Interpretation

Of Chest Radiographs
& Radiation Protection

Dr. Sayed Munirpasha

Specialist Radiology
LLH Hospital, Abu Dhabi

1
 Objectives
 Technical aspect in chest radiography.

 Radiological anatomy of chest.

 Interpretation of chest radiograph.

 Pattern of diseases on chest radiograph.

 Brief overview on radiation protection.

 X -Rays
 Sir Wilhelm Conrad Roentgen discovered X rays on 18th Nov, 1895
 Electromagnetic radiation with short wavelength.
What is a Chest Radiograph?

SHADOW
 Start at the beginning

Identification!
 Correct patient
 Correct date and time
 Correct examination / Correct marker.
 Are old films available?
 DO THIS EVERYTIME – It buys you time and is
vitally important.
 Approach to the CXR: Technical Aspects

 Projection – PA or AP
 Position – Upright or Supine (Supine folks are
sick)
 Inspiratory effort
 9-10 posterior end of ribs
 Penetration
 Thoracic intervertebral disc space just visible
 Positioning/rotation
 Medial clavicle heads equidistant to spinous process
Projection
Portable (AP or Antero-
posterior)
FILM
PA (Postero-anterior)
FILM
 Projection

PA AP
Over Exposure Proper Exposure
9
 Anatomy

RUL

RML
RUL (Right Upper Lung)
RML (Right Middle Lung)
RLL (Right Lower Lung)
Right Sided Fissures
LUL (Left Upper Lung)
LLL (Left Lower Lung)
Left Side Fissure

LUL

LLL
 What to Evaluate

 Lungs
 Pleural surfaces
 Cardiomediastinal contours
 Bones and soft tissues
 Abdomen
 Where to Look

 Apices
 Retrocardiac areas (left and right)
 Below diaphragm
Apical TB
Left Retrocardiac Opacity
Normal Anatomy: Frontal CXR

 Heart
 Aorta
 Pulmonary arteries
 Airways
 Diaphragm/costophrenic sulci
 Maximum x-ray Blackest
Transmission
air
(least dense tissue)
fat
soft tissue
calcium
bone
x-ray contrast
Maximum x–ray metal
Absorption
(densest tissue) Whitest
 Chest Radiographic
Patterns of Disease
 Air space opacity
 Interstitial opacity
 Nodules and masses
 Lymphadenopathy
 Cysts and cavities
 Lung volumes
 Pleural diseases
LUL Pneumonia
 Air Space Opacity

 Components:
 air bronchogram: air-filled bronchus
surrounded by airless lung
 confluent opacity extending to pleural
surfaces
 segmental distribution
 Air Space Opacity: DDX

 Blood (hemorrhage)
 Pus (pneumonia)
 Water (edema)
 hydrostatic or non-cardiogenic
 Cells (tumor)
 Protein/fat: alveolar proteinosis and
lipoid pneumonia
Interstitial Opacity: Small Nodules
Interstitial Opacity:
Lines
Interstitial Opacity: Lines & Reticulation
 Interstitial Opacity

 Hallmarks:
 small, well-defined nodules
 lines
 interlobular septal thickening
 fibrosis
 reticulation
 Interstitial Opacity: DDX
 Idiopathic interstitial pneumonias
 Infections (TB, viruses)
 Edema
 Hemorrhage
 Non–infectious inflammatory lesions
 sarcoidosis
 Tumor
Well-Defined

Calcification

Ill-Defined Mass
 Nodules and Masses

 Nodule: any pulmonary lesion represented in a

radiograph by a sharply defined, discrete,
nearly circular opacity 2-30 mm in diameter
 Mass: larger than 3 cm
 Nodules and Masses

 Qualifiers:
 single or multiple
 size
 border definition
 presence or absence of calcification
 location
Right Paratracheal
Lymphadenopathy
Right Hilar LAN
Right Hilar LAN
Left Hilar LAN
Subcarinal LAN

*
AP Window LAN
 Lymphadenopathy

 Non-specific presentations:
 mediastinal widening
 hilar prominence

 Specific patterns:
 particular station enlargement
 Cysts & Cavities

 Cyst: abnormal pulmonary parenchymal

space, not containing lung but filled with air
and/or fluid, congenital or acquired, with a
wall thickness greater than 1 mm
 epithelial lining often present
 Cysts & Cavities
 Cavity: abnormal pulmonary parenchymal
space, not containing lung but filled with air
and/or fluid, caused by tissue necrosis, with
a definitive wall greater than 1 mm in
thickness and comprised of inflammatory
and/or neoplastic elements
Benign Lung Cyst : PCP Pneumatocele
• Uniform wall thickness
• 1 mm
• Smooth inner lining
 Benign Cavities :
Cryptococcus

• max wall thickness 4 mm

• minimally irregular inner lining
 Indeterminate Cavities

• max wall thickness 5-15 mm

• mildly irregular inner lining
Malignant Cavities: Squamous Cell Ca
• max wall thickness 16 mm
• Irregular inner lining
 Cysts & Cavities

 Characterize:
 wall thickness at thickest portion
 inner lining
 presence/absence of air/fluid level
 number and location
Pleural Effusion
Pleural Effusion
Pleural Calcification
Pleural Disease: Basic Patterns
 Effusion
 angle blunting to massive
 mobility
 Thickening
 distortion, no mobility
 Mass
 Air
 Calcification
Pneumothoraces
 Expiration reduces lung volume,
making a small pneumo easier to see
Tension Pneumothorax on CT

Tension Pneumo
Mediastinum
Rt. Lt.

