CHEST X RAY

DR. ABRAHAM AHMAD A.F., SPJP

INTERNAL DEPT MEDICAL FACULTY - UNUSA
OVERVIEW

NORMAL CHEST X RAY

RECOGNIZING CARDIOMEGALY

CARDIAC CONTOURS

THE PULMONARY VASCULATURE

CONGESTIVE HEART FAILURE AND PULMONARY EDEMA

VALVULAR AND CONGENITAL HEART DISEASE

 NORMAL CHEST X RAY

A = ascending aorta
AA = aortic arch
Az = azygous vein
LA = left atrial appendage
LB = left lower border of pulmonary
artery
LV = left ventricle
PA = main pulmonary artery
RA = right atrium
S = superior vena cava
SC = subclavian artery.
NORMAL CHEST X RAY
LATERAL PROJECTION
PA PROJECTION
RECOGNIZING CARDIOMEGALY
 Ratio the transverse diameter of the heart shadow
the widest transverse diameter of the thoracic cage

CTR >50% CARDIAC ENLARGEMENT

CARDIO-THORACIC RATIO
PENYEBAB GAMBARAN CARDIOMEGALY PADA FOTO POLOS YANG
DISEBABKAN KARENA FAKTOR EKSTRA KARDIAK:

1. Proyeksi AP akan menyebabkan gambaran jantung lebih besar

dibandingkan dengan posisi PA karena jarak film dengan posisi jantung
lebih jauh pada posisi AP dibandingkan dengan posisi PA
2. Kondisi obesitas, hamil dan asites dimana tekanan intra abdominal yang
meningkat menyebabkan diafragma lebih condong ke sisi rongga thorax
dan thorax kurang berekspansi ketika inspirasi
3. Pada kondisi straight back syndrome dan pectus excavatum akan
menyebabkan kompresi jantung oleh dinding sternum dan tulang belakang
4. Posisi kurang AP atau rotasi ke kiri akan menyebabkan bayangan jantung
terlihat lebih besar pada foto polos dada
5. Efusi perikard
Adequate Inspiration vs Inadequate Inspiration
 Mengenali kardiomegali pada foto toraks AP

Gambaran jantung pada AP Ukuran Jantung

Batas kiri jantung menyentuh batas kiri jantung pasti membesar

dinding thorax

Batas kiri jantung hampir menyentuh jantung kemungkinan membesar,

batas kiri dinding thorax lanjutkan dengan menghitung CTR

Batas kiri jantung dalam batas normal jantung kemungkinan normal

Batas kiri jantung hampir Batas kiri jantung
menyentuh batas kiri menyentuh batas kiri
dinding thorax jantung dinding thorax
kemungkinan membesar jantung membesar
PERICARDIAL EFFUSION

Erlenmeyer
Shape
CARDIAC CONTOURS
DOUBLE DENSITY OF LA ENLARGEMENT
Normally, the LA forms no border
VENTRICLE
The easiest way to evaluate which ventricle (right or left) is
enlarged is to examine the corresponding outflow tract for each
ventricle
If Then cardiomegaly is made up
of

The heart is enlarged (CTR > 50%) At least RV enlargement

+
The MPA is enlarged

The heart is enlarged (CTR > 50%) At least LV enlargement

+
The Aorta is prominent
LVH RVH
 HYPERTENSIVE HEART DISEASE

Booth Shaped
 FIVE MOST IMPORTANT CARDIAC CONTOURS
Ascending Aorta should not project beyond right heart border
Indentation on right side of heart where double density of LA
enlargement will appear ovelapping of LA and RA walls
Aortic Knob should be less than 35 mm from the edge of the
trachea

MPA segment can be prominent if there is increased

pressure or
increased flow in the pulmonary circulation
Concavity where the LA, when it enlarges, will
appear on the left side of the heart
We evaluate ventricular enlargement by looking
at the outflow tracts for each ventricle
THE PULMONARY VASCULATURE
THE PULMONARY VASCULATURE CAN BE CLASSIFIED
INTO THE FOLLOWING FOUR CATEGORIES

Normal

Pulmonary Venous Hypertension

Pulmonary Arterial Hypertension

 STATE OF THE PULMONARY VASCULATURE
Description Size of Distribution of flow Distribution of flow from
of state RDPA from Apex to Base Central to Peripheral

Normal < 17 mm Lower lobe larger than Gradual tapering from central
upper lobe to peripheral

Venous > 17 mm Upper lobe equal to or Gradual tapering from central

Hypertension greater than size of lower to peripheral
lobe (Cephalization)

Arterial > 17 mm Lower lobe larger than Rapid attenuation in size

Hypertension upper lobe between central and peripheral
vessels (Pruning)

* These relationship require an upright chest

PULMONARY VENOUS HYPERTENSION
PULMONARY ARTERY HYPERTENSION
RECOGNIZING CONGESTIVE HEART
FAILURE AND PULMONARY EDEMA
 Thickening of the interlobular
septa

Peribronchial cuffing
Pulmonary
Interstitial Edema
Fluid in the fissures

Congestive Heart Pleural effusions

Failure

Fluffy, indistict pathcy airspace

densities

Pulmonary Alveolar
Edema Bat-wing or butterfly
configuration

Pleural effusions
PULMONARY INTERSTITIAL EDEMA

Kerley B
PULMONARY ALVEOLAR EDEMA

Bat Wing
Appearance
VALVULAR AND CONGENITAL
HEART DISEASE
MITRAL STENOSIS

LV Normal
MITRAL REGURGITATION

Prominent
LAA

LV
enlargement
AORTA STENOSIS

Dilatation of
Aorta
Ascendens

LV
enlargement
AORTA REGURGITATION

Dilatation of
Aorta Dilatation of
Ascendens Aorta
descendens

LV
enlargement
 ASD

Prominent
Inverted MPA
Comma Sign
 VSD

Increased flow Increased flow

of pulmonary of pulmonary
vasculature vasculature

LV
enlargement
PDA

Prominent
MPA