Notice the skewed positioning of the heads of the clavicles (red arrows) and the spinous processes.

Since the large airways contain air and are therefore of lower density than the surrounding soft tissue, they should be
visible on most good-quality radiographs.
The trachea may be slightly off midline to the right since it passes to the right of the aorta.
The trachea can appear deviated if the patient is rotated.

For the heart, the silhouette sign can be caused by an opacity in the RML, lingula, anterior segment of the upper lobe,
lower aspect of the oblique fissure, anterior mediastinum, and anterior portion of the pleural cavity. This contrasts with
an opacity in the posterior pleural cavity, posterior mediastinum, of lower lobes which cause an overlap and not an
obliteration of the heart border. Therefore both the presence and absence of this sign is useful in the localization of
pathology.

The right heart border is silhouetted out.

This patient has bilateral lower lobe pulmonary edema. The alveoli are filled with fluid making the bronchi visible as an
air bronchogram.

Consolidation / Lingula Density in left lower lung field

Loss of left heart silhouette
Diaphragmatic silhouette intact
No shift of mediastinum
Blunting of costophrenic angle

Atelectasis Left Lung

Homogenous density left hemithorax
Mediastinal shift to left
Left hemithorax smaller
Diaphragm and heart silhouette are not identifiable

Atelectasis Right Upper Lobe

Density in the right upper lung field
Transverse fissure pulled up
Right hilum pulled up
Smaller right lung
Smaller right hemithorax

Atelectasis Left Lower Lobe

Loss of left diaphragmatic silhouette
Blunting of costophrenic angle
Left main bronchus pulled down

Pneumonia is airspace disease and consolidation. The air spaces are filled with bacteria or other microorganisms and
pus.
Pneumonia is NOT associated with volume loss.
What differentiates it from a mass? Masses are generally more well-defined.

Consolidation Right Upper Lobe

Density in right upper lung field
Lobar density
Loss of ascending aorta silhouette
No shift of mediastinum
Transverse fissure not significantly shifted
Air bronchogram

In the supine film, an effusion will appear as a graded haze that is denser at the base. The vascular shadows can
usually be seen through the effusion. An effusion in the supine view can veil the lung tissue, thicken fissure lines, and
if large, cause a fluid cap over the apex. There may be no apparent blunting of the lateral costophrenic sulci.

A patient with bilateral pleural effusions.

Note the concave menisci blunting both posterior costophrenic angles.

Air in pleural space

Lung margin

ARDS
Non-cardiogenic pulmonary edema
Distinguishing characteristics:
Normal size heart
No pleural effusion

CHF may progress to pulmonary venous hypertension and pulmonary edema with leakage of fluid into the interstitium,
alveoli and pleural space.
In the pulmonary vasculature of the normal chest, the lower zone pulmonary veins are larger than the upper zone veins
due to gravity. In a patient with CHF, the pulmonary capillary wedge pressure rises to the 12-18 mmHg range and the
upper zone veins dilate and are equal in size or larger, termed cephalization.
With increasing PCWP, (18-24 mm. Hg.), interstitial edema occurs with the appearance of Kerley lines (These are
horizontal lines less than 2cm long, commonly found in the lower zone periphery. These lines are the thickened,
edematous interlobular septa).
Increased PCWP above this level is alveolar edema, often in a classic perihilar bat wing pattern of density. Pleural
effusions also often occur.

This is a typical chest x-ray of a patient in severe CHF.

Note the cardiomegaly, alveolar edema, and haziness of vascular margins.

Kerley B Lines
These are horizontal lines less than 2cm long, commonly found in the lower zone periphery. These lines are the
thickened, edematous interlobular septa.

Batwing pattern

bullae (lucent, air-containing spaces that have no vessels and therefore are not perfused)
In smokers with known emphysema the upper lung zones are commonly more involved than the lower lobes. This
situation is reversed in patients with alpha-1 anti-trypsin deficiency, where the lower lobes are affected.

Hyperlucent lung fields

Multiple blebs
Avascular zones
Prominent pulmonary arteries

Lung mass
Round or oval
Sharp margin
Homogenous
No respect for anatomy