 23. Radiographical Surfaces of the Heart in Lateral View [Dr. Yap’s PPT]
SPACES

Figure 21. Anatomical Structures of the Mediastinum in PA View. Inset: Labels

pointing to the aortic arch, pulmonary trunk, left atrial appendage, left ventricle,
cardiac apex, right atrium and superior vena cava. [Dr. Yap’s PPT]

BORDERS AND SURFACES

Table 1. Surfaces of the Heart
SURFACE STRUCTURE
Anterior Right Ventricle
Diaphragmatic Left Ventricle
Left Pulmonary Left Ventricle
Right Pulmonary Right Atrium
Table 2. Borders of the Heart
BORDERS STRUCTURE
Right Edge of Right Atrium
Figure 24. Anatomical Structures in Lateral View with Emphasis on the Spaces
Left Left Ventricle & Left Atrium [Wong Yung Kong, 2017]
Superior Right Atrium & Left Atrium • Retrocardiac space – where the lungs meet behind the
Inferior Right Ventricle heart
Posterior Left Ventricle • Retrosternal space – region between the sternum and
Apex Left Ventricle ascending aorta and above the heart border formed by the
Base Left Atrium right ventricular outflow tract (normally 3 cm deep) [Brant & Helms,
2007]

ANATOMY Radiology of the Chest Page 7 of 13

 Contains lymph nodes, hence if not seen in the
- o Located behind LV
radiograph may suggest enlarged lymph nodes or
lymphoma [Wong Yung Kong, 2017]
• Retrotracheal triangle – radiolucent region that represents
contact of posterosuperior portions of the upper lobe
CARDIAC SIZE
o Disappears when LV is enlarged G
● Pectus Excavatum (Funnel Chest)
→ Characterized by concave depression of sternum
● X-ray characteristics [Hapuarachchi & et. al, 2019]:
→ Widening of cardiac silhouette due to heart compression
→ Blurring of right heart border (PA/AP view)
→ Horizontal posterior ribs
→ Vertical anterior ribs (heart-shaped)
→ Displacement of heart towards the left
→ Obliteration of descending aortic interface

Figure 26. X-ray of patient with Pectus Excavatum [Dr. Yap’s PPT]
● Dextrocardia
→ Congenital cardiac malrotation
▪ Apex of the heart is pointing to the right

Figure 25. Anatomical Structure in PA View with Emphasis on the Elements of

Cardiothoracic Ratio [Dr. Yap’s PPT]

● Cardiothoracic Ratio (CR)

→ Measures the maximum diameter of the heart in relation to
the maximum diameter of the thoracic cavity
▪ Look for the midline
▪ Measure the maximal horizonal (transverse) cardiac
width (green + blue)
▪ Divide by maximal horizontal (transverse) thoracic width
(usually at the level of the diaphragm)
𝑚𝑎𝑥𝑖𝑚𝑢𝑚 𝑑𝑖𝑎𝑚𝑒𝑡𝑒𝑟 𝑜𝑓 ℎ𝑒𝑎𝑟𝑡
𝐶𝑅 =
𝑚𝑎𝑥𝑖𝑚𝑢𝑚 𝑑𝑖𝑎𝑚𝑒𝑡𝑒𝑟 𝑜𝑓 𝑡ℎ𝑜𝑟𝑎𝑐𝑖𝑐 𝑐𝑎𝑣𝑖𝑡𝑦
Normal Cardiothoracic Ratio G
→ PA view: <0.5
→ AP view: <0.6
→ Pediatric: <0.6
ABNORMALITIES Figure 27. PA View X-ray of Patient with Dextrocardia and Situs Inversus
Totalis (total transposition of abdominal and thoracic viscera: mirror image of
● Cardiomegaly normal organ positioning) [Iino, 2019]
→ Cardiac enlargement
D. DIAPHRAGM
→ Left heart occupies 2/3 of sternal length while right
● The right dome of the diaphragm (right hemi-diaphragm) is
occupies 1/3
usually HIGHER than the left dome of the diaphragm (left hemi-
▪ RV Enlargement
diaphragm).
− Retrosternal Space U → This is because the liver is found below to the right dome
o Space between the sternum and the right ventricle and the heart is superior to the left.
o If RV s enlarged, the retrosternal space is ● The stomach with the gastric bubble is found underneath the
obliterated G left diaphragm. G
▪ LA Enlargement ● Costodiaphragmatic or costophrenic recess/angle/sulcus:
− Carinal angle is >90 (Normal: 75) space found in between the diaphragm and the chest wall
▪ RA Enlargement ● Cardiodiaphragmatic or cardiophrenic angle: space found
− Distance from midline is >5.5 cm in between the heart and the diaphragm
− Usually accompanies RV enlargement ● Diaphragm must be checked for air (presence of air:
▪ LV Enlargement pneumoperitoneum – surgical emergency)
− Distance from IVC to posterior heart border is >1.8
cm
o Hoffman-Rigler Sign
= Measures shadows of IVC
− Retrocardiac Space U
ANATOMY Radiology of the Chest Page 8 of 13
 Figure 28. Chest X-ray in PA view with emphasis on the diaphragm (right
dome of the diaphragm appears higher than the left; yellow arrows:
costodiaphragmatic recess; green arrows: cardiodiaphragmatic recess) [Dr. Yap’s
PPT]
Figure 29. Pericardial Effusion seen in AP View (Water Bottle Sign)
E. EFFUSION
● Features on Chest X-Ray:
→ Blunting of costophrenic angle
→ Blunting of cardiophrenic angle
→ Fluid will insinuate within the horizontal or oblique fissures
→ A meniscus will be seen, on frontal films seen laterally and
gently sloping medially
→ With large volume effusions, mediastinal shift occurs away
from the effusion
● PA View: approximately 200 mL of fluid is usually required to
become radiographically visible
● AP View: ~300 mL
● Lateral View: ~70 mL
Pericardial Effusion
● Primary finding for pericardial effusion is an enlarged cardiac
silhouette (Water Bottle Sign).
→ AP View: The heart is not enlarged but appears like it
because of the abnormal accumulation of fluid in the
pericardial sac
● Lateral view: Oreo Cookie Sign
→ The pericardial fluid forms a vertical opaque line which
separates an anterior lucent line directly behind the sternum
(pericardial fat) and a posterior lucent line (epicardial fat)