Ao
Tip of ET tube Carina

Deep Right Mainstem Intubation

 Tip of ET

Pneumomediastinum
 ET tube
Obliterated aortic knob First rib fx

Tracheal deviation to Rt.

Chest tube

NG shift to Rt.
 Lt. Internal Carotid
Rt. Subclavian Art. Artery

ET
Lt. Subclavian
Artery
NG
Aortic
Rupture
Crushed right chest
After ventilated with PEEP
RADIATION PROTECTION
 Harmful effects of X-Rays.
 Skin Burns
 Skin ulceration.
 Hair loss.
 Infertility
 Cancer.
 Genetic effects.
 Radiation health effects
TYPE
OF
EFFECTS

CELL DEATH CELL TRANSFORMATION BOTH

DETERMINISTIC STOCHASTIC ANTENATAL
Somatic somatic & hereditary somatic and
Clinically attributable epidemiologically hereditary expressed
attributable in large in the foetus, in the live
in the exposed
populations born or descendants
individual

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 Biological effects of ionizing
radiation
 Deterministic
 e.g. Lens opacities, skin
injuries,
 infertility, epilation, etc
 Stochastic
 Cancer, genetic effects.

3 : Biological effects of ionizing radiation 77

 Deterministic effects

• Deterministic
(Threshold or non-
stochastic)
• Existence of a dose threshold
value (below this dose, the
effect is not observable)
• Severity of the effect
increases with dose
• A large number of cells are
involved
Radiation injury from an industrial source

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Skin injuries

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 Threshold Doses for Deterministic Effects

• Cataracts of the lens of the eye 2-10 Gy

• Permanent sterility
• males 3.5-6 Gy
• females 2.5-6 Gy
• Temporary sterility
• males 0.15 Gy
• females 0.6 Gy

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 Stochastic Effects
 Stochastic(Non-Threshold)
 No threshold
 Probability of the effect increases with dose
 Generally occurs with a single cell
e.g., cancer, genetic effects

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 Radio-sensitivity
High RS Medium RS Low RS
Bone Marrow Skin Muscle
Spleen Mesoderm Bones
Thymus organs (liver, Nervous
Lymphatic heart, lungs…) system
nodes
Gonads
Eye lens
Lymphocytes)

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 Effects of antenatal exposure
 As post-conception time increases = Radio-Sensitivity
decreases

 There are 3 kinds of effects: lethality, congenital anomalies

and large delay effects (cancer and hereditary effects).

Congenital anomalies

%
Lethality

Pre-implantation Organogenesis Foetus Time

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 Effects of antenatal exposure
 Lethal effects can be induced by relatively small
doses (such as 0.1 Gy) before or immediately after
implantation of the embryo into the uterine wall. They
may also be induced after higher doses during all the
stages during intra-uterine development.
0.1 Gy
%
Lethality

Time

Pre-implantation Organogenesis Foetus

85
 Delayed effects of radiation

 Classification:
 SOMATIC: they affect the health of the
irradiated person. They are mainly different
kinds of cancer (leukemia is the most
common, with a delay period of 2-5 years, but
also colon, lung, stomach cancer…)
 GENETIC: they affect the health of the
offspring of the irradiated person. They are
mutations that cause malformation of any
kind (such as mongolism)

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 The benefit of using ionizing radiation in medicine
is widely acknowledged. Although alternative
methods of imaging—for example, ultrasound (US)
and magnetic resonance imaging (MRI)—have
been developed, ionizing radiation will continue to
be used for the foreseeable future.
 However, it is recognized that ionizing radiation
can cause harm and it is therefore important that
the users of radiation are aware not only of the
clinical benefits, but also of the possible risks to
their patients

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 PROTECTION
 ALARA
 Protective shields- lead apron, gloves,
gonad shields, lead goggles
 Uses of alternative imaging modalities like
Ultrasound/ MRI
EFFECTIVE DOSES FOR COMMON RADIOLOGICAL EXAMINATIONS EXPRESSED IN TERMS OF THE EQUIVALENT NUMBER OF CHEST X-RAYS

TYPICAL EFFECTIVE EQUIVALENT NUMBER OF

EXAMINATION DOSE (mSv) CHEST X-RAYS
Limbs and joints (except hip) < 0.01 < 0.5
Chest PA 0.02 1
Skull 0.06 3.0
Thoracic spine 0.7 35
Lumbar spine 1 50
Hip 0.4 20
Pelvis 0.7 35
Abdomen 0.7 35
IVU (intravenous urogram) 2.4 120
Barium swallow 1.5 75
Barium meal 2.6 130
Barium follow-through 3 15
Barium enema 7.2 360
CT head 2.0 100
CT chest 8.8 400
CT abdomen or pelvis 10 500
Thank you
 References
 https://radiopaedia.org/articles/chest-
radiograph
 https://www.radiologyinfo.org/en/info.cfm?
pg=chestrad
 https://www.hagaziekenhuis.nl/media/4830
69/x_thorax_beoordelen.pdf
 https://www.iaea.org/topics/radiation-
protection