Figure 30. Pericardial Effusion seen in Lateral View (Oreo Cookie Sign)
Pneumoperitoneum
● Presence of air within the peritoneal cavity or immediately
under the diaphragm

ANATOMY Radiology of the Chest Page 9 of 13

 5 Lobes and Bronchopulmonary Segments of the Lungs [Moore]
● Right lung lobes - Mnemonic: A PALM Seed Makes Another
Little Palm
→ RUL – Right Upper/Superior Lobes
▪ Apical Segment
▪ Posterior Segment
▪ Anterior Segment
→ RML – Right Middle Lobe
▪ Lateral Segment
▪ Medial Segment
→ RLL – Right Lower/Inferior Lobe
▪ Superior Segment (RLL)
▪ Medial Basal Segment
Figure 31. Pneumoperitoneum in PA (A) and Lateral (B) views
▪ Anterior Basal Segment
▪ Lateral Basal Segment
F. LUNG FIELDS ▪ Posterior Basal Segment
● Left lung lobes - mnemonic: ASIA ALPS
→ LUL – Left Upper/Superior Lobe (ASIA)
▪ Apico-posterior Segment **
▪ Superior Lingual Segment
▪ Inferior Lingual Segment
▪ Anterior Segment
→ LLL-Left Lower/Inferior Lobe (ALPS)
▪ Anteromedial Basal Segment *
▪ Posterior Basal Segment
▪ Lateral Basal Segment
▪ Superior Segment
Note - ** typically combine into apico-posterior segment; * often
combined into anteromedial basal segment
● Normally, oblique fissures are difficult to visualize since they
are more oblique in orientation than the x-ray beam.
Horizontal fissures are then easier to visualize.
● RML is the only lobe that touches the right middle border.
● RLL overlaps RML and RUL
Left Upper Lobe Pneumonia
● Characterized by an opacity with air bronchograms in the left
midzone with loss of visualization of left heart border.

Figure 32. The Lung Fields [Dr. Yap’s PPT]

● Fissures
→ Right:
▪ Major Fissure – Oblique fissure (more oblique than L) Figure 34. Chest X-ray of Patient with Left Upper Lobe Pneumonia [Heyworth, 2018]
▪ Minor Fissure – Horizontal fissure Right Upper Lobe Pneumonia
→ Left
▪ Oblique Fissure ● PA view: alveolar infiltrate obscures right cardiac border
(middle lobe)
● Lateral view: consolidation is anterior to major fissure but below
minor fissure-middle lobe

Figure 33. Right and Left Oblique Fissure Comparison [Dr. Yap’s PPT]

ANATOMY Radiology of the Chest Page 10 of 13

 Figure 35. CXR of Patient with Middle Lobe Pneumonia [RMH Core Conditions, 2015]

G. GASTRIC BUBBLE
• Radiolucent rounded area generally nestled under the left
hemidiaphragm representing gas in the fundus of the stomach
G Figure 39. Radiograph of a patient with a pacemaker [Dr. Yap’s PPT]
K. MEDIASTINAL STRUCTURES
• Mediastinum &
® Occupied by the mass of tissue between the two pulmonary
cavities, is the central compartment of the thoracic cavity
® Contains all the thoracic viscera and structures except the
lungs
® Highly mobile region because it consists primarily of hollow
(liquid- or air-filled) visceral structures united only by loose
connective tissue, often infiltrated with fat
• Borders:
® Superior: superior thoracic aperture
® Inferior: diaphragm
® Anterior: sternum and costal cartilages
Figure 36. Radiograph indicating the presence of gastric bubble [Dr. Yap’s PPT]
® Posterior: bodies of thoracic vertebrae
• Evaluate the whole chest cavity by looking at the
H. HILA
mediastinum
• Hila – junction of the lungs and the mediastinum; made up of
® Check if widened or not (normal)
pulmonary arteries and main bronchi
® Must be familiar with the different compartments in relation
• Check for masses and lymph nodes
to different pathologies, masses, and lesions in each
• Lymph nodes are not normally seen and are therefore,
compartment
abnormal findings G
• Four regions:
• Normally, the right hilum is usually somewhat lower than the
® Superior Mediastinum
left; neither same level nor higher
® Inferior Mediastinum
§ Anterior Mediastinum
§ Middle Mediastinum
§ Posterior Mediastinum

Figure 37. Radiograph indicating presence of lymph nodes [Dr. Yap’s PPT]
I. INSTRUMENTS
• Pacemakers, wiring, circuitry, leads, etc. Figure 40. Compartments of the Mediastinum [Moore]
• X-ray imaging may be used to check if inserted instruments are
placed correctly.
ANATOMY Radiology of the Chest Page 11 of 13
 a. Carina
b. Gastric Bubble
c. Main Bronchus
d. Tracheal Shadow
6. Which of these views would enable you to better appreciate
the lung apices?
a. Anteroposterior
b. Apicolordotic
c. Expiratory
d. Lateral decubitus
7. Which chamber may be enlarged if the retrosternal space is
obliterated in a lateral chest radiograph
a. Left atrium
b. Left ventricle
Figure 41. Radiograph of compartments of the mediastinum (left lateral view) –
Green line: separates the superior (above sternal angle) and inferior
c. Right atrium
mediastinum. Yellow circle: marks middle mediastinum; left side of circle: d. Right ventricle
anterior mediastinum; right side of circle: posterior mediastinum [Dr. Yap’s PPT]
Answers: B, A, A, D, B, B, D
• Thymus VIII. REFERENCES
® The presence of thymus is the major difference of a child’s ● Dr. Yap’s PPT
CXR versus an adults, occasionally appearing to project out ● 2022 A Trans
into the lung (“sail sign”) & ● 2023 A Transc
● 2023 B Trans
● Metter, F. (2014). Essentials of Radiology. Elsevier Saunders
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IX. APPENDIX
Appendix 1. How To Look at a Chest X-Ray
Figure 42. Sail Sign on CXR of a child [Mettler, 2014]

VII. QUIZ
1. Which of the following chamber of the heart is not visible in PA
view as it is located anteroinferiorly?
a. Left Ventricle
b. Right Ventricle
c. Right Atrium
d. Left Atrium
2. On lateral radiographs, the right oblique fissure usually has a
more oblique course than that of the left.
a. True
b. False
3. The following are normal findings on a PA view CXR, except:
a. Equal level bilateral hilar points
b. Gastric bubble on the left side
c. Right diaphragm appears higher than the left
d. Anterior ribs are in oblique position
4. Which anatomical structures are correctly arranged in the
increasing order of theoretical radiodensity:
a. Air, Fluid, Fat, Bone, Metal
b. Air, Fat, Fluid, Bone, Metal
c. Air, Bone, Fat, Fluid, Metal
d. Air, Fat, Fluid, Bone, Metal
Disclaimer: Appendices 1 and 2 are additional information to supplement the
5. In a normal chest radiograph (PA view), the presence of last two objectives of the lecture. These were obtained from Dr. Yap’s main
lucency underneath the left hemidiaphragm represents the: reference: Essential of Radiology by Metter, F.

ANATOMY Radiology of the Chest Page 12 of 13

 Appendix 2. Circumstances in which a CXR is not indicated

Appendix 3. Superior View – X-ray of the Head

Appendix 4. Lateral View – X-ray of the Head

ANATOMY Radiology of the Chest Page 13 of 13